Midwifery in Ireland
The History of Birth and Midwifery in Ireland
Until the late eighteenth century, childbirth and lying-in had been exclusively under female control and principally within the jurisdiction of the female midwife. Traditionally a local married woman, the midwife oversaw the labor, directed events in the birthing room, and supervised the lying in period, and only called upon ‘medical men’, who often knew little of the mechanisms of labor or the anatomy of the uterus, when the delivery of a live infant was remote and thus their surgical expertise in removing a dead fetus needed. However, by the late eighteenth century, a new breed of male practitioners referred to as the “man-midwife” challenged the norms surrounding childbirth and undermined the esteem in which female practitioners had been held in Ireland: with their unique access to university education and application of “modern” obstetric techniques on poor women in the Dublin lying-in hospital, later known as the “Rotunda,” the man-midwife constructed a childbirth practice exclusive of the female midwife. State-sponsored campaigns for regulating midwifery training and practice in accordance with the growing medical model of obstetrics emerged in response to the relative high rates of maternal mortality in especially rural Ireland; while this initiative resulted in the foundation of the 1882 Central Midwives Board and the 1902 Midwifery Act in Britain which implemented exclusive standards and measures aimed at filtering out the traditional birthing attendant, its might was not matched in organizational terms in Ireland where religion, gender, class, and professional tensions with doctors hindered “progress” until 1918 with the passing of the Midwives Act.
While training schemes emphasizing “medical midwifery” and a comprehensive male-dominated public health system encouraging the centralization of maternity services in hospitals were established in Irish cities, traditional medicine and traditional female practitioners referred to as “handywomen” dominated midwifery amongst the rural poor. Scholars such as Ciara Breathnach (2016) contend that the establishment of district nursing schemes and implementation of “Jubilee nurses” in rural Ireland failed in large part not only due to their precarious financing but also due to their foreignness, as the majority of these supposedly superior medically trained female practitioners were middle-class, Anglican and from urban region; thus few women would risk their relationship with the local handywomen by availing such risky nursing services. In fact, the majority of women in rural Ireland would continue to depend largely on the traditional midwife or “handy-woman,” to assist in their deliveries and supervise their lying-in periods until the early twentieth century, wherein such midwives were demonized as “drunken louts” and criminalized for their ‘unqualified’ and ultimately ‘dangerous’ practice by the moralizing and medicalization missions of the Irish government.
In the early twentieth century, the stubbornly high rates of infant and maternal mortality in urban and rural Ireland, respectively, was routinely blamed on the continued widespread use of lay female midwives and encouraged legislative attempts to professionalize nursing and midwifery services. Successive government reports, informed by the emphasis on reproductive bodies “at risk” by the medical establishment, vilified lay midwives as unqualified professionals who in “spreading puerperal fever,” the then primary cause of maternal mortality, and “causing unnecessary torture,” were responsible for the “fatal consequences” of birth in rural Ireland and thus were a social menace. In contrast to this smear campaign, the medically and surgically trained nurses implemented across Ireland were heralded as a saving grace in the national press, an idealization of medical practice that forwarded the publication of the 1918 Midwives Act. The 1918 Midwives Act not only established a Central Midwifery board and registration process but critically made it an offense for ‘untrained practitioners’ to tend to maternity cases unless under the direct supervision of a male medical professional with little consideration of the social realities that led to the lifetime dependence on the ‘unqualified midwife in rural Ireland.
In order to resolve this seeming “rural-urban” divide in maternal outcomes, the Irish government attempted to raise the standard of county-based care with the Local Government Act of 1925 which, among other things, appointed County Medical Officers and encouraged the use of female public health nurses and health visitors to supervise the operation of maternity and child services and discourage country women’s reliance on handywomen. In 1927 the Department of Local Government and Public Health established a national policy to refer cases ‘requiring more specialized care’ to maternity hospitals in Dublin and Cork, contending that complicated cases were best served in “centers of excellence,” and facilitated the coordination of hospitals services through their antenatal clinics and almoner departments with the municipal maternity and child welfare schemes, thus centralizing the hospital in Irish maternity care services. In order to ensure that the maternity care provided within hospitals was in accordance with the standards of the male-dominated medical establishment, the Irish government published the 1933 Public Hospital Act, which, amongst other things, provided discretionary funding, termed the “Hospitals’ Commission,” to local maternity hospitals which would be subject to regular internal reviews and audits. The implementation of this policy seemed to have had the tangible effect of shifting cultural norms surrounding birth, as the 1933–1934 Hospitals’ Commission Report claimed that mothers were opting for hospital births due the convenience of the hospital-based maternity care system which had become increasingly integrated with county maternity services.
The displacement of maternal mortality in rural Ireland by early infant mortality in Irish cities in the “hierarchy of official concern” in the 1940’s prompted a shift in culpability, as in addition to the “irresponsible” lay midwife emerged the “uneducated” urban mother (Earner-Byrne; p. 48). While a higher percentage of infants died in the first month of life in rural areas due to, according to the Department of Local Government and Public Health, inaccessibility to ‘better facilities for obtaining prompt medical and midwifery services’ and over-reliance on handywomen, a higher percentage of infants died in the succeeding months in urban areas as a result of both ‘unfavorable urban home conditions’ and ‘maternal ignorance’. Prominent political and medical figures, such as Edward Coey Bigger, identified the lack of instructive ‘mother-craft,’ the innate or passed down skills and knowledge regarding motherhood, to be an important failing in the Irish approach to preventative maternal health and identified the lay midwife, who encouraged the mothers intuition and decision-making, to be a danger. Parallel to this condemnation of the female knowledge of motherhood passed down by the lay midwife was the idealization of the knowledge of the male medical professional who was tasked with ‘enlightening’ mothers of the risks to themselves and their children.
Ironically, systematic attempts to universalize access to medical knowledge and services to Irish women, such as the 1951 Mother and Child Scheme, were rejected as a result of the vested economic interests of the very group critiquing women’s continued use of lay medical knowledge and practices: the male-dominated medical profession. The medical scholar Patricia Kennedy (2012) has argued that “the rejection of Noel Browne’s Mother and Child Scheme shaped maternity services for the next 50 years,” as it allowed the introduction of the 1954 Maternity and Infant Care Scheme following the 1953 Health Act which, in turn, prompted a series of policies that encouraged the centralization and medicalization of maternity care in Ireland. While the 1954 Maternity and Infant Care Scheme only offered free hospital-based maternity services to women who experienced maternity-related illnesses, the initial provision of “choice” of obstetrician as well as “choice” of the hospital or maternity home with an additional payment created a distinction between those who could pay for the (presumably) superior hospital-based services and those who couldn’t, further discouraging women from opting for home births as the poor woman’s option. Moreover, the Maternity and Child Health Services (Amendment) Regulations of 1956 politically endorsed the hospitalization of maternity care services by allowing, in many cases, free hospitalization; thus obstetricians were afforded access to what was to become the predominant form of maternity care in Ireland, obstetric led maternity services, in midwife-assisted hospital units.
The expansion of hospital-based maternity services to all women regardless of risk or income with the 1970 and 1991 Health Act Amendments concretized the trend towards hospitalized birth in Ireland; while 33.5% of births took place at home in 1955, by 1970 and 1991 only 3.0% and 0.3% of all births took place in the home. The historic deligitimization of female knowledge of childbirth, as evidenced by the criminalization of lay midwifery, and the historic legislative push for the hospitalization of maternity care services has undoubtedly contributed to the current consultant-led, hospital-based model of childbirth in Ireland.
The Current Model of Birth in Ireland
Maternity care in Ireland has been described by international health observers, such as Mardsen Wagner of the World Health Organization (WHO), as a “highly medicalized, doctor-centered, midwife marginalized” system of care typified by the use of “active management of labor” (AML) procedures. AML is used in various forms within most of the 20 maternity hospital units across Ireland and typically involves a consultant obstetrician, one-to-one midwifery care in labor, routine artificial rupture of membranes (ARM) and intravenous oxytocin, all for the purpose of decreasing the “risk” to the birthing person.While under the Maternity and Infant Care Scheme, maternity care in Ireland is provided free of charge to all women using ‘public,’ hospital based services, more than 50% of women in Ireland opt for private health care insurance which covers, or partially covers, the costs for them to attend care on a ‘semi-private’ or ‘private’ basis.
While women receiving public maternity care in Ireland are cared for antenatally by a team of doctors led by a consultant, cared for in labor and at birth by a team of qualified and student midwives under the supervision of obstetricians, and cared for in the postnatal period for 2–3 days in a public hospital ward by a mixed group of birth attendants, women receiving private maternity care receive antenatal care by a chosen obstetrician, are cared for in labor and at birth by either a team of qualified and student midwives under the supervision of a chosen obstetrician or a chosen midwife, and receive 2–5 day of postnatal care in a private hospital setting.With specific regard to antenatal and postnatal care, under the Maternity and Infant Care Scheme Irish women are afforded a preliminary examination by an obstetrician or general practitioner (GP) by 12 weeks and at least six examinations from their GP throughout their pregnancy, especially if suffering from a significant illness, such as diabetes, while postnatally their infant receives an examination by their GP at 2 weeks and they and their infant are examined at 6 weeks for postnatal complications. Additionally, all Irish women are entitled to free inpatient and outpatient public hospital services in respect of pregnancy and birth.
The universal provision of GP and obstetrician led antenatal and postnatal care and obstetrician supervised labor within Ireland originates from a historic agreement between the Health Service Executive (HSE), the federal government agency responsible for the provision of health and social services, and attending GP’s and obstetricians; by exclusively funding hospital-based, doctor-centered maternity care, health service agencies essentially had neglected, or at the very least underdeveloped, midwifery led services in Ireland until its acceptance of the Maternity Services Review Group, also referred to as the “Kinder Group,” recommendations for implemented two midwife-led units (MLU).
The centrality of the obstetrician in maternity health services at large is reflective of their position in the “Mastership” system characteristic of Irish maternity units, a hierarchy of knowledge and profession that subordinates the female midwife for the benefit of the male obstetrician. In Ireland, where obstetrics is an extremely lucrative business, state-employed midwives care for obstetricians’ own private patients, which firmly places the midwife as the subordinate ‘obstetric nurse’ rather than an independent, autonomously functioning alternative birth attendant. Murphy-Lawless (1991), in his study of independent and hospital-based midwives’ experiences of their position in hospital maternity units, found that Irish midwives acted as relatively powerless intermediaries between their female patients and their supervisory obstetricians, an uncomfortable position he referred to as ‘piggy in the middle,’ as part of a larger professional and knowledge based “Mastership” system. Within this system, the lead obstetrician, the “Master,” sets the policy for maternity care services within the maternity unit that must be unquestionably abided by all secondary birth assistants, namely midwives and obstetric nurses.
The historic institutionalization of this hospital-based, obstetric-dominated model of birth in Ireland has contributed to increasing rates of obstetric interventions, namely C-sections, epidurals, and episiotomies. The C-section rate increased from 7.4% in 1984 to 20.6% in 1999 and steadily rose to approximately 28.0% in 2013 (see figure1), though there exists variation across maternity hospitals; for instance, while the C-section rate was 14.2% at the National Maternity Hospital, Holles Street, it reached 25.5% at the Rotunda in 2001. The rate of epidurals has increased steadily since 1980 with more than half of all labors having received epidural anesthetics by 2000 and increasing thereafter, though, as with C-sections, these rates vary across maternity hospitals; for instance, the rate of episiotomy has been reported as low as 14.4% at the Coombe and as high as 27.2% at the National Maternity Hospital, Holles Street in 2011 (see figure 2). In fact, despite that 73% of births in Ireland in 2002 were recorded as ‘spontaneous deliveries’ and thus presumed to be normal, uncomplicated births, the combined C-section and operative vaginal delivery (e.g. vacuum or forceps facilitated) rates were close to 50% in some Southern Ireland maternity units.
The existence of the “Mastership” system coupled with the increasing rates of obstetric interventions in Irish maternity units begs the question as to what exactly are the birth experiences of both mothers and midwives in Ireland. Larkin and colleagues (2012) conducted a series of semi-structured interviews on women’s child-birth experiences within urban and rural hospitals throughout Ireland and found that women reported unmet labor expectations, experienced anxiety regarding obstetric interventions and the hospital environment and reported a lack of communication with birth attendants (i.e. midwives and obstetricians) yet viewed their traumatic experience as “typical” of the Irish maternity care system. More specifically, women expressed distress in having to “establish” their labor before being admitted into the hospital or attended by an obstetrician, reported little to no communication with obstetricians or midwives who often failed to advocate for their birth choices, and experienced severe anxiety surrounding the possibility of an episiotomy, the uncertainty of their labor duration, and their overall vulnerability to obstetric interventions. Moreover, while women often times described these hospital conditions as “inappropriate” and even “degrading,” they believed that a live healthy baby was the ultimate concern of their birth and their experience of labor came secondary and further refrained from criticizing the obstetrician or midwife who partook in these practices, instead critiquing ‘ the system’.
These women’s birth experiences corroborate with other women’s, midwives, and obstetricians perspective on the relative “woman-centerdness” of hospital-based birthing practices in Ireland. Pointedly, Hunter and colleagues (2017) found that obstetricians and especially midwives reported a lack of alternatives to the prevailing hospital-based and consultant-led model of maternity care in Ireland and indicated that while they aspired to women-centered care, they were routinely prohibited from providing it due to a professional hierarchy within maternity units, which midwives identified as (the previously mentioned) “Mastership” system. Critically, hospital-based midwives contended that this system reinforced an emphasis on “safety” and “risk” aversion rather than being based in evidence and was for the benefit of the obstetrician rather than the patient. In corroboration with Larkin et al.’s (2012) findings, while women appreciated the woman-centered care values of choice and normalizing childbirth, they nonetheless endorsed the fetal-centric viewpoint that a live healthy baby was the ultimate goal of their childbirth experience. Thus the Irish midwife seemingly finds herself in a difficult position: she must either sacrifice the central values of woman-centered care in operating within the dominant obstetrician-led and hospital-based model of maternity care or step outside this protected, coveted realm in an independent practice. But before this decision can be explored in full, it is necessary to consider who exactly is the Irish midwife.
The Irish Midwife
The difficult position of the Irish midwife stems in large part from the insecurity of her professional organizations. While midwifery has been officially recognized in Ireland since the 1918 Midwives Act, according to midwifery organization experts, such as then-chair of the International Confederation of Midwives (ICM), Bridget Lynch, it has been seriously underdeveloped and subsequently rendered powerless due to being professionally subsumed under An Board Altranais (ABA) or the Irish Midwifery and Nursing Board (IMNB) since the 1950s. While the Midwives Section of the Irish Nurses and Midwives Association (INMO), an extension of IMNB, has attempted to maintain a professional voice and national presence in the ICM, its “trade union roots and combined nursing and midwifery representation inevitably compromises its focus on professional midwifery issues,” and further hinders the ability for an organized midwifery front against current obstetric practices.
The purposes set forth by the Nursing and Midwifery Board of Ireland (NMBI) under the 2011 Nurses and Midwives Act is to protect the public and ensure the integrity of nursing and midwifery practices by “promoting high standards of professional education, training and practice, and professional conduct among nurses and midwives”. The undergraduate programs in midwifery prescribed by NMBI’s standards and requirements emphasize a dual focus on education and practice and on the “arts” and “sciences”; while students complete their arts and sciences courses in the first three years of the program, their fourth year comprises of a continual 36 week rostered clinical placement or internship in variable medical settings, including medical or surgical wards, intensive care units, and community health centers. Due to their specialized training, the registered midwives graduating from these undergraduate programs can enter specialized positions ranging from a Clinical Midwifery Manager/Specialist to a Lactation Consultant, to an Academic and, rarely, an Independent or Self-Employed Community midwife.
As with medically-trained, registered midwives in other European countries, the Irish midwife is responsible for not only providing family planning advice, diagnosing and monitoring normal pregnancies and assisting in deliveries and the postnatal period under the supervision of an obstetrician, but depending on the extent of her medical training, is also tasked with conducting spontaneous deliveries, including episiotomies and breech deliveries in the absence of an obstetrician. Critically, as a supposed reflection of their “balanced” coursework and practical training, all registered midwives in Ireland maintain a holistic, woman-centered perspective of birth: midwives believe that birth is a normal physiological event, that the birthing person is the primary decision maker and thus should be empowered throughout the birthing process, and that care should take into account not only women’s physical but also social, emotional, cultural, spiritual, and psychological experience.
While the NMBI’s practice standards, “Respect for Dignity of the Person,” “Professional Responsibility and Accountability,” “Quality of Practice,” “Trust and Confidentiality,” and “Collaboration with Others,” represent common midwifery values, they also represent points of conflict for midwives practicing within a hospital-based, obstetric-led maternity care system. For instance, “Respect for the Dignity of the Person,” which protects and promotes the safety and autonomy of the female patient by respecting her experiences, choices, priorities, beliefs and values, and “Trust and Confidentiality,” which underpins midwives equal and trusting partnership with their female patient and her family, conflicts with the often times described impersonal and technical nature of birth in the maternity hospital the majority of midwives operate within. Moreover, while the practice standard of “Collaboration with Others” is ideal in any medical practice involving a team of professionals, as with modern midwifery and obstetrics, it seems dubious that the onus for professional collaboration should fall on the midwife who occupies a precarious position within a consultant-led model of maternity care services. The question thus emerges as to what unique challenges the Irish midwife faces when attempting to practice within and outside of a predominant system counterintuitive to her values and standards of practice.
The Experience of the Hospital-Based vs. Independent Midwife in Ireland
The Irish midwife is seemingly met with a profound dilemma when considering her practice: she must either sacrifice central tennets of her philosophy to securely practice within the predominant hospital-based and consultant led maternity care system or sacrifice the very security of her practice as an independent midwife. Hyde and Roche-Reid (2004) conducted a series of in-depth interviews with highly experienced, hospital-based midwives throughout Ireland and found that while the majority of them attempted to encourage and facilitate women’s control over and choice in their childbirth, their efforts were ultimately circumscribed by active management of labor protocols that demanded technical consistency, forcing the midwife to exploit her professional power over female patients in accordance with obstetrician demands. While midwives were aware that the majority of technical interventions primarily reflected consultant preferences rather than best practices, they reported immense difficulty containing these practices since obstetricians largely supervised deliveries and postnatal care within the maternity units. Moreover, midwives reported difficulty in even ‘re-socializing’ their female patients to demand greater choice and control over their own birth experiences, with the shortage of midwives, greater obstetrician control over private patients, and the time consumption of this practice emerging as key factors.
While some may look towards the independent or self-employed community midwife as a more viable alternative, the reality is that a history of restrictive midwifery legislation in Ireland has in effect discouraged independent midwifery practice. While the Health Service Executive (HSE) undermined the previous legislation by the Nurses and Midwives Association (INMO), which withdrew insurance coverage for independent midwifery practices, in its creation of a memorandum of understanding (MOU) granting indemnification for planned home births in Ireland, it nonetheless required all self-employed midwives to adhere to its ‘suitability criteria’ which prohibited, amongst other things, the performance of vaginal births after C-sections (VBAC) and breech births at home despite little supporting evidence. More recently, the Nurses and Midwives Act of 2001 explicitly required all registered midwives to have ‘adequate indemnity insurance’ to attend women during childbirth, a particularly difficult standard for home birth midwives who are not covered by private insurers; in order to secure their legal right to practice, home birth midwives are forced to abide to the MOU’s “suitability criteria” even in relatively isolated areas where access to “medical professionals” is limited.
This legislation has had the discernible effect of severely limiting the availability of independent midwives and home births in Ireland despite high demand. As of 2012, there existed only 20 midwives able and willing to use their professional autonomy to offer home births and only two hospital-based outreach schemes facilitating fewer than 80 home births annually. Recent personal accounts by self-employed community midwives (SECMS) attest to the isolation, vulnerability and anxiety associated with this under-developed independent midwifery practice. For instance, O’ Boyle (2013) found that self-employed community midwives (SECMS) or independent midwives experienced severe isolation and vulnerability in their practice due to their scarce numbers and geographical dispersion and lack of an identified midwifery supervisor or governance structure that would protect them from malpractice accusations. Thus independent midwives offering the only alternative to hospital-based births have not only been forced to practice alone but have also been forced to defend themselves with no overarching legal protection in accordance with the Nursing and Midwifery Board of Ireland’s “fitness to practice” hearings. The historic legislative and institutional maintenance of this consultant-led, hospital-based maternity system in Ireland raises the question as to the relative virtue of this system compared to its unexplored alternative: a midwife-led, out-of-hospital maternity system.
The Outcomes of Consultant-Led vs. Midwife-Led Maternity Services in Ireland
The expansion of alternative maternity care services emphasizing maternal choice and satisfaction in neighboring developed nations, such as the U.K. and the Netherlands, in the late 1990’s encouraged the development of the Maternity Services Review Group, later referred to as the Condon Group, by the Health Service Executive (HSE) in Ireland which, in turn, facilitated a series of legislations aimed at expanding midwife-led care in the especially North Eastern region of the nation. Unfortunately, focused on the Irish institutional framework for consultant-based care, the Condon Report recommended the closure of two existing maternity-care units in Louth Hospital, Dundalk and in Monaghan Hospital due to lowly number of annual births in an effort to centralize maternity care services in the region, an effort that has historically been aimed at increasing the “economic functioning” of maternity units. Despite the rejection of the Condon Report by the Health Board in 2000, the former Health Board withdrew insurance coverage and in effect closed the two maternity units in March of 2001 prompting an immediate and voluble reaction by local women who expressed their discontent through local action groups, media campaigns, petitions, and even legal action. This public outcry and demand for local maternity services led to the immediate establishment of a novel Maternity Services Review Group, referred to as the Kinder Group, tasked with investigating all maternity care service options considering the opinion of both maternity care experts and local women, thus representing a significant departure from the norm of lay person exclusion in Irish legislation. The Kinder Group recommended the establishment of two midwife-led units in Our Lady of Lourdes Hospital (OLOL) in Drogheda and Cavan General Hospital in Cavan, which would develop a uniquely strong relationship with independent home birth teams and integrate maternity service between themselves and general practitioners in the community.
Following the Kinder Group’s recommendation, the supervisory Health Board introduced the two midwife-led units (MLU’s) ‘alongside’ pre-existing consultant-led maternity units (CLU’s) in a randomized trial to assess their comparative rates of interventions, neonatal and maternal outcomes, cost-effectiveness, and maternal satisfaction, an endeavor referred to as the “MidU Study”. The primary researchers of this study, Begley and colleagues (2011), found that women cared for in the MLU’s were significantly less likely to receive continuous electronic fetal heart monitoring (EFM) or have their labor augmented through the use of labor stimulants, such as Pitocin, with no significant differences in adverse neonatal or maternal outcomes, such as low Apgar scores, resuscitation, instrumental birth, postpartum hemorrhaging or C-sections. Additionally, Begley et al. (2011) found that the higher augmentation rates for women in the CLU’s were not associated with a reduction in complications in the fetus or neonate or with a decrease in operative or instrumental birth rates, suggesting that these otherwise standard invasive procedures may be unnecessary in low-risk women.
Critically, these findings are in accordance with the international 2008 Cochrane Review which found, across 11 trials including 12,276 low to high-risk women, that women who received midwife-led care were not only less likely to receive obstetric interventions, such as instrumental birth, episiotomy, or regional anesthesia (e.g. epidural), and more likely to experience spontaneous vaginal birth, but were also no more likely to experience maternal and/or neonatal complications than women who had received consultant-led care. Begley and colleagues (2011) concluded that, in accordance with international findings, midwife-led care was as safe as the predominant model of consultant-led care in Ireland perhaps as a result of fewer obstetric interventions. If midwife-led maternity care is as effective as the predominant model of consultant-led maternity care in Ireland then what can be done to ensure its expansion? What pre-existing obstacles and new challenges must be addressed and overcome?
The Future of Midwifery in Ireland
As previously discussed, the underdevelopment of a strong, well integrated midwifery association in Ireland has contributed to the profession’s lack of influence over maternity care policies that, left unchecked, have produced a consultant-led, hospital-based maternity care system. Nowhere is the negative impact of Ireland’s weak midwifery association more evident than in the experience of the independent or self-employed community midwife who, without an identified midwifery supervisor or a governance structure, has no assured practice protection. Recent efforts have been made to compensate for this weak professional association in order to not only encourage the adherence of woman-centered practices by midwives operating inside maternity hospital units, but also, most importantly, to protect the practice of independent midwives offering alternative birth options. For instance, the Community Midwives’ Association (CMA) was founded in 2008 to develop collegial support for home birth midwives and to combine their largely separate efforts to influence the organizations currently regulating midwifery in Ireland, namely the Health Service Executive (HSE) and the Nursing and Midwifery Board of Ireland (NMBI). In 2009 the CMA published a peer review document that outlined a process whereby independent midwives could demonstrate continuing professional development and gain a degree of support and supervision through an annual review process as well as recently devised and delivered to their membership emergency skill and drill protocols for the home birth setting. It remains to be seen, however, the extent to which these supervisory efforts influence the national policies for midwifery developed by the NMBI and overseen by the HSE.
The recent influx of pregnant refugee and asylum seeking women in Ireland demands improvements in midwives’ cultural competence and sexual assault sensitivity training as well as increased clinical support, in terms of debriefing procedures, for midwives working with these often times traumatized women. Pointedly, recent studies investigating the experience of maternity care in Ireland by midwives and refugee and asylum seeking women have found that the lack of appropriate training on the part of midwives in both cultural competence and sexual assault awareness have contributed to poor and sometimes insensitive communication and treatment of refugee and asylum-seeking women and have also contributed to the extreme psychological distress these midwives often experience with little to no professional support whilst treating these often times traumatized women.
Tobin and Lawless (2014), exploring Irish midwives’ experience of providing care to women in the asylum process, argued that cultural awareness and competence training, which has been offered by the Irish midwifery curriculum since 2005, must be expanded so that midwives are not only made aware of the “facts” about other cultures, which they argue can actually encourage further objectification and stigmatization of their patients, but are also trained to be fully attentive to and respectful of women’s diverse beliefs, fears and goals when attending to them. Tobin and Lawless (2014) additionally found that not only were many Irish midwives ill-prepared to treat women with such extensive sexual assault histories but they importantly had no access to a formal system of clinical supervision or debriefing that would have supported their mental well-being and alleviated their sense of helplessness. Tobin and Lawless (2014) thus suggested the implementation of debriefing and other individual and group support systems. Adherence to these above recommendations would not only protect and expand midwifery in Ireland, as with a stronger professional association, but would improve it for both the midwife and the woman.
