The strategic policy direction for maternity care in Northern Ireland is contained within the Maternity Strategy for Northern Ireland (Department of Health, Social Services and Public Safety (DHSSPS), 2012). A review of maternity services in Northern Ireland, carried out in 2011 and co-chaired jointly by Professor Cathy Warwick of the Royal College of Midwives (RCM) and Dr Paul Fogarty of the Royal College of Obstetricians and Gynaecologists, highlighted wide variations in the care provided by different maternity units in Northern Ireland. Despite Northern Ireland being a small, self-contained geographical area, women's choices in relation to maternity care varied widely depending on where they lived. The availability of midwife-led care (in either a free-standing or alongside midwifery unit) was not consistent across Northern Ireland, and obstetric intervention rates in maternity units varied widely. A report from the Northern Ireland Audit Office (2014) highlighted that the caesarean section rate ranged from 22.9% to 35.8%, with an average of 28.4%.
As a direct result of the review findings, the then Health Minister commissioned the development of a multidisciplinary, woman-centred maternity strategy which, following an extensive consultation process, was published in 2012. The strategy has six clearly defined outcomes:
However, the publication of the strategy in July 2012 was only the beginning of an ongoing process. The establishment of a Maternity Strategy Implementation Group (MSIG) and the appointment of a project manager have ensured that the strategy is a living document, which provides a clear pathway for those working in the maternity services. Northern Ireland has experienced a further and ongoing development of midwifery-led care and now has eight midwife-led units, including three free-standing community midwifery units. Midwives in Northern Ireland are currently working with the RCM as part of the Better Births Initiative to develop information in relation to maternity care choices for women, and a community maternity care steering group is overseeing the transfer of maternity care from hospitals to community settings, with women with low-risk pregnancies encouraged to opt for midwife-led care and women with more complex needs having their care provided by a multidisciplinary team in the most appropriate environment. The Community Maternity Care Project is developing a Core Pathway for Pregnancy Care, and the Guidelines and Audit Implementation Network (GAIN) has funded the development of guidelines for the admission to midwife-led units.
There are challenges, however, that remain to be met—particularly in relation to providing care for the growing number of women with diabetes. The RCM continues to campaign also for the establishment of comprehensive perinatal mental health-care services. Despite the recommendations of a review of mental health and learning disability services (DHSSPS, 2005) there is only one Trust in Northern Ireland that provides a very limited specialist mental health service for pregnant women or new mothers. There are no dedicated mother- and-baby units on the island of Ireland for women who require inpatient psychiatric treatment.
The end of 30 years of violent internal conflict and the establishment of a more peaceful community in Northern Ireland has led to an increasingly multicultural society as it becomes a more attractive place to live and work. This has brought its own challenges and the RCM is working proactively with other agencies, notably the NSPCC, to highlight the absence of any dedicated service for women who have experienced female genital mutilation.
There is also, of course, the challenge of an ageing midwifery workforce, and the RCM works closely with the DHSSPS to ensure that sufficient numbers of midwifery education places are commissioned each year. We are concerned, however, that as no pay agreement has yet been reached for health-care staff in Northern Ireland for 2015/16, this could potentially lead to an exodus of newly qualified midwives to the other UK countries, and indeed to the Republic of Ireland.