There is reason to hope the condemnation by the Health Information and Quality Authority (Hiqa) of the failures in care at Midlands Regional Hospital Portlaoise will be responded to. Minister for Health Leo Varadkar has promised it will not be “just another report”. The scandal will hopefully be a watershed in Irish maternity care.
But to resolve the crisis in maternity services the full extent of the problem needs to be acknowledged. The forthcoming review of the Cavan deaths will bring to four the number of hospitals subject to inquiry following fatalities in maternal and neonatal care since 2012. At this stage it is time to recognise that maternity services in Ireland are not experiencing localised faults that can be repaired; there is a systemic problem that needs root and branch review and reform.
Varadkar’s pledge in the Dáil this week to establish a women and infant health programme to improve maternity services is a welcome one. However, there is a risk here of papering over what is a fundamental problem. The most significant question to be addressed is continuity of care (during pregnancy, at point of delivery and after birth) and respect for women’s voices at every level of the health service. While further resourcing for services for women and babies is beneficial it does not wholly remedy the fact that Irish maternity care is overly medicalised and has become focused on bringing pregnancy to the point of delivery in the most direct way possible.
The prioritisation of bringing pregnancy to delivery has resulted in maternity care which emphasises the efficient and effective “management” of birth.
Labour in Ireland is highly controlled and medical intervention common. Obstetrics dominates care provision, and the risks of particular courses of treatments are mitigated by how far and how well they will propel labour forwards.
At Portlaoise, as the chief medical officer noted, the drug oxytocin had been used liberally to induce and speed up labour and the rates of Caesarian section were significant.
The focus on delivery also potentially explains why so little attention was paid to the emotional needs of families after birth, why basic services like transport of infant remains or private rooms for bereaved couples were absent, and why post-birth monitoring of women and infants was so poor.
When the main concern is moving labour to the point of childbirth, in a context where resources are stretched, the capacity of staff to provide comprehensive support to women and children after birth is limited. To move Ireland forward from this problematic position a number of things need to happen.
Holistic experience
First, the holistic experience of pregnancy needs to be appreciated. Recent scandals in maternity care – the infant deaths at Portlaoise and post-delivery deaths at Sligo in particular – throw the neglect of health needs outside of and after the moment of childbirth into stark relief. There is an immediate need to unsettle the focus on point of delivery and give greater consideration to the health of newborns and women after birth.
This may well introduce a robust discussion on the role of social care professionals in supporting bereaved parents in their transition out of hospital and the availability of frontline bereavement counselling. It would also include the long-term impacts of particular treatments (such as Caesarean sections and medical inductions of labour) into best practice discussions.
Second, the dominance of obstetrics in Ireland must be challenged. Midwifery is severely under-resourced. As the report highlights, the number of midwives was insufficient to ensure adequate holistic care of pregnant women and children.
Preferable model
This national preference towards obstetrics is at odds with international guidance. The WHO and NHS both promote midwifery as the preferable model, limiting obstetric care to high-risk patients. The rationale for this promotion is that midwifery provides emotional support which is so important for women (particularly bereaved women).
The research is also very clear; obstetrics is no safer than midwifery. On the contrary medical interventions (the use of oxytocin and Ceasarean sections) which proved so problematic at Portlaoise are more common in obstetric-managed pregnancies.
Third, the “lived experience” of maternity care needs to be investigated. Hiqa’s report drew its evidence from the families who had been isolated from each other. This discussion needs to be collectivised to understand what other issues there are.
Portlaoise demonstrates how little we know about what is happening in maternity settings. Most importantly patients need to be not just afforded a place at the table through the participation of advocacy groups in a patient safety body. They need to be accepted as experts of their own medical circumstances by both practitioners in hospitals and inquiry committees. Portlaoise is not a localised event; it sits alongside maternity care scandals in Galway, Sligo and Cavan. Something is rotten in maternity services. This needs to be resolved. Dr Deirdre Duffy is a specialist in evaluating social programmes and policy; she works as a lecturer in social science at Edge Hill University in Lancashire, England.