Thursday 19 October 2017

Drastic surgery needed for our 'Dickensian' maternity service that is creaking at the seams

Parents believe national safety statements are a ‘significant step’, says John Meagher

Dr Tony Holohan, chief medical officer at the Department of Health Photo credit: Martin Nolan
Dr Tony Holohan, chief medical officer at the Department of Health Photo credit: Martin Nolan
John Meagher

John Meagher

The move was first mooted in 1998, but for many of the thousands of women who have given birth there - and the large population of its staff - the National Maternity Hospital should have relocated from its base at Holles Street in Dublin a long time ago.

As the master of the hospital, Rhona Mahony, put it on RTÉ's 'Prime Time' on Tuesday, the hospital isn't fit for purpose and has not been for a long time. As she led Miriam O'Callaghan through the cramped corridors and busy wards, where its Victorian origins could be discerned at every turn, the doctor was adamant that nothing should derail the plans to move to a world-leading facility at the St Vincent's Hospital complex 3km away.

And, Ms Mahony insisted, the Catholic ethos of the owners of the land on which it is to be built, the Sisters of Charity, would have no impact on how the hospital was run, particularly when it came to such issues as IVF or abortion.

It's a row that's likely to rumble on and on, especially as such high-profile figures as Peter Boylan, an ex-master at Holles Street who stepped down from the board yesterday, believe the new maternity hospital would not have full autonomy if it is under Catholic ownership.

For many of those looking on, the controversy epitomises just how broken the country's maternity hospital system is - and how far Ireland has to go to match the experience of similarly populated countries like Denmark and New Zealand.

The latest crisis comes in the wake of a recent report which revealed that significant risks still remain to the safety of patients attending another of the country's major facilities, the Midlands Maternity Hospital at Portlaoise.

After the death of infant babies at the hospital, the Health Information and Quality Authority (Hiqa) had set out hundreds of recommendations to restore safe and quality services in a report published in 2015. But, in an update on the provision of safe and quality services published in December, Hiqa insisted that, while some progress has been made and maternity services are being provided in a safer way, the hospital is still understaffed and struggling to recruit non-consultant hospital doctors.

Sobering

Among its findings was the sobering statistic that just 38 midwives are staffed in a maternity unit that should have 52.

It was a black stain on the country's maternity service that came just weeks after consultants at Cork University Maternity Hospital voiced concerns over failure to invest in what's one of the country's largest maternity hospitals.

In a leaked letter, a group of 19 consultants at the hospital warned management that they "cannot and will not take responsibility" for women suffering adverse outcomes "rising from a well-documented chronic lack of investment in the gynaecology service".

More than 4,000 are awaiting outpatient appointments and surgeries at the hospital, the longest waiting times for such appointments in the country.

These damning controversies arrived at a time when another shameful report is in the public mind - the compensation payments, totalling €34m, to hundreds of women who underwent the severe symphysiotomy procedure when giving birth between 1940 and 1990.

It may have been an echo of a different time, when procedures in maternity hospitals were more crude than today, but it highlighted the fact that Ireland is still a far from perfect place in which to give birth.

For many, the country's maternity services are creaking at the seams, even if the sort of concerns expressed about Midlands Regional Hospital and Cork University Maternity Hospital are not echoed everywhere.

Although the birth rate is dropping slightly, Ireland's is still the highest in Europe at 14.4 per 1,000 (the EU average is 9.7 per 1,000) and with the population of 4.6 million - the highest it's been since the 1860s - the country's maternity hospitals have never been busier. Roughly 200 babies are born every day and 19 maternity hospitals through the country have to share the burden.

The National Maternity Hospital, Holles Street, and Cork University Medical Hospital take a huge share of this, with respectively, 10,000 and 8,500 babies born each year.

A midwife who has worked in Holles Street for more than a decade says it's become noticeably busier in the past few years. "Don't get me wrong - it was always busy, but it's really full-on now. Just walk through the corridors and you'll get a sense of just how many people give birth here. Since Mount Carmel [the private maternity hospital in south Dublin] closed [in 2014], the numbers have gone up. It puts a lot of pressure on staff, but I think we still provide a really good service," she said.

"Everybody knows that the building is antiquated and it will be a relief to be able to move into a purpose-built unit at St Vincent's in a few years." The move - assuming it will happen - cannot come soon enough according to one mother who gave birth to her three children at Holles Street.

"It's Dickensian in there," she said. "Cramped wards, narrow corridors, lifts that take an age to work. I can't fault the work of the staff, but it must be very hard to work in those sort of conditions. It seems crazy that after all the money in the boom years the country's main maternity hospital is so outdated."

And yet, Holles Street is regarded as one of the country's better maternity facilities. Instead, serious issues have come to light in our regional units, as Mr Boylan pointed out last year: "All of the recent problems in our maternity services have been in maternity units which are integrated into, and not co-located with, general hospitals.

"Maternity care comes down the list of priority when it comes to scarce resources in these hospitals," he said. "Midwives get re-allocated to surgical or medical wards, operating theatres get used for non-obstetrical or gynaecological procedures and operating lists get disproportionately cancelled."

The sense that some hospitals are better than others has been echoed time and time again, as has the idea that very different approaches are employed from one unit to the next. That was evident when monthly safety reports for all hospitals were published this year.

CUMH had a perinatal (stillborn and early newborn) mortality rate of 4.5 per 1,000 total births, in December 2015, whereas the NMH's rate was zero for the same month. But the HSE emphasises that such data be interpreted with caution "particularly when reporting low numbers which may vary naturally from month to month and are influenced by case complexity".

Yet, there appears to be a huge difference in how procedures such as caesarian section are viewed by certain hospitals. In South Tipperary General, 40.3pc of children were born this way in December 2015, while C-sections accounted for just 21.3pc in University Hospital Waterford. The national rate is just under 30pc - a huge increase from 1984, when just 7pc of births were delivered this way.

The publication of detailed information on the performance of maternity units was championed by Department of Health chief medical officer Dr Tony Holohan and stemmed from a recommendation in the Hiqa report into baby deaths at Portlaoise hospital. However, it ran up against resistance from the masters of the Dublin maternity hospitals.

They argued, in correspondence with the HSE last year, that publication of the data would leave hospitals open to adverse publicity and media scrutiny, pose risks to patient confidentiality and encourage inappropriate comparisons between maternity units of varying size and complexity.

Subsequently, both Holles Street and the Rotunda, Dublin, stopped publishing monthly data, and have favoured making statistics available on a quarterly basis "as a more informative and accurate reflection of a trend rather than the individual monthly rates previously reported".

Information on baby deaths, major obstetric events and clinical incidents continues to be published monthly for the other 16 HSE-run maternity units in the State.

Roisín and Mark Molloy have had their fair share of heartbreak when it comes to maternity hospitals being completely open about baby deaths. Their son Mark died just after birth at Midlands Regional Hospital, but it was incorrectly recorded as stillborn.

The couple's experience helped lift the lid on practices at Portlaoise, which were uncovered on 'Prime Time', and just before Christmas, Mr Molloy, along with Stephen McMahon, founder of the Irish Patients' Association, appeared before a Joint Committee on Health and called for 'open disclosure' for all healthcare professionals.

"We've worked for this for 21 years," Mr McMahon said. "There has to be that transparency. It's so badly needed. A report from earlier this year showed that one out of every eight admissions to hospital results in an adverse event and of those, 6pc results in death."

Mr McMahon says the publication of national maternity safety statements is a welcome action and "a significant step forward in assuring patients of the safety and quality of maternity services".

But he believes it is just the first step on building greater trust between patients and healthcare professionals.

"We're calling on greater accountability to management in our hospitals," he said, "not just about safety, but about how money is spent."

Irish Independent

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