Friday 30 September 2016

The obstetric paradox that's challenging staff morale

Hospitals are now much safer for mothers and babies, writes Dr Rhona Mahony, the Master of Holles Street

Dr Rhona Mahony

Published 06/12/2015 | 02:30

As a tertiary referral centre, the NMH welcomes women and new-borns with complex medical needs from all over Ireland.
As a tertiary referral centre, the NMH welcomes women and new-borns with complex medical needs from all over Ireland.

Recently, I delivered a lecture entitled 'Through the Eyes of the Masters' to an obstetric society. This was a reflection on half-a-century of obstetric care at the National Maternity Hospital (NMH), as recorded in the clinical reports published annually over the past 50 years.

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In the course of my talk, I documented the various clinical advances and demographic changes that have had such a profound effect on obstetric outcome. From the introduction of IVF to the extraordinary advances in neonatal care, we have steadily pushed the boundaries of obstetric medicine, achieving outcomes that would not have seemed possible in 1965.

Every mother and baby delivered in the hospital has been part of that journey.

While my lecture focused on changing clinical trends, some of the questions from the floor caused me to reflect on the changes that have occurred in the general environment in which the NMH operates.

Over the past century, Masters have often worried about poor infrastructure, lack of funds, overcrowding and increasing patient activity.

As the current Master, I take some comfort from the fact that the hospital has survived several wars and recessions. In more recent times, clinical advances and changes to the in-patient demographic have increased the complexity of the care that we provide.

As a tertiary referral centre, the NMH welcomes women and new-borns with complex medical needs from all over Ireland.

Yet despite some of the most exciting advances in modern medicine, confidence in the maternity services is shaken and public perception is relatively negative. The obstetric paradox. It is a curious and complex phenomenon but worth consideration.

Over half-a-century, there has been huge technological advancement reflected in dramatic improvement in clinical outcome, such that present outcomes compare very favourably with international standards in the developed world.

In my own hospital in 2014, the corrected perinatal mortality rate is 3.6/1,000 births and the maternal mortality rate is 3.7/100,000 births.

These are excellent outcomes by any measure.

Improved antenatal care, the introduction of obstetric ultrasound, minimally invasive surgical techniques, regional anaesthesia and intrapartum monitoring are just some of the advances seen.

The introduction of neonatal intensive care, which has continuously pushed back the threshold of fetal viability and improved outcome in preterm birth, has been among the most exciting.

Over the 20 years of my career, babies that would have had little chance of surviving now have excellent outcome, with 80pc of babies born after 26 weeks' gestation surviving.

Despite this, virtually every day we read or hear about negative outcomes in the maternity services. While the vast majority of outcomes are good, the complex physiology of pregnancy means that the potential for catastrophic outcome is never far away.

There is adverse outcome in all areas of medicine but there are few human outcomes as devastating as fetal or maternal loss. Even in environments much better resourced than ours, there will be tragic outcomes, despite society's best efforts.

Cerebral Palsy (CP) is a good example of this. Despite fetal monitoring in labour and caesarean section rates that have increased up to fivefold in some countries, the prevalence of CP at term is unchanged at 2/1,000, reflecting a complex causation that current technology is unable to prevent.

The dramatic and tragic outcomes that can arise naturally draw media focus. Nonetheless, we rarely read about the very good outcomes, which far outnumber the bad.

There is no doubt that 50 years ago adverse outcomes were more common and perhaps this resulted in greater acceptance and understanding of the natural risks pertaining to childbirth.

As obstetric outcomes have improved, expectations have increased concurrently, while society has less direct experience of poor outcome.

When outcomes are poor, grief can be accompanied by isolation. Clear empathetic communication and practical medical support become more important than ever.

The obstetric paradox is seen again in spiralling litigation rates, despite improvement in clinical outcomes.

Patients are rightly compensated for harm done and in any human endeavour there will be error or suboptimal performance. However, not all adverse outcome is the result of medical negligence. Complications can arise despite excellent care. Complex cases often have no easy answers.

A clinical scenario unfolds prospectively over time but cases are reviewed and judged retrospectively when outcomes are known. It is easy to be expert then. We tend to learn from identifying deficiency in care but not from excellent care, which can equally inform.

In an effort to standardise care, there is rightly a focus on guidelines and standards but without the accompanying resources, unachievable standards are set.

We talk in parallel about inadequate staffing and adverse outcome and we use high standards to judge. Intermittently NMH is assessed by HIQA.

Undoubtedly the aim of HIQA is to elevate care and its excellent campaign on hand hygiene is a very good example of its positive role. However, at times it seems that the standards set by HIQA are incompatible with the resource and the infrastructure within which we operate.

The fact that clinical outcomes are ignored can create an unfairly negative picture and the focus on media reporting does little to enhance the potential for collaboration and undermines patient confidence and lowers staff morale. Low staff morale is a serious issue in a specialty that deals with high volume and high complexity and one which is inherently high-risk.

Staff fear being part of the next scandal and without support an increasingly litigious and punitive environment will take its toll on recruitment and retention. This will not make patients safer.

Negative perception in a hospital undermines patient confidence, creating another layer of anxiety. This undermines the relationship between doctors and patients.

I often wonder what patients make of preoperative consent as young doctors produce an exhaustive and defensive list of potential disasters associated with the procedure that one is just about to have. Not easy for those with excellent imagination.

It will be a long time, if ever, before we fully reverse the current obstetric paradox of negative perception, despite good clinical outcome.

However, we will achieve a great deal through clinical excellence but we must never forget the value of open communication and empathy. Ruthless process without humanity can be chilling. A little humour and a lot of kindness go a long way.

Sunday Independent

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