To mark Mother’s Day, Helen O’Callaghan talks to midwives and experts about the growing woman-centred Domino service in Ireland.
ONCE pregnancy’s confirmed, more and more women living within 10km of Cork University Maternity Hospital are phoning to get on its Domino service.
Since Domino started at CUMH in June 2014, 488 women have used domiciliary care in and out of hospital (on an annual basis, the service accounts for 6.1% of total births).
“Demand is growing — much is by word of mouth. I get phone calls from women saying ‘my sister was on it, my friend was’.
"They ring as soon as they get pregnant to ensure they get on it,” says Martina Dillon, clinical midwife manager at the Domino service.
For healthy women at low risk of pregnancy complications, Domino offers the same team of four to five midwives to care for them throughout pregnancy up until the week after baby’s born, as well as one-to-one midwifery care throughout the birth.
“These women are highly motivated to give birth in the most natural way they can — they’re empowered towards non-intervention,” says Mary Jeffery, another clinical midwife manager and who oversees CUMH’s Domino service.
While Domino — run by a team of nine midwives — is separate to the consultant-led service, it works in close partnership with the doctors.
So if a woman needs to change to consultant care for the safety of mum/baby during pregnancy/labour, that’s what happens.
And once the reason for transfer has been safely dealt with by the consultant, the mum can return to Domino for the post-natal period.
“Midwife means ‘with woman’ — we’re with her every step of the way. This builds great rapport and trust,” says Dillon.
At this time of great transition, with a woman journeying towards motherhood, the value of the known, trusted face of a small team of midwives is enormous.
“If I’m a total greenhorn — never been pregnant before — they become a real anchor for me, a real source of learning,” says Jo Murphy-Lawless, sociologist at Trinity College Dublin’s School of Nursing and Midwifery.
“Giving birth is such a fundamental shift. At a moment when a great life demand is being made on you, to see a known face gives great confidence and self- belief and sense of safety.”
Domino is about getting women to a place where they understand ‘how my body works and how I can help birth this baby’.
At CUMH, Domino midwives don’t use the word ‘deliver’ — instead they talk about ‘birthing the baby’.
“Right through pregnancy, we encourage women to be empowered, we allay fears, we instil confidence,” says Jeffery.
This includes re-framing ‘pain’.
“The word ‘pain’ has negative connotations. We call it ‘a surge of a contraction’ — reminding women contractions won’t be really long, they’ll get breaks, and every contraction gets them nearer to when they’ll hold their baby in their arms.”
Domino-eligible women are those with straightforward pregnancy.
Excluded, for example, are women who had previous Caesarean section, who are expecting twins, who have more than five children (greater blood-loss risk).
Women also exclude themselves — a big reason would be if they want epidural.
“Number one reason for transfer [out of Domino] is for more pain relief if the woman finds labour too intense — it’s usually with first-time mothers,” says Dr Krysia Lynch, chair of the Association for Improvements in the Maternity Services.
A woman in the Domino scheme can change to obstetric-led care at any stage.
“We have yet to meet a woman that wants to,” says Jeffery.
For pain relief, the most popular go-to measures are water immersion in pool, use of gas and air, and TENS.
Most women entering pregnancy in Ireland know little about midwifery-led care or about continuity of carer and the value of these, from ante-natal through to post-natal phases.
“There’s a myth that obstetric-led care is best — midwives don’t have a high profile in Ireland,” says Murphy-Lawless.
“Women know they have a choice between going public and private — they don’t understand a great deal beyond that.”
About 40% of women opt for private obstetric care, believing they’ll get individual attention and care.
“They’re more likely to end up with a higher number of interventions in labour without clinical need and with C-section without clinical need”.
A 2014 Irish study found, among women going private, all forms of labour induction were higher, as was epidural use.
Episiotomy rates were substantially higher and women were almost twice as likely to have elective C-section.
British research found 75% of women in midwifery-led care had normal births compared with only 58% of low-risk women giving birth in consultant-led units.
One intervention often leads to more, says Murphy-Lawless.
“C-section is safe but it’s major abdominal surgery and needs lots of recovery time. A woman needs significant pain relief for 48 hours after giving birth. She can’t easily lift her baby. It leaves her having to catch up with herself.”
Lynch says giving birth is a momentous event requiring a lot of women.
“It’s much easier to engage with a difficult, intimate event if you feel you can trust those around you. If you feel you can’t trust someone not to do something [clinically intervene when unnecessary], you’ll feel stressed.”
The uterus doesn’t do well with stress hormones, she says. “It needs oxytocin — released when a woman feels mellow and safe. Oxytocin makes the uterus contract — otherwise, labour is prolonged.”
After intervention-free birth, women feel well and go home much faster, says Jeffery.
At CUMH Domino, women generally transfer home six hours after giving birth and on each of five consecutive post-natal days a Domino midwife visits.
Lynch lists benefits of fast home transfer: “You’re in familiar surroundings, just you and your baby. You don’t have to listen to everybody else’s baby or put up with their visitors.
"There’s lower infection-risk. If you’ve got other children you’re not separated from them.”
Hospital post-natal care is “awful”, says Lynch, because of woman-to-midwife ratio. Midwives are run off their feet, dealing with the aftermath of medicalised childbirth.
A woman after normal birth, needing help with breastfeeding, is well down their list.
“She rings the bell — she might get five minutes. In comparison [Domino] midwife home visits are quite long.”
One-to-one care on home visits means at least 30 minutes to talk about anything bothering the woman.
“It’s good for emotional health. The midwife, knowing the woman, will notice if she’s not her usual self. She’ll engage with family members. She’ll give tips and they’ll benefit too.”
Following high-profile failings in delivery of safe, high-quality care in maternity services — baby deaths at Midland Regional Hospital, Portlaoise, and the death of Savita Halappanavar at University College Galway — HIQA published National Standards for Safer Better Maternity Services in December 2016.
In designing these, HIQA met 138 people comprising frontline staff, women, and their partners.
“Women want to be partners in their care. They want to be listened to. They want good quality, evidence-based information so they can make informed decisions about their care,” says HIQA standards manager Linda Weir.
Women also said what they liked and didn’t like about current services during the public consultation phase (survey of 1,324) of the National Maternity Strategy, launched in January 2016.
They liked the dedicated frontline staff, the free access to care under Maternity and Infant Care Scheme. They liked community midwives/Domino and early hospital discharge.
They didn’t like lack of choice, overmedicalised childbirth for low-risk women, overcrowding, lack of resources/staff (clinic is “like cattle — check, prod, go”), poor engagement with women as partners in care, and poor breastfeeding support (“exacerbated by ready provision of infant formula in hospital”).
The National Maternity Strategy promises each mother choices/options about her care, according to whether the pregnancy’s normal, medium, or high-risk.
Midwife numbers will increase by 100 a year. Murphy-Lawless believes the strategy’s compromised.
“It doesn’t talk about midwifery-led care. It talks about woman-centred care.”
Which is OK, she says, but she sees a subtext.
“Maybe obstetricians [in private practice] are unwilling to share the professional stage with midwives.”
However, much of the support for midwifery-led units has come from obstetricians, many of whom have a public and private practice.
Dr Peter Boylan, chair of the Institute of Obstetricians and Gynaecologists, says: “Most doctors would be keen to have births in hospital, particularly for first-time mums. The Domino system is a great compromise for women.”
Consultant obstetrician/gynaecologist Professor Declan Keane was master in Holles St when Domino was introduced in 1998.
“We wanted to increase choice and reduce time in hospital for low-risk women both before and after birth.”
The service has been hugely successful, extending its catchment and inspiring approaches in other Dublin maternity hospitals.
Keane says the greatest problem in current maternity services is inequality across the State’s 19 maternity units.
“In Dublin, Cork, and Galway, we offer the routine 20-week scan — that’s not available in six of the 19 units in the country. It needs to be corrected.”
(Under-resourcing in Cork means about half of new mums are offered the scan.)
Depending on where women live, options are variable — services aren’t equitable, says Lynch. “For women in the north-west, the only option is local hospital care — no home birth option, no Domino, no early transfer home, no midwifery-led care.”
Of the 19 maternity units, two are midwifery-led. Versions of Domino exist in about seven further units. In Britain, Domino is “absolute standard care”, says Murphy-Lawless.
“Scotland has roughly the same population as us — they have 19 midwifery-led units. In the Netherlands, 30% of births are at home — for low-risk women.”
For such women, midwifery-led care is “unquestionably the best”.
Here, Lynch would like improvements in Domino — more midwives to extend it, birthing pool in all hospitals, and review of Domino-excluding criteria for some women.
“A small fibroid, for example, shouldn’t affect labour.”
Women in midwifery-led care are less likely to experience post-natal depression and more likely to be confident new mums, says Murphy-Lawless, citing British research.
“That makes a difference to so much, whether they breastfeed, bonding with baby, how competent they feel taking their child through first months of life.”
At CUMH, Domino midwives speak of immense job satisfaction. “If you’ve been with a lady in labour a long number of hours, it’s lovely to be present for the birth of her baby,” says Dillon.
For Jeffery, it’s a privilege “to be involved with women in this experience of pregnancy, labour, and birth”.”
Giving birth is a team effort
Douglas-based mum-of-one Mary McGahern, 37, used CUMH Domino having five-month-old Lily Rose.
“The idea of natural birth appealed — I’m quite holistic. I find it important to have a relationship with someone, especially with something so intimate and huge in my life.
“My worry was ‘what if I’m not able to give birth naturally’. The midwives said my body was designed for it — they’d be there to help. They emphasised preparation.
"I did spinning babies — exercises to better position baby’s head — and yoga to help muscles and breathing. I spent much of the last trimester sitting on an exercise ball. I had very little discomfort at the end of pregnancy — I just felt healthy.
“In ante-natal classes, Lynda said ‘it’s about Dad too, it’s a team effort giving birth’, which was great — Brian’s a sergeant in the army and needs a plan.
“I started contractions at 8am. I waited a good few hours before ringing Domino and talking to Liz. She said to stay at home as long as I could. I found it hard sitting still or lying down. Constantly moving helped.
“Lynda had explained when you can’t talk through a contraction, it’s time to go to hospital — even Brian knew when it was time. I went at 7pm.
“I said I wanted an epidural. Lynda asked: ‘Are you sure? Brian had a chat with me — ‘remember you wanted a natural birth? Do you want to go into the birthing pool? Will we just try?’
"The minute I put my foot in, it was a game-changer. The pain was much more manageable.
“When I asked should I be pushing, Lynda said: ‘Mary, this is your birth, your body, you do whatever you want’.
“She was checking baby’s heart rate every 10-15 minutes. I was doing my own thing in the pool. Lynda and Brian were chit-chatting among themselves — it was all very pleasant and sweet.
“I got up and said I’d like to get out of the pool. I said ‘I’m ready to meet her’. They have a pole. I held onto it and pushed. It was tough — I had to find a good bit of stamina but I didn’t have to push for long.
“Lynda said, ‘the head’s out Mary, don’t push anymore, put your hands down and birth your daughter and bring her to your chest’ and I did. It was amazing, so empowering. She was born at 10.21pm.
“We were sitting in the Blackrock Inn at 11am the following morning having breakfast. I bounced out of that hospital. If I ever give birth again, I want to go exactly the same way.”
Midwife Liz Clancy: “On the phone, you want to ensure the woman’s coping with contractions. Has baby got the right movement?
"Each baby has its own pattern. During ante-natal visits, we’d have sussed out what’s normal for hers.
"If the woman’s able to keep talking — contractions aren’t stopping her in her tracks — you’re able to reassure her: ‘Yes, these are early contractions but you have a long way to go, so it’s important to eat, get himself to rub your back, have a bath, some Paracetamol and go to bed’.
"Labouring like this at home, a woman’s muscles are suppler, she’s more hydrated, her mind’s more active — she really gets in the zone. When she comes into us, there’s this focus in her face. She sees a familiar face and she’s happy.”
Midwife Lynda Moore assisted Mary in birthing her baby: “I really want women to have the kind of birth they want. A mother remembers her birth forever — the better it is, the more it stays.
"During labour you have to be in the moment. It’s intense and all-consuming, especially for the woman. There’s a key moment in labour, when a woman can easily go along with medicalisation, like epidural.
"But we know these Domino women all along wanted a birth without epidural so that’s the aim. A natural birth’s a very powerful experience, it’s very enhancing to a woman whenever she births the way she wants to.”
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