Áine O’Sullivan is not the first mother to say “never again” after giving birth. But she felt so traumatised by the experience in hospital that she was adamant, if she were ever pregnant again, it would have to be different second time around.

When she was expecting her first child, Matthew, who is now four, she knew little about birthing. Her mother had plenty of positive things to say about giving birth in hospital. “I assumed that I would be the same. All my research was into what buggy to get and what maternity clothes to wear.”

She was certain of the conception date but when she was given an “averaged” due date while booking into a Dublin maternity hospital, she didn’t question it. In hindsight, that may have been the start of her problems.

At 14 days over the due date she was told she had to be induced, although she believed she had another five days to go before reaching the 42-week limit. Her waters were broken and, although nothing started for a while, “when it did happen it was very intense” and she asked for an epidural.

“I was terrified and I was on my back on a bed.” She didn’t know anything about the advantages of being active in labour.

It was night-time and she recalls that there were no blinds or curtains drawn on the huge windows in the room and, with apartments across the street, “I had a really big sense that I wasn’t private”.

It got to the stage “when he just wasn’t coming out and I had to have ventouse twice and then forceps”. By the end, she says, she felt dehumanised.

“I didn’t feel any connection. It wasn’t my birth. It was like an out-of-body experience.”

Benefits of natural birth
Afterwards, through a breastfeeding group, she started learning about the benefits of natural birth.

“Before that, I had seen it as more of a lifestyle choice.” But at that point she began to understand why women would aim for one. She wasn’t sure a home birth would be for her, but says “as soon as I knew I was pregnant a second time, I rang an independent midwife”.

Having researched the options, she felt the HSE’s home birth service, which includes registering with a hospital, was the best choice. “It was really about the safety and as little intervention as possible.”

Apart from a couple of hospital appointments, her ante-natal checks were at home in Dublin with the midwife, with whom she built a close relationship.

She and her husband, Diarmuid, did a “Birthing from Within” course with a doula (birth assistant) who would also attend the birth. Then, if a hospital transfer were needed, the doula could go into the delivery room with her “and that meant the world to me”, says O’Sullivan. “I felt all aspects were covered.”

Going into labour 11 days after her due date, this time was “brilliant”. “I felt like it was my birth and my baby’s birth,” she says of Evie’s arrival after just six hours.

Some people tell her she was brave to have a home birth but she thinks it was the opposite, doing it where she felt safer.

"I feel, as an Irish woman, there is no knowledge about birth for us," she says. "All the knowledge is about how to be managed, which is really sad, now I see it from this side of things."

Aims
Krysia Lynch, co-chairwoman of the Association for Improvement in Maternity Services (Aims) Ireland, says her mantra is that women will give birth best in the place that they feel is safest for them.

“If a woman feels a heavily medicalised hospital setting with lots of white-coated doctors around makes her feel safe and gives her reassurance, her body is going to respond accordingly,” she explains. “And if another woman feels that frightens the hell out of her and she would feel better in a homely setting, whether that is actually in her home or a home-from-home in a hospital, that will make her feel safe and her body will respond to that.

“So it is not saying one is better than the other. It is just saying you need to find what makes you feel safe.”

The polar extremes of O’Sullivan’s two births are the types of stories Aims tends to hear but may not be representative of the average delivery.

“One of the things we have noticed is that a lot of people come to us, either because they have had a brilliant experience or because they have had a very difficult experience,” says Lynch.

This is why she hopes “middle Ireland” will participate in the new Aims online questionnaire for women who have given birth here within the past five years. “What Matters to You?”, which is open until the end of June, is the largest consumer survey of maternity care ever carried out in Ireland, says Lynch.

The feedback will be used to inform hospitals and the HSE.

Women are invited to share their views and experiences by answering 101 questions covering antenatal care, labour and birth, and postnatal care. No matter how or where you gave birth, Aims wants to know how you rate it.

“I think a lot of women believe that the organisation is only for supporting women who want a drug-free labour, and that is not true,” says Lynch.

“We want women who are going to have obstetric-led care to have the best possible obstetric-led care . . . and for their obstetric-led care to be evidence-based and for those women to be happy afterwards and for them and their babies to be well,” she says.

That is why, for this self-selecting survey, she is particularly encouraging participation by women who have had a reasonable experience: “There were perhaps things they liked and a few things they thought were a bit off, but they are not motivated enough to do anything with that information. That is what this survey is trying to catch.”

Where you live is likely to have a significant bearing on your maternity care choices, even before medical history or pregnancy health are taken into account. Unless you live in Dublin, where there are three public maternity hospitals, the chances are there is just one maternity hospital within a reasonable driving distance.

Maternity and midwife care
Obstetric-led care is prevalent in the Republic's 19 public hospitals that provide maternity care, while some offer midwifery-led care services.

Home birth is not common, accounting for fewer than 200 of the 71,986 babies born in the Republic in 2012.

“The majority of people in Ireland perceive that the normal person to attend you in a normal birth is an obstetrician. In fact, the normal person to attend you in a normal birth is a midwife,” says Lynch.

Even within obstetric-led care, individual hospital policies may determine a woman’s birth experience.

In a country with a broadly homogeneous population, there is no other explanation, says Lynch, for the regional variations in medical interventions.

For example, 2012 figures for all those 19 hospitals, obtained from the Health Service Executive last month by Aims under the Freedom of Information Act, show that the Caesarean rate for first-time mothers ranged from a low of 22.95 per cent in Sligo General Hospital to a high of 40.15 per cent in St Luke's Hospital in Kilkenny.

Among women who had a Caesarean delivery, some 33.86 per cent had a vaginal birth after Caesarean (Vbac) with a subsequent baby during 2012 at the National Maternity Hospital (NMH) in Dublin, while three hospitals – Castlebar, Letterkenny and Mullingar – registered a Vbac rate of zero.

An episiotomy was performed on 9.4 per cent of all women giving birth at Wexford General Hospital but in the NMH the rate was 22.65 per cent, while the instrumental rate for deliveries in first-time mothers ranged from 36.64 in Cork University Hospital to 19.94 in the NMH.

Post

nat al depression
The fall-out from difficult or premature births is something that counsellors with the charity Nurture see in their work with women experiencing post-traumatic stress or post

natal depression.

"Yes, there are great deliveries out there but unfortunately we get the calls about the bad ones," says Nurture's chief executive, Irene Lowry.

She set up the organisation with Lilian McGowan in 2011. This was prompted by the deaths, by suicide, of two women who had been suffering postnatal depression for many months before coming to her counselling practice.

Nurture, which operates in 14 counties, offers timely and affordable counselling and will see a woman (or a family member), who is highly distressed, within 24-48 hours.

Apart from one-to-one counselling, it runs 10-week support groups for affected women, who will then often continue to meet as friends.

“Our aim is to destigmatise this area of mental health, says Lowry, who attributes some of the problems to lack of communication in overstretched, understaffed maternity hospitals and the fact that women are discharged so soon after birth. She also believes new mothers are set up to think they will be “superwomen”.

“The reality is you will have cracked nipples; you will be stitched; you will be tired; your baby may not sleep. And those with post-traumatic stress disorder having flashbacks to the birth don’t even realise what is going on and are unable to talk about it.

“They are so isolated, in their minds and in their lives.” But, if they get the chance to talk to a counsellor, they can begin to understand and share the burden.

To fill out the Aims Ireland survey, see aimsireland.com.
For more information about Nurture, see nurturepnd.org.

swayman@irishtimes.com

‘I want a ventouse delivery and without any pain relief’

Sian Eustace, who lives in the Burren, Co Clare, has had two hospital births because she didn’t have any other option. But her ideal would have been to use a midwifery-led centre like those available in her native UK.

She had a very long labour with her first child, Olivia, who was facing the wrong way, and feels she was lucky with the midwives who cared for her in the Galway hospital as they did everything they could in supporting her in the natural birth she wanted. Without their efforts, she is sure she would have been told she needed a Caesarean section.

"But I did end up having to have a ventouse delivery," she says, although she argued successfully that it should be done without pain relief, as she feared pethidine would affect the establishment of breastfeeding.

Two years later, when she looked into having a home birth on her second pregnancy, she found out her hospital notes said she had had a post-partum haemorrhage, of which she wasn’t aware.

This precluded her having a home birth and she was devastated.

“I don’t think it is too strong to say I felt it as a grief;” even though, she stresses, there had been positive aspects to the hospital experience the first time.

The birth of her son, Levi, who is nearly one, turned out to be very similar, albeit after a labour that was only half as long. He too was facing the wrong way, so she was slow to progress again, but this time she was put on syntocinon, which she hadn't wanted.

Labour speeded up and the pain rapidly became more than she could bear.

“The baby was very low down but didn’t seem to be coming any further. And I said the words that I never thought I would say: ‘I need you to go and get the ventouse.’”

She then had a long discussion with a doctor who insisted ventouse was not possible without pain relief but, because she had done it before, she was able to fight her corner.

“It wasn’t hugely pleasant but it was fine and my baby was born within five to 10 minutes and I was really glad that I had stuck to my guns.”

Home birth helped end the ‘disconnect’ of hospital

When Liz Morrin was expecting her first child in 2011, she read “loads” about pregnancy and very little about birth.

“I had this assumption that things would go as they were meant to go and doctors would tell you what you needed to know.”

She had pre-existing high blood pressure and when she became pregnant in her native US, she had to change her medication. But after moving to Ireland a few months later, hospital staff did a “double take” at her first scan and said the baby was measuring small.

“Then it was scans every other week for the rest of the pregnancy.” Her blood pressure continued to rise and she was induced at 36 and a half weeks.

Labour was "a nightmare". She was feeling contractions but they were not showing up on the monitor, so she think s staff did not believe she was in pain.

"I felt really, really small and ignored through the whole thing." She told them her waters had broken but again they didn't seem to believe her.

Caesarean section
Finally she did have "readable" contractions, during which the baby's heart rate was dropping, so they took her to theatre for a Caesarean section.

She held her daughter, Madison, for about three minutes before the baby was taken to special care for two days, during which Morrin managed to shuffle very slowly down the hallway once to see her.

Being her first baby, she didn’t have any concept of what she had missed during those two days. After eight weeks of pumping breast milk and feeding with bottles, she finally managed to establish breastfeeding.

When Morrin became pregnant again last year, she says she was "quite frightened" and decided to go private, finding a consultant who was supportive of trying for a Vbac (vaginal birth after Caesarean).

“I needed to know that the doctor knew me, knew my pregnancy history and I would have some control over the decisions made.”

This time she read “absolutely everything” and she and her husband, James, did an active-birth workshop.

Labour at home
At 41 weeks she went into labour at home in Dublin at about 1am but didn’t leave for hospital until about 9am.

The baby was facing the wrong way and progress was slow and painful. She had an epidural, which allowed her some rest.

The consultant was “brilliant”, she says, and kept trying to buy her more time before, under hospital policy, he would need to perform a section.

After the epidural was increased in preparation for theatre, she was told they would try on two more contractions to deliver the baby first.

Ventouse on the first of those contractions didn’t work, but baby Gráinne arrived on the final one, with the help of forceps.

Morrin was very relieved to have avoided a section and recovery was so much quicker.

“I felt like I had given birth to her,” she adds.

“I know that seems ridiculous but it was like a disconnect the first time round.”