Babies are being put at risk because too many doctors and midwives in maternity units are so busy they cannot take time to update their training on vital monitoring equipment.
The stark warning is highlighted in the first overview of the country's 19 maternity units by the patient watchdog, the Health Information and Quality Authority (Hiqa).
A key concern was the variation in the uptake of training in interpreting technology known as CTG - cardiotocogram tracing - which checks an unborn baby's heart rate for signs of distress.
This is caused if the oxygen supply to a baby in the womb is reduced or blocked. If this happens it can lead to rapid brain damage and even death.
The report highlighted how this training is mandatory and failures in reading or acting on abnormal CTG fetal heart readings were found in a number of key investigations into baby tragedies, including in Portlaoise Hospital, since 2011.
It found the rate of uptake of this training within the two-year time frame ranged from 19pc to 100pc and was not standardised.
"Difficulties in releasing clinical staff to attend training because of staff shortages were reported as a key challenge by some maternity units and hospitals," said the report.
The cramped outdated buildings housing maternity hospitals and units, where most of the 60,000 babies are born annually, has been well documented. Hiqa estimated that only units in Wexford, Cavan, Drogheda and Cork are in surroundings physically fit for purpose. But the problems go well beyond the state of the buildings. Many are beset with staff shortages and overworked doctors and midwives.
The inspectors found maternity services were very reliant on front-line medical staff working onerous rosters and midwifery staff doing overtime.
This raised significant questions around "sustainability and service safety."
Around 15pc to 20pc of approved permanent jobs for consultants were unfilled.
Outside the four larger maternity hospitals, the provision of 24-hour maternity care was dependent on doctors who were not on a training scheme to be a specialist.
In many cases these doctors have been in their job for years and given vital service.
Six of the 19 units and hospitals did not have a full quota of approved doctors' posts filled.
The units which faced most difficulty recruiting and retaining doctors had rosters where they were on call one in every five nights.
There was particular worry about the uncertainty of availability of a specialist anaesthesiologist out of hours in some hospitals in the event of an emergency.
These specialists are needed in cases where a woman needs an epidural for pain relief or requires caesarean section.
Individual reports on the maternity units at St Luke's Hospital, Kilkenny, and University Hospital Kerry found deficiencies in anaesthetic cover, although efforts were made to address this.
The report also disclosed five maternity units still did not offer fetal ultrasounds at the stages of pregnancy recommended in national standards. In 2017 it was confirmed five babies died at Portlaoise Hospital over a number of years due to failings that led to a lack of oxygen.
It led to promises to overhaul maternity services, particularly smaller units across the country, and pledges to fund the National Maternity Strategy.
However, the Hiqa report showed it is under-funded. It was estimated it would take €75m to implement its recommendations over 10 years. But in its first years it received just €8.5m.
Hiqa warned the investment would need to accelerate if it is to be implemented.
Hiqa's chief inspector Mary Dunnion said while it found good practice in how maternity services detect and respond to obstetric emergencies, it also identified opportunities for improvement to ensure they remain safe and effective.