Mastering the art of maternity care

  • Niall Hunter, Editor

Dr Rhona Mahony took over as the first female Master of a Dublin maternity hospital in January of last year, attaining the mastership of the National Maternity Hospital against some tough competition from other obstetricians.

As part of her application for the post, she prepared a presentation on 'The National Maternity Hospital - the future'.

Recently, the future of the 119-year old hospital was put a more solid footing when its long sought after move to the St Vincent's site in south Dublin was sanctioned by Health Minister James Reilly. While it could be at least five years before this project becomes a reality, Dr Mahony believes this is a crucial development for the State's health service and for women generally.

In an interview with irishhealth.com, she said her main hope now during the remaining five years or so of her Mastership is that the new home for Holles Street will come to fruition at St Vincent's.

"We expect it to be at least a five year project. The aim to be not too much beyond the five year mark. Essentially, we are building a new hospital within the existing hospital grounds at St Vincent's."

€150 million has been earmarked for the project, but this is highly unlikely to cover the full costs of what will be a substantial building project.

"It is  an indicative figure. I think the first thing is to work out what is required," Dr Mahony said.

"This is a project of really critical State importance and we would completely acknowledge the very difficult environment that the Government is working in and also the additional difficulty posed by the IMF in terms of balancing the books, and this is not easy."

But nonetheless, Dr Mahony says, the fact that it is written into the health service Capital Plan is significant. "It means this is a very serious project and so it should be."

"This will be a really significant development, not just for Holles Street but for women nationally, and I am very committed to that."

Pressures on Holles Street

The announcement of the planned move to a new home comes at a time when the Holles Street site is finding it increasingly difficult to cope with infrastructural and funding pressures.

"We have had a large increase in our activity levels over the past six years. We have a moratorium on staff recruitment. We have had diminishing resources in terms of our budget, we have to some extent increasing patient expectations. Also we have increased expectations from our regulatory bodies such as HIQA, HSE, etc. so when you put that all together that is quite a challenge."

"Looking back at recent years and where we are now, I think we have performed really well, considering all of these challenges, and the reason for this has been in us having a highly skilled and committed workforce."

Rhona Mahony believes this survival against the odds has been a 'good news' story. "While the effects of the recession have been really painful across all sectors of society, not just health, there are positives here too, and the fact that staff have stepped up to the plate so successfully gives me great hope and inspiration."

Practical examples of the pressures Holles Street has been under include the placing of extra beds in wards.

"That has been difficult for patients in terms of privacy, and very difficult for staff who are managing in excess of the normal complement. What has also happened has been a push towards the public side of care and a big decline in private practice. Again this is a reflection of the current economy but that has put further pressure onto the public side, which was already under pressure. Our clinics numbers are very large indeed and doctors and midwives are working very hard to get through the volume that makes up our clinics day on day."

Dr Mahony points out that Holles Street does not have the 'luxury' of running up waiting lists or placing patients on trolleys.

"We have an 'open door' system. We work at peak all the time and we also have 'super-peaks' which are unpredictable. On April 5 this year, for example, we had almost 50 deliveries in the hospital, whereas normally we would have 25-30 per day. We don't have the option of a waiting list or having a 'trolley' system."

The number of births of births per year at Holles Street are currently around 9,000. "Our perinatal mortality rate is low - we are just under four per 1,000 for 2012 corrected for congenital anomalies, which is a phenomenal result."

Are there enough maternity beds in Dublin?

"I think it's not a question of beds because a lot of our work is outpatient. It is really a question of staff. That is where we fall down - Ireland has the lowest number of obstetricians in the OECD. This hospital has 8.7 wholetime equivalent obstetricians, 3.5 wholetime equivalent neonatologists, and we are below the recommended ratio of midwives. So this is a real challenge when you look at the volume of people coming through the door. Our infrastructure and space is also a problem."

Can 'doing more with less' compromise safety?

"We are certainly doing a lot more with a lot less. Our outcomes, thankfully, so far appear to be holding up but if you keep on cutting, yes you will have to restrict services. Some of that service restriction won't cause death and harm, but it would cause a great deal of inconvenience and low grade morbidity."

Would cuts, if they get to a certain stage, ever affect maternal mortality and morbidity?

"If you cut things enough it will it will. If you keep on cutting, and there isn't adequate staff to deal with cases then you will. One problem we have at the moment is the complexity of our cases. Our typical patient is changing. Women having babies tend to be older than before, there are increased rates of obesity, increased diabetes, increased multiple pregnancy, an increased number of women who have underlying disorders who are now getting pregnant because of better healthcare. So that is giving us a much more complex groups of patients and I think that is going to impact on morbidity and on mortality."

"So we need to invest in our future if we are going to be able to manage these women appropriately. We need now to lay down the infrastructure and the resources that can deal with these very complex cases. We must work in an environment that can provide these women with all of the disciplinary expertise that they require to navigate their pregnancy and delivery."

Is the level of litigation against maternity services affecting the provision of care?

"I think the current system (of seeking redress in cases of alleged negligence/adverse events) is not working very well. The courts are overwhelmed and the medical services are struggling to keep up with the volume of work. The current legal system is one of tort, that relies on finding fault in order to compensate. So if you like, the 'pillars' of medical negligence, are blame, litigation and punishment. Most doctors and midwives set out to do a good job, to care for their patients to the best of their ability. Not all adverse outcomes are the result of a person being negligent or careless, so it is very difficult for staff to be faced with the accusations and the personal questions raised about them when they go through a litigation case."

"It is extremely difficult for staff when they find themselves in a courtroom setting. We are not trained for that. Doctors and midwives by their nature are inherently self-critical, that is the way we are trained and so it can be very damaging for staff to go through this."

"We actually now have a medical disorder called 'medical malpractice syndrome' suffered by clinical staff. The symptoms include anxiety, loss of appetite, depression etc." Dr Mahony says there is certainly quite a high rate of depression among doctors and midwives who go through the legal system.

"What we see in some cases, what I have seen directly and this hospital has experienced, is people changing their practice following a major case. They may either stop practising or avoid high-risk situations, or take early retirement."

"That, of course, is not to say that where harm is done people should not be compensated. There are very clear-cut cases where an error has been made and it is imperative that patients are cared for and looked after - there is no issue with that. But in many cases the causation is complex, and so many days and weeks and years are spent arguing the toss in these cases."

But the bottom line is, Dr Mahony points out, that if a patient is to be compensated then fault must be found under the current system.

"A doctor or midwife must be blamed and that is very difficult in this climate where everyone is working so hard and doing their best. This is also difficult for the patient, of course, who has to go through the system."

"As regards solutions to this, there is no perfect system. You look at no-fault compensation , mediation etc, in other countries and it is not always as simple as it sounds. But I think we need to look in Ireland about how we can do it better."

Cerebral palsy

"This is a major issue. Obstetrics accounts for over 60% of the medical litigation payouts in Ireland. This is largely related to the fact that cerebral palsy is within our sphere. It is a catastrophic outcome for the child and for the family, and what we find is that the aetiology of the condition is very unclear. It is certainly not all related to labour. Some people estimate that only 10% of cases are related to labour and underlying this there can be genetic causes, prematurity, metabolic disorders etc, and the problem here is that it is very difficult for parents to access care from the word go."

"So they either don't have a legal case, or they have a case that can take many years to go through the High Court, and I think we should be aiming to care for 'every child, every time'. She points out that parents often have no choice but to litigate in order to get the necessary services and income; often they have to give up their jobs to look after their child.

"Our first priority must be to care for these children and their families. What you don't want to see is some children and families having no compensation, some not getting enough, and others perhaps some getting in excess of what is required."

Major recent developments in maternity care

Rhona Mahony believes among the major developments in maternity care in recent years has been advances in terms of survival of pre-term infants.

"The good thing about our care for pre-term birth is we are managing very well to deal with babies born early once they are born. We understand the importance of in-utero transfer, allowing the baby be born where the tertiary neonatal unit exists."

"We can give antenatal steroids to promote lung development; which makes a big difference in terms of respiratory distress and inter-ventricular haemorrhage, which are two big complications for pre-term births."

"We have now introduced magnesium therapy for babies as a neuroprotective element, which reduces the outcome of cerebral palsy in very pre-term babies. At term, the big development has been using therapeutic cooling for babies with neonatal hypoxic ischaemic encephalopathy (lack of oxygen during delivery) and that is reducing the incidence of adverse neurological outcome."

However, there is still one issue that puzzles obstetric experts.

"We still haven't got to the 'holy grail' of why women give birth early. Pre-term birth accounts for 75% of perinatal mortality and over 50% of the long-term adverse outcomes like cerebral palsy. We still don't know why women go into labour when they do - it's as basic as that."

However, Dr Mahony point out that very small babies indeed can now survive. "Our threshold of survival is about 23 weeks and about 500 grams. It's not just about survival, it's really about intact survival."

"We have made huge progress after 26 weeks in terms of the survival rates and the quality of that survival. We are still struggling between 23 and 25 weeks. It is very difficult to make a big impact there on mortality and morbidity ,- those babies are very tiny. We have had one baby here who is doing brilliantly who was surviving from 440 grams (around one pound), which was tremendously exciting for the hospital."

Governance structures

Holles Street's governance structures are facing change with the rearranging of hospitals into groups and a drive to modernise voluntary hospital governance.

"We are still not quite sure how that will pan out. We are now part of the Ireland East hospital group. We are looking at how we can care for our patients in a network of hospitals and make things better in terms of services, but the detail is a little bit unclear at the moment."

Does she agree with the Holles Street Governors Chairman, the Catholic Archbishop of Dublin, that the Holles Street governance structure is anachronistic, certainly in terms of having the Archbishop as chair of the board?

"I don't think he meant this particularly as a critical comment. I think he was being relatively positive in terms of just allowing the hospital create a modern environment. We have a very robust governance structure at board level and internally. And we have been updating and upgrading our governance structures."

In the modern sense, Rhona Mahony says. the National Maternity Hospital is not a Catholic hospital.

"The Archbishop is very much a titular head. I have never met him. He has not in any way sought to interfere with hospital policy. We have a range of religions and ethnicities attending our hospital. And our staff are the same, so we do not see ourselves as a Catholic institution."

The abortion debate

Dr Mahony played a prominent role in the debate leading up to the passing of the Protection of Life During Pregnancy Act.

She says the guidelines to be drawn up in line with the legislation will be very helpful in terms of the day to day operation of the legislation and will be very necessary.

"I think that is the step we are waiting for now and they will give clarity as to how this will play out. But again, very little changes practically with the legislation, despite the intense debate. This legislation does not change practice particularly, it very much copperfastens what existed already in terms of the Supreme Court's interpretation of the Constitution. And it really just addresses the criminality that existed under the 1861 Offences Against the Person Act."

As to whether further liberalisation of the law on abortion is likely in the longer term, Rhona Mahony says that would be much more a question for society than obstetricians.

"Obviously, the recently passed legislation was very medical. We were dealing with risk to life and therefore we had a role in that conversation, But in terms of liberalising and providing choice, that is a matter for society."

Maternal mortality

Maternal mortality rates have been highlighted lately in the wake of the tragic death of Savita Halappanavar. Dr Mahony stresses Ireland's rate is low by international standards.

"Our rate is somewhere around 8 per 100,000, in America it is about 24, in the UK it is about 12.5. I think we perform really well in terms of maternal mortality. What should be borne in mind is that we have much fewer resources than many other countries yet we are performing extremely well. We should never be complacent; the whole issue of maternal mortality is very much a global conversation and there is no sensible obstetrician practising in the world who isn't very concerned about it. Most maternal deaths are related to issues like haemorrhage, high blood pressure, sepsis, clots in the leg or the lung."

"I think the new early warning system recently introduced for maternity care here will be very helpful. Should it have been put in place some time ago? "There's nothing new about an early warning system;we have always looked at blood pressure, pulse, routine respiratory rate, temperature, etc. These observations have been recorded for many years."

"I think with the new system we will standardise care throughout the State and that is a very good thing. I think where we have adverse outcomes, the main consideration must be to learn and to put systems in place to prevent such a thing happening again. This is not always possible; obstetrics is very unpredictable, very challenging, but we must never waste any learning opportunity we get."

"We can spend a lot of time blaming people and looking for heads to roll but the most important thing is that we learn. I think a lot of lessons have been learned from the Savita Halappanavar case and will be carried forward, and that is as it should be."

Birth options

"We work hard to provide a range of birth options for mothers. We are the only maternity hospital in Dublin running a home birth service. Then we have the Domino service. We have midwifery-led clinics, we have doctor- led clinics, we have high-risk clinics. We have private options for patients if that it what they choose. We really do try to give women a range of choices they are comfortable with so that they can choose a package of care that suits their needs"

As for her views on home birth, Dr Mahony says Holles Street has had a very good experience with its home birth scheme. "But it is very carefully regulated so we have very strict criteria as to eligibility for home birth and a very clear understanding that if a situation arises where we feel there is risk then there is a seamless transfer to hospital care."

"For first-time mothers, there is a very high transfer rate to hospital with home birth, up to 50%, and that merits consideration, but for women who may be having a second or third baby who are very uncomplicated it can work well. But obstetrics is unpredictable and things can sometimes go wrong very suddenly."

As regards the view in some quarters that the HSE places too many restrictions on women seeking to have home births, Dr Mahony says this all comes down to a safety issue, which has got to be paramount.

The Mastership system

"I think the Mastership system is a very good one. I am essentially CEO of the hospital. I have a very good understanding of obstetrics and gynaecology so I understand my business very well. It is a seven-year post and the work is very arduous and extremely demanding at every level"

She does not necessarily think the title Master needs to be changed, even though two of the three Dublin maternity hospital Masters are now women. "I think the title Master is an affectionate one within the hospital and everyone understands what the title Master means. So it's a case of ‘what's in a name?' It doesn't bother me. The point is the clinical involvement in the strategic development of an organisation, that's what is key."

 


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