Sir, - The problem with Irish health services, according to Finbarr Fitzpatrick's diagnosis (Opinion, October 16th) is that too many people fail to gain access to hospital care within a "medically acceptable" timeframe. Can two obstetricians, he asks, or even one, be in the labour ward for every delivery?
The answer, of course, is a resounding no. Nor were they ever. Irish midwives conduct all uncomplicated deliveries, without distinction. Consultants may rush in for the crowning of the baby's head, but it is the midwives who generally care for women in normal birth, regardless of their status as public or private "patients". Finbarr Fitzpatrick clearly favours a "consultant-delivered service". This may be a euphemism, we fear, for a consultant-controlled service, unless the clause making consultants responsible in law for the actions of junior staff (i.e. all other members of staff) is removed from the "common contract" - that is, the contract between the State and medical consultants.
The consultant model of care, requiring "at least" 1,000 extra consultants, would add approximately £75 million in salaries alone to our annual health bill, not to mention the knock-on costs of "bed nights"; the use of high-technology diagnostic tools such as MRI scanners; nursing and midwifery time; pathology, radiology, and all the other facilities provided free by the State to consultants for their private patients in public hospitals. This is one aspect of the present system which your correspondent, Maev-Ann Wren, neglected to mention in her groundbreaking series.
The 1993 Tierney Report on Medical Manpower, according to Maev-Ann Wren, advocated "co-operation" between smaller hospitals, centralising some maternity units while closing others. Centralisation in maternity care, however, does not work. It results in unplanned, out-of-hospital births, which, as research shows, carry very high mortality rates.
Two-person maternity units will, from January 2001, no longer be recognised by the Medical Council for training purposes. This will result in the widespread closure of maternity units in Ireland. In addition, the EU directive limiting the working time of doctors in training to 48 hours a week will also result in the closure of hospitals.
Since the policy of the State continues to be that all births shall take place in consultant-controlled units, how are we to cope with babies who insist on arriving at unpredictable hours in undesirable locations - i.e., outside the catchment area of designated "regional centres of excellence"?
The consultant model in maternity care is proving too expensive. According to a survey done by the Irish Childbirth Trust, our annual Caesarean section rate is now 18 per cent. Caesareans, it should be remembered, cost three times more than vaginal births. Defensive obstetrics has been blamed for the rise in Caesareans, as has the foetal monitor - a technology in widespread use both here and in Britain, despite the introduction of evidence-based medicine; recommendations from the Royal College of Obstetrics and Gynaecology in Britain; and a mountain of research to the contrary.
Irish obstetricians (Letters, October 11th) reject claims that their work is not or cannot be monitored. So why is there such a dearth of public statistics on Caesarean sections, forceps and vacuum deliveries, inductions and so on? Irish obstetricians say (October 11th) that morbidity rates among obstetricians far exceed those of their patients. Last year indemnity cover for obstetricians in this State rose by 88 per cent, although for other specialities the rise was a modest 12 per cent. Can somebody please explain this conundrum?
The more obstetricians intervene, the more birth injuries occur: the more they get sued, the more they intervene. The Department of Health solution is to propose no-fault compensation, directed at brain-damaged infants. This scheme will make it impossible for parents to bring an action against an individual practitioner. Has it occurred to nobody that consultants might reasonably be asked to pay the bill for their own professional indemnity themselves? With the tax offset, this new, punitive measure would hardly be noticed, and taxpayers would save £17 million a year.
In New Zealand and Canada, midwives are paid the same flat fee for delivery as obstetricians and general practitioners. Irish midwives, on the other hand, the sole carers of women in normal birth, are paid a tenth of what consultant obstetricians are paid for "carrying ultimate responsibility" (or being liable in law should someone sue) - to quote obstetricians themselves (October 11th). In Ireland, the private obstetrics market is worth an estimated £18 million a year. Assuming that this is divided equally among fewer than 100 obstetricians, each obstetrician stands to make £180,000 a year from his private practice, on top of an annual State salary ranging from £69,000 to £86,000.
Our level of maternal mortality is the lowest in the world, Finbarr Fitzpatrick asserts. Leaving aside that only 27 countries in the world are classified as industrialised by UNICEF, this assertion raises other questions. In a 1998 report on obstetric claims over a 20-year period, issued by the Medical Defence Union (Ireland), maternal deaths accounted for 8 per cent of all maternal negligence claims against obstetricians in Ireland.
The fatal flaw in an otherwise excellent series was the failure to consider health as a whole. Primary health care, at the level of the community, received only a passing glance. Yet primary health care is the way to a healthier, more equitable and more affordable future. To put it in a nutshell, more primary care means more prevention and health promotion, which ultimately means less disease and less hospitalisation.
When are midwives going to be permitted to provide services for women in childbirth at primary health care level? - Yours, etc.,
Marie O'Connor, Philomena Canning, Directors, The European Institute of Midwifery, Rathdown Road, Dublin 9.