'Maternity staff cuts affecting care'

  • Niall Hunter, Editor

 Updated 26/3/2015

An obstetrician who plays a key role in compiling statistics and carrying out research on maternity services says staff shortages in maternity units may be a factor in how adverse care incidents are being handled.

Prof Richard Greene, who is Professor of Clinical Obstetrics at UCC and Director of the National Perinatal Epidemiology Centre (NPEC), says, however, that research carried out at his centre does not raise obvious alarms about the overall safety of maternity care in Ireland, which he say still scores well in international comparisons.

On the controversy over infant deaths at Portlaoise hospital, he says an analysis of the results from this unit by his centre has indicated that its rate of unexpected deaths was well within current norms. Prof Greene stressed, however, that problems in cases such as Portlaoise point to the need for better communication between hospital staff and families.

A HIQA inquiry report on the Portlaoise deaths, a draft of which is currently the subject of a legal dispute between the health safety body and HIQA, is not expected to be published in final form for a number of weeks.

Prof Greene also revealed that the number of maternal deaths in Ireland in 2013, for which statistics are being finalised by his centre, was half of that reported the previous year.

In the latest national analysis on perinatal mortality (deaths of infants around the time of birth) by the NPEC, it was noted that there was a three-fold variation in the perinatal death rate among maternity units nationally in 2012.

This, however, says Prof Greene, is as to be expected. "Although there are differences in terms of the actual numbers, statistically this is not significant in terms of analysing the figures. We look at the figures on a unit by unit basis, so if you were a small maternity unit, and you might have an extra case of perinatal death in any one year, you can really look out of kilter, whereas if you look at the figures based on the size of the unit, you will find that the majority of units are falling within the mean and are within the statistical limits we would expect."

Breaking down the stats further in to neonatal (newborn) mortality rates, the 2012 report shows that there was one 'outlier' unit that was above the norm as regards this type of mortality.

"This unit, which is one of the bigger centres that takes referrals from elsewhere, is actually going through this in detail. They are working through this to see what exactly their differences are under this heading and we will be reviewing it with them."

This unit did not have a neonatal mortality rate above the norm in previous years, says Prof Greene, so it may have been a ‘blip'.

The latest national perinatal report specifically highlights unexpected infant deaths following intrapartum events (something happening during the labour or birth) of normal birthweight infants.

This issue has come to the fore recently following the controversy over infant deaths at Portlaoise Hospital.

The report stresses the need for further investigation of perinatal deaths of intrapartum origin. Says Prof Greene: "This has become very topical in Ireland because of the Portlaoise case, where babies died during labour or subsequently because of problems in labour."

"We looked at the national figures when that came out. We also looked statistics for individual units for these deaths and there was no statistical difference between the units. We went back over these statistics over a couple of years. The figures at the smaller units tend to go up and down, and one case can lead to an increase in the mortality rate, but they were all still within the range you would expect."

"Whereas Ireland's rate was around one in 6,000 infants, the rates in one recent Scottish report were one in 2,500 and the rate in a review done in an English centre was around one in 4,000. On the basis of the information we can get, Ireland appears to be performing better than some of our neighbours in terms of that particular group of babies who died."

Prof Greene says this is a group of infants whose unexpected deaths units would like to learn lessons from because they are generally normally-formed babies and there would be an expectation that most of them should survive.

He stresses that despite the public concerns over these deaths, the analysis done to date by the NEPC would not raise any specific alarm bells on service quality and safety.

Prof Greene says while there had been a question about safety in terms of these deaths when the Department of Health's report on Portlaoise came out last year - on a national basis NEPC data suggest that Ireland compares well internationally for unexpected infant deaths due to intrapartum issues.

"Looking at the Portlaoise figures, if we took their rate for these deaths over the period the Department of Health report looked at, which was six years, and compared it against all their deliveries over that time, and compared it with perinatal figures for the three years (2009-12) we had for all units, they fell right in the middle of the range for maternity units in the country."

"Obviously with these cases on an individual basis, sadly they are tragic events for the families concerned, but there is always something you can learn from them, and units do look at infant mortality on a rolling basis with this in mind. So there is quite a lot of audit going on in the maternity services."

However, Prof Greene admits that a lot of the problems in cases such as Portlaoise come down to communication - "how we deal with these scenarios, whether we have openness, discussing the issues and if there are problems, identifying where we went wrong."

He said while the final figure was yet to be confirmed, it is estimated that there were between four and five maternal deaths in maternity units in 2013, half the number reported in 2012. Maternal deaths are recorded and examined through the Maternal Death Inquiry Ireland (MDE Ireland) system, which is attached to UCC.

The number of maternal deaths reported in Ireland between 2009 and 2012 was 38; however this included seven 'coincidental' deaths not due to either direct or indirect obstetric causes, leaving 31 deaths between 2009 and 2012 from either direct (due to an event surrounding the pregnancy or birth) or indirect (due to an event related to a pre-existing condition in the mother worsened by pregnancy).

While there were 10 deaths reported in 2012, the numbers reported in 2013 were lower; while the final figure has yet to be confirmed, there were between four and five maternal deaths, both direct and indirect, in 2013.

This includes three deaths at the Rotunda and one in Sligo Hospital (the extensively-reported death of Sally Rowlette).

"In 2012 there had been a bit of a blip upwards on the average number of maternal deaths. The figures in 2013 won't alter the average maternal mortality rate in Ireland very much, which is currently around 10 per 100,000 maternities, and once the 2013 figures are factored in it will probably be just below the 10 mark, when we have finalised those cases."

Prof Greene says there is a perception that maternal deaths are on the rise, which is not necessarily the case.

"People are seeing the figures now and are comparing them to the time prior to the confidential inquiries starting through MDE Ireland from 2009, when until then we had quoted rates of around two per 100,000. These were figures from the Central Statistics Office (CSO). We have worked with the CSO and have looked at the cases that were reported to them. In the majority of cases these were direct maternal deaths from direct obstetric causes, and they were not always capturing the indirect deaths."

Do the number of maternal deaths in Ireland in recent years raise any concerns about quality and safety of services?

"We know there is no evidence of clustering of cases in any one hospital since 2009. Two major hospitals in one year had three deaths and two deaths - most of them were indirect deaths. Some hospitals will have had one death and most of the other hospitals would have had none, and it would vary around that generally from year to year."

"The reason we do this research, however, is to see if there are any things we can improve on. The single most common direct cause of maternal death is thromboembolism - leg clots or lung clots. That is the same as in the UK. There is a new guideline just published on managing thromboembolism in pregnancy. Hopefully, as this guideline is adopted we will see some improvements in this area. Five of the direct deaths from 2009 to 2012 were associated with thromboembolism."

Other causes include pre-eclampsia (hypertension in pregnancy) - there was one death due to this in 2012 and one in 2013. Sepsis (the cause of death of Savita Halappanavar in 2012) is a rare cause of direct maternal death as in the Savita cause, but there were also two maternal deaths between 2009 and 2010 from sepsis associated with swine flu, according to Prof Greene.

In international terms in relation to maternal mortality, says Prof Greene, our maternity service is relatively safe.

"The closest we compare ourselves to statistically, as they do similar detailed analysis, is the UK and France and both those countries are around the 10 per 100,000 maternities mark. So we are doing as well as them." And if you look at figures from the United States, they are in the twenties per 100,000 at least, he adds.

Asked if recent controversies on infant and maternal mortality raise issues about the viability of smaller units in terms of critical mass and safety, Prof Greene says the research carried out at his centre would not bear this out.

"No, we wouldn't see that, and in fairness to a lot of the smaller maternity units here, things that would help them would include their linking with larger units in the new hospital groups. I think that would help to show that these smaller units are doing a good job.

"An analysis would show that that even our smallest maternity unit, with around 1,000 deliveries per annum, is actually a comparatively big unit internationally."

However, Prof Greene agrees that maternity services are getting a little more complex. "We now have greater ethnic variations than we used to have, we have an increasing number of women who have particular diseases before they enter pregnancy, we have increasing rates of obesity, for example."

"So one of the concerns I would have and one of the reasons we have had some of the issues of maybe not dealing as well as we could with patients and families who have a bad outcome in this country, in terms of both maternal and perinatal deaths, has a lot to do with the actual staffing levels in units. I think overall, staff are managing to do a reasonably good job, but maybe they are not able to give as much to some of these cases, and to doing reviews.

He said while good clinical outcomes were being achieved, "the issues with some of the events that have been reported are more around people maybe missing some cues with respect to particular cases, people perhaps not being able to devote enough time to parents, for example."

Prof Greene said if units are short on staffing, there are potential repercussions from that. Prof Greene said it should be borne in mind that Ireland still has one of the lowest rate of obstetricians per population among OECD countries. "As things get increasingly more complex in maternity care, that sort of factor must have consequences."

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