Midwife Crisis

On the 1st of August 1997, Ann Kelly—one of Ireland's fourteen domiciliary or home-birth midwives—was informed that a High Court injunction had been taken out against her by the Irish Nursing Board. This injunction suspended her from the practice of midwifery, her full-time profession for the past 25 years.

Kelly hadn't been informed that the High Court case was even taking place. She had no legal representation at the hearing. Finding herself unexpectedly suspended from midwifery, she was unable to continue caring for the women she was already working with. She was not allowed to check up on a client who had given birth just the day before, nor could she attend another client who was miscarrying and needed her help.

Kelly discovered that the injunction was the result of four complaints made against her, two from a senior Dublin obstetrician and two from a matron of a maternity hospital. They accused her of delaying too long before bringing the women concerned into hospital. Kelly only knew about one of the complaints, and had been preparing a defence for the upcoming inquiry with her solicitor. Even though an inquiry into the complaint had not yet taken place, Kelly found herself suspended, guilty until proven innocent.

The case against Ann Kelly is remarkable for other reasons apart from the peremptory and seemingly unfair way that she was suspended. The four complaints made against her did not originate from the mothers whom they concerned, but from two professionals in orthodox obstetrics. Indeed, the mothers about whom three of the complaints were made have formally requested that the complaints be withdrawn, and one has already booked Kelly's services for her next birth. The fourth complaint concerned a woman who had attended a different midwife throughout her pregnancy, and was not a client of Kelly's, who was simply asked at the last minute to step in as "an extra pair of hands".

Even stranger is the fact that the Nursing Board insisted that Ann Kelly's expert witnesses would not be allowed to attend their fitness to practice hearing. Ann had to take her fight for the right to witnesses all the way to the Supreme Court, where she submitted that it was not just herself that was on trial, but the whole system of domiciliary midwifery. Last December the Supreme Court ruled in her favour, and now Ann's witnesses—who are highly respected experts in their fields, and include two professionals from the UK where Ann used to work—will be permitted to attend the Nursing Board's fitness to practice hearing when it eventually resumes.

Writing in support of Ann Kelly in The Irish Medical News (6/7/98), columnist Dr. Andrew Rynne has suggested that the complaints against Ann by hospital professionals may have as much to do with the antipathy many maternity hospitals have towards home-birth as with any real wrongdoing. He writes: "[Ann Kelly] may be being used as a discouragement to other private midwives attending at home-births in order to have the practice discontinued altogether." In another article (IMN, 21/9/98) he describes the "phenomenon of a global witch-hunt against home birth midwives by hospital-based professionals", citing the "ridiculous power struggle over women's rights to give birth to their babies at home if they should so choose". He notes that if, for example, a woman were to attend ante-natal clinics and then decide that she wanted to have her baby at home, she would not be allowed to do so.

Dr. Rynne considers what has happened to Ann Kelly as a new, more subtle and insidious version of the medieval witch-craze, in which thousands of European midwives lost their lives. "Is it not extraordinary," he asks, "that where the inquisitors of the Middle Ages left off, the obstetricians of today have taken up the persecution. The obstetricians today do not torture midwives, nor do they burn them at the stake. I understand that they are not allowed to do so. What they do is hardly less painful and terminal. They report them on trumped-up charges to fitness to practise committees and try to get them struck off, or at least suspended."

If the Fitness to Practise Committee does not acquit her of any professional wrongdoing when it resumes, Ann Kelly has stated that she will appeal the case to the High Court, and, if necessary, to the Supreme Court. After this, the case may be referred to the Court of Human Rights in Strasbourg.

Last year Ann received a standing ovation at an international midwifery conference held in London. Her case is being seen as a test-case of international significance. In order to be able to avail of her services, 50 Irish women so far have gone to the High Court to have Kelly's injunction lifted for their own individual cases, so that she might attend them during their pregnancies. She has garnered amazing support, in Ireland and the UK, from people in many walks of life, including those who believe that a serious human rights issue is at stake. So far her supporters have raised £28,000 to fund legal costs. They are determined to vindicate the rights of women to control their own births, and the rights of domiciliary midwives to continue to practise one of the oldest professions in the world.

"Women choose home-birth not because they want their babies at home necessarily," says Ann Kelly, the woman currently at the centre of the controversy, "but because they want to have them naturally."

This natural approach according to Ann is "a holistic approach. As domiciliary midwives, we take into account everything: the woman's emotions, her physical needs, her fears, her concerns, everything that's happening with her during pregnancy and during labour, and indeed, during the aftercare, and the care of her baby as well.

"Every woman is different, every labour is different and every baby is different. If it's a big baby, then it probably will take longer. We don't assume anything, because at the end of the day, women have got to decide for themselves what's right for them and their babies."

Personalised care is another factor that makes home birth so attractive, as opposed to the "production line" feeling that some women experience when giving birth in hospitals.

"Because it's personalised care, I can't take on any more than four mothers a month. And I tend to do quite a number of first-time mothers, so you need to give them time, not only in the ante-natal care but also in the labour, and in the aftercare. The aftercare is an extremely important time for them to get to know their baby and vice versa, and the changes within that family. So it's very much a continuity of one-to-one care from about 12 weeks of pregnancy.

"The philosophy around natural childbirth is quite different to medicalised approaches. A woman can come to me and say 'I want to have my baby this way or that way, in the pool, standing up or whatever.' So usually I say to her 'fine, no problem—but listen to your body.'

"I'm very much into spontaneity," Ann goes on. "A lot of times what is happening in labour is that your body is working at an instinctual level. I always see three people in labour: the mother as she is, and the mother who is working instinctually, and then the baby. So when she's in very heavy labour, she may not want anything. She may not even want you to touch her. And that's quite natural. She may have said before, 'I want my back to be massaged, I want this I want that,' but come the labour, she may want nothing at all. Whereas other women would love to be massaged, would love to be getting into water, and that's fine, whatever she feels like doing, that has to be respected. That's natural birth—to be able to be yourself, and to be able to follow what your body is telling you to do, rather than what the books say."

Ann explains why pre-birth care and counselling is as important as delivery.

"I prepare couples," she says. "These sessions are aimed at the father, because a lot of times it's the father who needs a lot of support, because this is happening to her, and he's never seen the woman like this before, and it can be quite daunting, especially the first time round. And if he feels that he's finding it hard to support his partner, it can be very difficult for him. And so he needs to be supported and prepared for what it may be like. It's important to get people into listening to themselves, and not be dictated to."

In domiciliary midwifery, men are seen as important members of a team, deserving of care and support.

"I feel a lot for the fathers, because I know the woman is fine—I've seen women like this many times, but he hasn't, and it's important that he keeps up his positive vibes, because if he starts going, 'Jakers, this is awful,' that itself can be communicated to the mother, and can create a negativity within her. So therefore I prepare him as much as possible, and I build up his confidence. Sometimes I support the father much more than the mother.

"While I'm doing the ante-natal care, I'm picking out problems that I do not want to have at home," Ann continues. "And also building up the confidence of the woman, and getting to know the family. So when it comes to the actual birth, a lot of my work has already been done. Before I take mothers on, I brief them first that nobody can guarantee a live, perfectly healthy baby. In my preparation sessions we go over the 'what ifs', and it's very important to discuss those cases."

Ann trained as a midwife in England, but a great deal of what she knows comes from having lived in Africa, and with Eskimos and Indians in remote parts of northern Canada, where traditional non-medicalised midwifery is still practised.

"When I came back from overseas," Ann observes, "I noticed that western women have this belief that because we only have two or three children, everything will be perfect. But with creation, there is always an element that things may not be right. You see this in any part of life, be it tree life, animal life, plants . . . it's the same in human creation. And I think because in western society they're given the impression that everything will be perfect, women get quite a shock when it's not. So we do prepare women."

Unlike indigenous cultures, western society has gradually taken away women's control over birth, institutionalising it into hospitals and clinics. Many women have unsatisfactory and sometimes frightening experiences giving birth in hospitals. They can be made to feel helpless, passive, and anxious that things are not happening the way the professionals tell them they should be. Domiciliary midwifery, on the other hand, treasures and encourages individual women's control.

"Essentially," says Ann Kelly, "I shouldn't say I deliver babies, because I don't. It's the woman who actually gives birth. I catch the baby."

Keri Doyle gave birth to her first child in hospital when she was 18 years old.

"The birth itself was fine, but I felt that they were trying to push certain injections on me. I remember saying at one stage that I'd sue if they injected me with anything. Even at that age I wanted to see if I could do it myself, though I had a really good doctor.

"I wouldn't say that I had a terrible experience, but it wasn't great either. I felt that they had taken the control away from me. It was like they were telling me that I needed drugs, but I didn't want them. And I was annoyed because I had no support about wanting to breastfeed. Nobody showed me how to do it; nobody told me that the milk doesn't come for three days. So I said to myself, the next time around, I'm going to have a home-birth."

Keri's mother, aunts and uncles were all born at home, so her family considered her request for a home-birth when she became pregnant again as perfectly normal.

Keri became a client of midwife Dolores Staunton. "Dolores was brilliant," she says. "She'd come in for visits and stay there for as long as I wanted. I had 100% trust in this woman. She listened, and made my partner and myself very relaxed about it. The birth was absolutely super. We hired a birthing pool, which I found brilliant. It was really relaxed and easygoing, no troop of people running around me, pulling my legs. It was lovely, and ever since the birth there's been a lovely energy in the house. And Dolores came over for 10 days in a row afterwards, and she showed me how to breastfeed."

Home-births were standard practice until earlier this century, but today, women who want to give birth at home are seen to be bucking the system.

"When I was telling people that I was having a home-birth, I felt I was jumping out of an aeroplane without a parachute on. People were looking at me as though I was mad. But I felt it was a very natural thing—people have been doing it like that for thousands of years. I believe that it should be encouraged."

Next issue: interview with Jo Murphy-Lawless, author of Reading Birth and Death, a controversial and often shocking new book charting the history and current state of obstetric practice in Ireland.