Rhona Mahony: Our mothers and youngest citizens deserve better
Medicine, particularly obstetrics, will never be error free, but error can be reduced by well-trained, well-supported staff
Published 17/05/2015 | 02:30
Birth is full of joy and full of heartbreak and full of risk.
Over the last few years we have heard harrowing stories of mothers and babies who have died in childbirth. These stories go to the heart of us as individuals and as a society because the experience of birth affects each and every one of us in the most fundamental and universal way.
Around 90,000 women become pregnant each year in Ireland. Approximately one-in-five women will miscarry in the first trimester of pregnancy - the majority of these miscarriages are the result of chromosomal abnormality.
Some 70,000 babies are born annually with a perinatal mortality rate of five per 1,000; in other words, 99.5pc of babies weighing more than 500g survive. The maternal mortality rate is eight-to-10 per 100,000, with the majority of deaths arising from indirect causes.
The incidence of severe maternal complication is four per 1,000 and is disproportionately higher among ethnic minorities. Almost one-in-three women in Ireland are delivered by Caesarean section and one-in-eight first-time mothers in labour require instrumental assistance to deliver.
The majority of these interventions are for suspected foetal distress and slow or dystocic (failure to progress) labour. In a large tertiary referral unit like the National Maternity Hospital, one-in-five infants will require some form of rescuscitation or neonatal intensive care. The majority of these babies will make a good recovery.
These results compare very favourably with international standards in the developed world and are worlds apart from the outcomes in developing countries where maternal mortality rates of 400 per 100,000 and perinatal mortality rates of 100 per 1,000 accompany unassisted childbirth, where there is no access to medical intervention.
However, behind these headline statistics, there are all kinds of patient experiences and myriad potential outcomes, both good and bad.
At times, it seems, we do not give sufficient regard to the unpredictability, the severity and the catastrophic potential of obstetric outcome. Two lives -sometimes more - balanced by a unique and complex physiology. In situations that are perceived to be of the lowest risk, things can go very wrong, and very quickly.
Emergency surgery is frequently carried out in a context where minutes count. Activity levels fluctuate significantly but childbirth cannot be cancelled or put on a waiting list. Yet, increasingly, we frame birth in a consumer context that is full of all kinds of expectation. It is a natural phenomenon but it is not without risk, particularly when we note the changing demographic of our patients and increased care requirements.
Thirty-five percent of women at the NMH are over 35, 40pc are overweight with increased incidence of other co-morbidities, such as gestational diabetes. Increasing rates of multiple pregnancy and high rates of previous Caesarean section are just some of the trends that are of major concern.
Recently, reports of obstetric services have been dominated by cases of poor outcome, intimate patient details on front pages, confidential and sensitive reports leaked in draft form. Numerous reports, recommendations, standards and guidelines have been issued over the last decade.
These are very welcome in terms of standardising and improving quality of care. Unfortunately, they are not always accompanied by the necessary resources. In this context, clinicians on the frontline face increasing challenge as the bar is set higher in an environment of diminishing resources.
Our overarching aim must be to deliver safe care and prevent adverse outcome. The recent HIQA report examining service quality in Portlaoise makes many excellent observations which have universal application to any unit practising obstetrics. The recurring theme in this report is a lack of governance and oversight, and a lack of resources. We are now seeing the effect of years of neglect of maternity services.
One of the most important challenges we face in Ireland at present is insufficient frontline staff and difficulty in recruiting and retaining midwives and doctors. Medicine will never be error free, but error can be reduced by appropriate staff who are well trained and well supported.
We have known for a long time that we have the lowest number of obstetricians per head of population in the OECD, despite relatively high parity. The UK has three-to-four times the number of obstetricians with similar figures for neonatology and anaesthetics. Over-reliance on agency staff has proved to be expensive in terms of cost and risk.
We have not yet succeeded in fully complying with the European Working Time Directive, while relentless and excessive service commitments overwhelm training opportunity. Education and training of staff are critical components in the delivery of safe health care.
Over the last decade, numerous reports have addressed the need for consultant expansion in Ireland, but the ability to address this issue becomes increasingly difficult in an environment where recruitment and retention of staff is so difficult. Overexposure to case volume and complexity combined with the punitive effect of spiralling litigation do little to ease the situation.
Similar problems exist on the midwifery side. Irish midwives are highly sought after by recruitment companies in the UK and beyond. Low entry salaries, difficult working conditions and poor reward for clinical career progression all entice midwives to seek work in countries which offer better terms, creating further problems.
The importance of good clinical governance cannot be overemphasised. It is about leadership and accountability. I am fortunate to work in a Voluntary Hospital where I report to a Board which guides and challenges me. An integral part of any governance system is the knowledge of outcome.
Like the Coombe and the Rotunda, it has been NMH's policy to continuously audit clinical outcome and produce an annual clinical report which is, rightly, in the public domain. This permits us to benchmark ourselves against best practice and to constantly monitor our performance.
It also facilitates learning and strategic planning. It is critical that we learn from clinical experience, whether this is positive or negative. It is also critical that we share openly and communicate fully with patients, particularly when errors or complications occur. When patient complaints are reviewed or mistakes made, poor communication is often a contributing factor .
The current focus on maternity services is an opportunity that must be grasped in its totality. The Maternity Strategy initiative is to be welcomed and should provide a best way forward.
Most patients have a joyful experience in giving birth. However, we must never forget those who endure tragic outcomes. Skill and competence should be a given in our maternity services but so must humanity and compassion. Everyone is born and every birth matters. Our mothers and youngest citizens deserve better.
Rhona Mahony is Master of the National Maternity Hospital, Holles Street, Dublin