Steps we must take to end the maternity crisis
Patients must be given a greater voice in planning of our maternity services, writes Dr Peter Boylan
Recent media revelations have focused attention on Ireland's maternity services.
This attention is welcome. It must result in improved services, starting now.
For this we have the media to thank - RTE's Prime Time has truly done the public a service.
Analysis of the statistics of childbirth in Ireland is reassuring: Ireland is similar to other EU member states.
Bare statistics, however, disguise our problems. There is little point in rehashing tragic events which have been well aired over the past few years.
The intense focus on failures has finally forced the hand of those who can provide the professionals with the means to do the job.
So what needs to be done?
• An independent patient advocacy agency to ensure patients have a strong voice in monitoring and planning of maternity services is planned by the Minister for Health, Leo Varadkar, and is to be welcomed.
• Patients need to be embraced as partners in the provision of health care and we midwives and doctors, as professionals, need to be able to have a relationship of trust with our patients so that when adverse events occur, as they will, we can be frank with them about what went wrong. This is known as a policy of 'open disclosure'. Too often a distressing outcome is made worse for patients by poor communication, which can give rise to a suspicion that something is being hidden.
•Deficits in the staffing of our maternity services need to be rectified. The recommended midwife to patient ratio is 1:30, the recommended consultant to patient ratio is 1:350. Our consultant numbers need to almost double to achieve the recommended level, while the number of midwives in the system is unclear due to methods of counting, but it can safely be assumed the numbers are inadequate. Recent calculations suggest a deficit of up to 600 midwifery posts nationwide. Dublin hospitals have a particular difficulty in retaining staff due to the cost of living in the capital. Perhaps a 'Dublin weighting', similar to London, could be considered for essential public servants.
•Most of the disasters which occur in childbirth occur during labour, often unpredictably. A first-class maternity service should have a consultant presence in the hospital 24/7/365 working in partnership with our midwifery colleagues. The current number of consultants in the system makes this an impossible aspiration. The situation is analogous to allocating trainee pilots to fly planes at nights and at weekends because there are not enough trained pilots available.
•Additional staff in the area of obstetric ultrasound need to be appointed to ensure the ready availability of skilled, high-quality scanning for all pregnant women.
•The rate of stillbirth in Ireland is similar to other developed nations. This means that in Ireland there are approximately 300 stillborn babies every year. A drive to reduce the number of deaths will require significant investment in personnel and infrastructure. In addition, there are babies who die in the newborn period and mothers who have miscarriages. The need for a well resourced bereavement counselling service is self evident. The HSE is developing a programme to improve bereavement counselling in our maternity units. This is welcome.
•In order to assess our maternity services on an ongoing basis, a formal system of audit of pregnancy outcomes needs to be introduced. The World Health Organisation (WHO) has recently endorsed a system for worldwide use which was developed in Ireland (The Robson Ten Groups Classification). This needs to be introduced to all our maternity units. This system, which is not complicated, will allow us to benchmark Irish maternity services against other countries, and will allow comparison between hospitals in Ireland in a constructive, educational way. It will alert those monitoring pregnancy outcomes to spot 'outliers' early so that appropriate interventions can happen in a timely fashion. With this system we will not be reliant on the media to highlight adverse outcomes. Public discussion is distressing for the families involved, for the staff, and undermines public confidence.
• The question of accountability for deficiencies has been discussed. There are well-recognised accountability and disciplinary mechanisms in place for midwives and doctors, but none for managers. One has to have some sympathy with hospital managers who are given a budget and told, effectively, to 'get on with it'. It appears that it may be the more senior managers who need to accept responsibility for failing to heed warnings about threats to patient safety. This is an area which might bear further investigation. How far up the organisation the trail might lead would be of great interest to those on the front line who carry the can when it comes to adverse outcomes flagged by clinical staff in advance. There is clearly no excuse for a lack of compassion in dealing with patients - it is unprofessional if not inhumane. However, asking people to do a difficult job, not giving them the resources to do it properly, and then blaming them when things go wrong is demoralising for staff. Real accountability at senior level would also signal in the clearest terms to the public that previous failures have been acknowledged and real change is being made.
The maternity strategy which the minister has recently announced provides an opportunity to build on the strengths of our maternity services - and they are many - and correct the deficiencies.
Among our strengths is the close working relationship between midwives and obstetricians, in contrast to that in many other English-speaking countries. It is critical that a wedge is not driven between us for that would be harmful to our patients. Midwifery-led, stand-alone units would be a retrograde step away from the current partnership model of care.
Finally, rationalisation of services (that means closure of small units), if that is what the maternity strategy recommends, must not be subjected to inappropriate political interference.
Dr Peter Boylan is consultant obstetrician and gynaecologist at the National Maternity Hospital