The Context and Consequences of Professional Indemnification of Home Birth Midwifery in Ireland

Abstract

PURPOSE: The indemnification of home birth midwifery practice is a concern internationally. This article reports on recent changes in the indemnification of home birth in Ireland. A background history of maternity services in Ireland is given. Home birth midwives’ own perspective on the withdrawal of trade union indemnification and the instigation of a means of state indemnification are offered. The notion and expectation of professional clinical indemnification is discussed using Eliot Freidson’s theoretical framework on professionalism.STUDY DESIGN: Indemnification is just one concern identified in an ethnography of independent midwifery in Ireland carried out between 2006 and 2009. Participant observation and interview supply data from the midwives themselves in that period. Documentary sources including health service reports and changes in Irish statute also form part of the ethnography and this article. Subsequent developments in what has been called a “national home birth service” are reported.MAJOR FINDINGS: Home birth midwives report that professional clinical indemnification is impossible to access on the open market. They are unwilling to practice without it, not least because legislation in the European Union and Ireland, requires that midwifery attendance at birth is “adequately insured.” The midwives feel that indemnification neither improves their practice nor guarantees good practice. They feel caught in a dilemma that they are now effectively criminalized if they attend any woman outside the narrow suitability criteria set by the Irish Health Service Executive (HSE).CONCLUSION: State indemnification of home birth midwifery practice now in place in Ireland is very positive. The nominally “national” home births service, however, is entirely dependent on a small number of self-employed community midwives. The service is therefore not available to all of those considered eligible. The home birth midwives report frustration at the exclusionary effect of tying their indemnification to narrow suitability criteria. Freidson’s conception of professionalism demonstrates how it is contingent on government and market forces. Midwives’ professional concern to be “with woman” is shown here also to be vulnerable to these competing external factors.