Tag Archives: Maternity care

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Last night.

In the Dáil.

Sinn Féin’s motion to ensure the new National Maternity Hospital has “legally-guaranteed independence” from all non-medical influence in its clinical operations was carried.

During a debate on the motion, Independents 4 Change TD Clare Daly spoke about maternal deaths in Ireland, and the lack of inquests for the same.

She said:

“Regardless of the justifiable public outcry over the handling of the new national maternity hospital and the prospective ownership of that facility being given to a religious order, this motion is incredibly timely. There is no doubt that our maternity services are in desperate need of reform. It is something that we need to discuss. The best response that the Government can come up with is that we compare favourably to other countries. Do we, and if so, which countries? I would not like to be compared to them.

Let us look at some of the facts. Between 2011 and 2013 there were 27 maternal deaths. These were otherwise healthy women who went in and lost their lives in childbirth or shortly afterwards. There were inquests in only three of those cases.

In 2014, there were 365 reported cases of severe maternal morbidity, but our data is incomplete because not all of the maternity hospitals participated in that.

Between 2007 and 2015 the HSE incurred a staggering €66million in legal fees arising from maternity cases involving serious injury or death to women or babies. During the same period the HSE, through the State claims agency, paid out an even more staggering €282 million in damages in maternity cases. That is 116 times more paid out in legal settlements and fees than the extra €3 million that is being given to the new national maternity strategy. Unless that culture of litigation, denial, lack of accountability and lack of oversight is dealt with our problems will continue.

There is no doubt that one of the key reasons for our problems is the significant under-staffing level of midwives and doctors across the State. Meanwhile, reports and reviews into adverse incidents are either not made available publically or they are badly delayed. The review of adverse incidents in Portiuncula hospital, for example, was supposed to be available by mid-2015. We still do not have it.

We did discover last week, however, that the hospital was carrying out a secretive review of care, with a doctor even ignoring advice and saying that he did not see the reason why there should be any review at all. We have to deal with these issues, because our maternity services are consistently running at sub-optimal levels, which is undoubtedly leading to trauma for women and their families and to catastrophic outcomes because of the lack of accountability and the completely inadequate and non-binding HSE open disclosure policy.

What we need is a statutory duty of candour in order to deal with these cases. It is more than urgent. It is one of the reasons why I moved the Coroners Bill 2015 and why that is so critically needed, yet we still do not know whether the Government has passed a money message even though the Committee for Justice agreed more than six months ago that it would go to committee stage next week.

We need accountability and openness if our services are going to improve. The widowers who lost their wives and the mothers of their children can testify to the failures of our maternity services and the need to change.

We know from the eight inquests held between 2007 and 2015 into the deaths of women in our maternity services that vital information was withheld. They were often not privy to internal investigations and reports until the HSE was ordered to produce them in public hearings by the Coroner’s offices.

Although hospitals and the HSE indicated that they would change procedures and protocols, those were not implemented and carried through. That is utterly devastating for those families.

It is not an exaggeration to say that if the HSE recommendations issued on foot of the tragic death and inquest into the death of Tanya McCabe had been made enforceable national policy then Savita Halappanavar may not have died.

If the inquest into Dhara Kivlehan’s death had not been delayed for four years – she died in 2010 and the inquest was in 2014 – then Sally Rowlette, who died in 2013 in the same hospital of the same condition, leaving four children, may not have died. These are very urgent issues that need to be addressed. It shows systemic failures and a lack of openness in our system.

We know that there are countries across the EU which have much better health outcomes than we have. We need proper audit and genuine open disclosure. We have to have automatic inquests into maternal deaths in order for maternity services to improve.

It is unforgivable that in this day and age that fetal abnormality scans are not available as a matter of course to women. The Minister has told us over and over again that all hospital groups offer such scans, but the reality is that the scans have to be implemented by doctors. Women outside of major centres have to travel, and the consequence is that abnormalities are not always picked up. It is not good enough.

I welcome the motion, but it does not go far enough. That is not a criticism, it is a point of observation. The national maternity strategy is far from flawless. The language in it is feeble. We talk about woman-led care, when there has been a deliberate decision not to have midwifery-led care because there is some seemingly mythical and highly polarised debate out there about midwifery care. I reject that. I would say that it is far more likely that expensive private obstetric practices are the ones who are worried about midwives. No one else is.

Midwifery-led care is the way forward. In Scotland, they have 18 free-standing or along side midwifery-led units serving a population the same as Ireland, yet we have two pilot schemes in Cavan and Drogheda.

There has not been a single sod turned to provide even one midwifery-led unit in Ireland, despite the national maternity strategy making promises on the issue over 14 months ago. The Scottish national maternity strategy provides that every woman will have continuity of care provided by a primary midwife who will provide the majority of her antenatal, intrapartum and postnatal care. The input of an obstetrician is an addition, but the provision of care is centred on the midwife, which is best for the State, health outcomes for women and the public purse.

The national maternity strategy is non-statutory, which is a huge problem. It is only the third national document on national maternity services since the early 1950s, but because it is non-statutory, it is not binding. We can refer to A Vision for Change which is a lovely vision, but it does not tally with the reality.

The Government has one month in which to look at the maternity hospital and we will see what happens, but St. Vincent’s University Hospital was built with public money. Is it not ironic that, in 1972, Noel Browne was questioning the funnelling of public money and cash into a hospital for the Sisters of Mercy? There should be no debate on this issue. It has to be sorted out as it is a public hospital which was built with public money and should be publicly owned.

Transcript via Oireachtas.ie

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Further to our post yesterday, Whose Body Is It Anyway, Jene Kelly, co-chair of Association for Improved Maternity Services in Ireland (AIMSI), writes:

This case has led to widespread debate on the issue of consent in the Irish maternity services. On one side, the argument is that no medical professional would perform an invasive procedure without obtaining consent – that medical professionals must be given scope to practice as they see fit, as the trained expert.

On the other, it is recognised that many of the practices used in Irish maternity services are not based on evidence nor best practice but routine hospital policy and that this judgement has stripped a woman of agency over her decisions and body; her right to consent.

The issue of consent in Irish maternity services is not new, but, it remains largely unexplored in mainstream society or media outlets. Sometimes, the issue of consent reaches our living rooms, in individual cases like this one or in group actions such as the Symphysiotomy survivors, giving the public a perception that consent breaches are rare, extraordinary, and perhaps even historical events confined to a darker chapter of Irish history.

The reality is that Ireland’s maternity consent issues haven’t gone away. Stories are shared everyday in private closed groups between women, over tea with friends, at the local toddler morning, on parenting forums, and in the dead of the night when everyone sleeps. While not the majority, a significant proportion of women will have experienced consent breaches at some stage of their maternity care, often with physical and psychological consequences.

Ireland has difficulties when it comes to pregnant women and rights. Every Irish citizen has the right to informed consent during medical treatments. This means tests, procedures, and interventions are to be discussed clearly with an individual in an unbiased manner, based on the highest quality evidence available, both the benefits and risks of opting in or opting out, in order for them to make the best decision for themselves at that time. For pregnant women in Ireland, these rights are challenged by the Irish Constitution and Article 40.3.3 – which gives equal rights to the woman and foetus. This conflict is highlighted in the National Consent Policy.

The National Consent Policy states:

Page 41: 7.7.1 Refusal of Treatment in Pregnancy.

The consent of a pregnant woman is required for all health and social care interventions. 
However, because of the constitutional provisions on the right to life of the “unborn” (12), there is significant legal uncertainty regarding the extent of a pregnant woman’s right to refuse treatment in circumstances in which the refusal would put the life of a viable foetus at serious risk. In such circumstances, legal advice should be sought as to whether an application to the High Court is necessary.

Citation: (12) Article 40.3.3 of the Irish Constitution (1937)

Relevant factors to be considered in this context may include whether the risk to the life of the unborn is established with a reasonable degree of medical certainty, and whether the imposition of treatment would place a disproportionate burden or risk of harm on the pregnant woman.

The result of this policy is it leaves women and medical professionals with a degree of uncertainty which is open to interpretation. Expert recommendations are often based on personal opinion, biases, and previous experience, not necessarily evidence. As a result, practice and policy varies not only between individual units, but individual providers. This latest High Court ruling brings a new component to this conflict by suggesting that routine practice is the benchmark for negligence cases, not evidence-based care, and that the medical professional can over-ride a woman’s right to consent/refusal regardless of the presence of serious risk.

Is consent an issue of concern in Irish maternity services?

In autumn of 2007, AIMS Ireland ran an online survey on the topic of Availability of Information and Consent. It was open to any one who wished to fill it in. Respondents who completed the survey were anonymous. The survey was small (161 women) and self-selecting.

The survey consisted of Quantitative (statistics) and Qualitative (comments) data. A larger survey by AIMS Ireland, What Matters to YOU 2014 , with nearly 2,000 respondents, will be published this autumn.

More than half of respondents (61%) said that in pregnancy (outside of antenatal classes), they had no opportunity to discuss choices and information regarding hospital policies, routine procedures and common procedures, tests or treatments which you may need to make a decision about during your pregnancy, labour or birth. Of the 39% who responded that they did have opportunities, over half (53.1%) had to be the one to initiate the discussion to gain access to information.

Information was seen to be based on hospital policy, rather than objective evidence-based sources. Women who tried to challenge this were put in a difficult and unfair position, for example:

“Information given is usually hospital-based policies only, rather than a full benefit/risks/alternatives etc analysis. My experience was that this information was presented in a very biased way and that, even if you refused and had the evidence to justify your position, you were still made to feel that you were in someway putting your baby at risk and were made to feel difficult or unreasonable. It takes a very strong person to be able to stand your ground in these circumstances especially for a first-timer”

They also perceived that information was used as a source of pressure on them:

“I feel that every woman needs to have access to all information. I was very
informed but it was due to research done by myself. However when you are in the hospital there is a subtle pressure put on you saying you want your baby to be safe”

This information was also felt to be very negative and undermining of women’s abilities:

“There is too much focus on what could go wrong with labour and birth and so
starting from a negative position – instead of building the expectant mother’s
confidence that things have as much chance of going well and what she can do to maximise this. This is particularly prevalent in hospital ante-natal classes which seem to overly focus on the pain of labour, need for interventions, etc instead of providing positive examples. Also, you are not made to feel that your body is capable of a successful and natural birth and so there is less trust and confidence going into labour.”

In this survey, 75.6% of respondents stated that they felt that consent is an issue of concern in the Irish maternity system. Further questions on the survey have unfortunately illustrated how key an issue consent is with only 38% of women in labour and 33% of women during birth responding “Yes, my consent was fully sought and given”.Continue reading →