COVID-19: challenging Ireland to move from Mastership to Midwifeship

In 2019, Ireland recorded a total of 59,796 births, one of the highest birthrates in the European Union. At the outset of the pandemic, we could thus roughly estimate demands on reproductive services in terms of numbers, but we knew little about how COVID would impact those services.

We, three midwives and a sociologist with lengthy records of research, teaching and activism in Ireland related to achieving change in our maternity care structures, have surveyed national media and the five Irish online midwife and maternity support groups for women and related twitter and Facebook comments as primary source data for our analysis of the changes set in place because of COVID-19. 

Ireland’s maternity services are virtually all hospital-based, obstetric-led services. They are based in five standalone maternity hospitals and fourteen acute general hospitals with a maternity unit. We have two small alongside midwifery units (known as ALMs for short) attached  to hospitals. Scotland, with a similar population, has 26 such midwifery units. By comparison, there is very limited scope for midwifery-led care in Ireland, even though this form of care leads to fewer unnecessary birth interventions and better birth outcomes. Maternity care in Ireland is free at the point of use, but just under half of women opt to pay for private obstetric care based in private wings of public hospitals because they want one-to-one care. Home birth is rare. Approximately 270 women per annum give birth at home, mostly availing themselves of a limited state-financed, state-insured scheme administered by the Health Services Executive (the HSE is the national administrator for all health services) with strict entry criteria. The midwives who support women at home are known as self-employed community midwives (SECMs) and are insured by the HSE. A tiny number of women opt to pay for completely private midwifery care in their homes.

At the national policy level, maternity care has scarcely ever figured in Irish social legislation.

The backdrop to this policy lacuna has several elements. The first is a legacy extending to the eighteenth century and the so-called “Mastership” system of the three major maternity hospitals in Dublin. All three hospitals were originally philanthropic medical charities. All three awarded the title “Master” to whichever obstetrician of senior rank and status was elected by his obstetric colleagues to run the hospital for a seven year term. There was no woman Master until the beginning of the second decade of the twenty-first century. Despite increasing numbers of female obstetricians, all three hospitals have retained thcontroversial title and system of Master/Mastership.

The paternalistic, patriarchal influence of the Mastership system and the historical weight given to the reputation of the Dublin hospitals influenced how maternity services in hospitals across Ireland evolved. Obstetricians set policies for maternity units into the twenty-first century. In a hierarchical organisation, midwifery has been consistently subordinated to the obstetrics profession, and midwives have never had the same status or decision-making power that obstetricians enjoy. The majority of midwives have trained and worked in hospitals, which have been overwhelmingly task-oriented according to obstetric criteria rather than oriented towards woman-centred one-to-one care. The second element has to do with a state-led patriarchy, heavily influenced by Catholic ideologies, which shaped Irish governmental policy and social attitudes into the late twentieth century.

Consistent activism in recent decades on the part of women and midwives, along with growing evidence in favor of the benefits of midwifery-led continuity of care, and the establishment of our two AMUs, all played a part in the crafting ofIreland’s first comprehensive national maternity care strategy, published in 2016. This policy recommended an expansion of ALMs units, which would give women one-to-one care. Following the publication of the 2016 national strategy, an encouraging development has been the growth in membership of the Community Midwives Association and the Midwives Association of Ireland (MAI), each serving as a platform for midwives’ voices for reform. Yet progress toward midwifery-led continuity of care remains achingly slow. We still have only two ALMs units.

COVID-19 has exposed many fissures in this archaic system, opening up possible space for reform. With the urgent need for the redeployment of midwives due to the public health emergency, critical opportunities emerged to meet women’s pregnancy, labor and care needs, to create genuine continuity of care, and thus to allow a considerably strengthened role of midwives which we are terming midwifeship, that is, midwives enabledtopractise to the full extent of their skill.      

Given the aforementioned organisational rigidities and deficits, along with problems of chronic understaffing and a long list of other pressing matters for maternity services, which the MAI documented in February 2020, COVID-19 was going to create substantive challenges. With an almost one hundred per cent hospital-based cohort of women, personal protective equipment (PPE) shortages alone caused great concern for midwives, as did the need to redeploy staff to replace midwives needing to quarantine when they contracted the virus. Providing full midwifery cover for pregnant women while minimizing women’s risks of exposure to the virus meant that antenatal care needed to be moved out of the hospital and into the community.  In March, 2020, the MAI produced a series of proposals to the HSE in which they outlined how midwives could be redeployed quickly to create much-needed flexibility while protecting pregnant women and women in labor.

The HSE did not reply to the submission of the MAI proposals and did not implement them nationally, but several hospital units did expand midwifery care to community settings, which they intend to keep in place. Another positive outcome was the small but steady increase in women seeking out the HSE national homebirth service.

There were, however, a number of retrograde moves by individual hospitals related to confusion about how the virus might be transmitted. In online forums, midwives and women were dismayed when some hospitals imposed outright bans on partners attending births. Hospitals that did not expand community antenatal care relied on telephone consultations to reduce traffic in hospital clinics. In online forums, midwives expressed their concerns about this development. They found these consultations challenging and were especially concerned about the emotional distancing these could entail and how they eliminated the chance to observe physiological changes, or subtle indications of domestic violence or mental health issues. Midwives’ comments online now show concern  that hospital authorities will see telephone consultations as the way forward post-COVID, as a more “efficient” approach to antenatal care.

In fact, Irish maternity services require the full implementation of the 2016 national strategy as soon as possible, which would bring about rapid national expansion of midwife-led continuity of care, with more ALMs. An evidence-based policy, this would give women one-to-one care as proposed in the strategy, and it will substantially improve outcomes for women while being cost-effective.  

Towards the end of lockdown, news broke that one of our two ALMs, in Cavan Hospital, was being “merged” with the hospital’s consultant unit, and that no further bookings were being accepted for the midwifery unit at all. Senior hospital officials had ordered the closure without consultation with the National Women and Infants Programme in the HSE and without consultation with the Minister for Health. The closure ran entirely counter to the national strategy which had called for more ALMs. The closure indicated the power held by local obstetricians if they are not challenged.

There was an immediate and heartening response to this shocking development. Childbirth groups and the MAI made representations at once to the HSE and the Minister for Health.  They organised a petition, which garnered over 10,000 signatures in three days, and elected legislators wrote to the Minister for Health objecting that this covert move would effectively kill off the National Maternity Strategy. In response, the Minister for Health replied with absolute clarity in Dáil Eireann that the unit would not be closed, that midwifery-led care via ALMs and community midwifery would be the future of our maternity services, and that he would meet with the midwives the following day. It was a stunning endorsement for Irish midwifery, left behind for so long. A small number of obstetric consultants also came out on social media platforms in support of a greater collaborative working relationship. 

COVID-19 forced many areas of the health services to change quickly. Against the odds, Irish maternity services have begun to open up, and there have been some clear gains despite restrictions imposed at the outset. Midwives and women challenged these and pushed for far greater out-of-hospital community midwifery care. The swiftness with which the crisis about Cavan’s midwifery unit’s closure was resolved points to a shift at last away from the older culture of Mastership, where obstetric voices absolutely dominated.

As Ireland makes the transition to living with COVID long-term, the force of what remains a major public health emergency will substantially re-shape maternity services in line with what the MAI put forward at the outset of the pandemic. We are hopeful of midwives’ determination to ensure these changes will displace the hierarchical Mastership system with midwifeship instead, opening a terrain of increasing skill and confidence for midwives to work in partnership with pregnant Irish women and on a more equal plane with their obstetric colleagues.  

Jo Murphy-Lawless, PhD is a sociologist who has taught about and written extensively on childbirth and maternity matters. She currently works with the Centre for Health Evaluation, Methodology Research and Evidence Synthesis, NUI Galway.  She is a member of the Elephant Collective and co-editor of Untangling the Maternity Crisis (2018).

Jeannine Webster is a practising midwife, mother and social activist. She has a special interest in supporting pregnant women coping with domestic violence and in mental health outcomes in pregnancy. She has written a number of policy submissions on key aspects of governance and midwifery structures in the Irish context. Jeannine is a founder member and current PRO of the Midwives Association of Ireland.

Patricia Hughes is a Midwife with over 30 years’ experience at clinical, managerial and executive levels. She has worked in the UK, NZ and in Ireland. She now runs her own business “Midwifery & Nursing Expertise” and is the current elected Chairperson of the Midwives Association of Ireland. 

Declan Devane is the Director of Evidence Synthesis Ireland and Director of Cochrane Ireland. He is Chair in Midwifery and Deputy Dean of the College of Medicine, Nursing and Health Sciences at NUI Galway. He is also Scientific Director of the HRB-Trials Methodology Research Network, and Principal Investigator with the INFANT – Irish Centre for Fetal and Neonatal Translational Research.