A leading obstetrician and head of the HSE's maternity service programme has said he is concerned that Ireland's historically low maternal and infant mortality rates could increase in future if funding and resourcing of maternity care is cut back too much.

Prof Michael Turner, Director of the HSE's obstetrics and gynaecology programme, told irishhealth.com that such cutbacks could also see an increase in Ireland's perinatal mortality rates, which have been decreasing in recent years.

"We still have one of the lowest maternal mortality ratios in the world. Having said that, there can be no room for complacency. My concern is that unless we prioritise maternity services we will see in the future an increase in maternal deaths if we cut maternity resources too much - that is the price that will be paid."

"And then what usually happens is there is a crisis and a knee-jerk response. We could face the same danger with our perinatal mortality rates," he added.

A recent study at the Coombe Hospital showed that the maternal mortality rate there over a 15-year period was only 2.7 per 100,000 live births.

In an interview with irishhealth.com, Michael Turner said the results in Ireland for maternal and infant deaths have been very good, and there was a reduction in the numbers of stillbirths and neonatal deaths in the years 2005 to 2009.

Prof Turner, a former Master of the Coombe, said while the physical state of the three Dublin maternity hospitals was less than ideal, there was a danger of focusing too much on the facility.

"From my perspective I think it is more important to focus on the number, quality and training of the staff. There is no point in having a world-class facility if it is not well-staffed and if the staff are not well-trained."

However, he said the health service recruitment embargo had hit maternity care like other areas of the service.

"This is an important issue that we are discussing with the HSE. It should be pointed out that Ireland has the lowest number of consultant obstetricians among OECD countries. Greece, which has also had the IMF in, has nine times as many obstetricians as we have."

He said maternity services needed to be prioritised in the context of planned cutbacks. "The analogy I would use that of a ship is sinking, traditionally women and children are prioritised when it comes to the lifeboats. We have to invest in our children and mothers because otherwise there will be life-long consequences from failing to do so."

Prof Turner also said there had been an 'exodus' of patients moving from private to public maternity care, as a result of the recession.

Michael Turner on:

Need for new hospitals

"The three Dublin maternity hospitals are fit for purpose in the sense that they have outstanding clinical results, which is a tribute to the people working there. But if you were building a service from scratch you would locate the three hospitals on the site of general hospitals. But that is clearly going to take a lot of capital expenditure. The current economic situation means that in my opinion, the Department of Health and the HSE are going to have to prioritise the new children's hospital, and in the meantime the maternity hospitals will have to make do with the facilities they have."

Pressure on maternity services

Prof Turner says as regards increased pressure on maternity services at a time of restricted resources, it should be emphasised that these services are demand-led. "Those of us working in maternity have no control over fertility rates. We can't control when people get pregnant and when they decide to go into labour, so it is very much demand-led. Ireland has the highest fertility rate in the EU and this will mean ongoing pressure on maternity services."

He points out that the maternity services have to provide 24/7 care. "Youn cannot defer maternity care for a woman and you cannot put her on a waiting list. Resource issues make it a challenge to deliver high quality maternity care. On the one hand you have pressure to reduce resources and then you have an increase in demand and high expectations in terms of risk, safety, facilities etc.

'Exodus' from private care

Prof Turner also points out that due to the recession, many women are no longer opting for private maternity care. There had been an exodus out of private maternity care into public care and this meant that the income stream for public hospitals treating private maternity patients has decreased substantially.

"And what has made this different from previous recessions is that even the professional classes can no longer afford private maternity insurance cover, eg. architects, young solicitors. This is a new phenomenon, and it is a major factor that is putting pressure on services, particularly outpatients."

Choice in maternity services

"The number of home births in the country is relatively small - there are approximately 200 home births per year out of a total of 70,000 plus." Asked whether that was due to the failure of the system to offer support for home births or women's personal choice, Prof Turner believes it is partly down to women's personal choice.

"A recent Coombe/UCD study asked women if they wanted the option of a home birth. Only 1.6% said they did and of these half were not suitable medically for home births. So you're talking about less than one per cent of women who want this option and who are medically suitable."

"The HSE Clincial Programme in Obstetrics has set up a subgroup looking at the different models of maternity care, including home births, domino, and midwife-led units, and it will be looking at whether all the different models of care should be available nationally in all 19 maternity units. We may not have the resources to roll out every option in every hospital."

Caesarean section rate.

Prof Turner stresses that the caesarean section rate in Ireland overall is in fact not high by international standards. "So it is a myth that our rates are much higher than other countries. The rates have increased in Ireland like anywhere else. If you look at caesarean section rates among OECD countries, we are around the  middle. I don't believe it is as great a cause for concern as it  is sometimes portrayed."

He says, however, that there are variations in caesarean rates between hospitals in Ireland and the HSE Obstetrics Programme is looking into this to see if care can be standardised nationally.

Prof Turner says one of the factors in the increase in caesareans in recent years is that it has become a safer procedure nowadays. "If a woman had a section in Dublin in the 1950s she actually had a 3% chance of dying."

Male dominated maternity care?

Another myth, Michael Turner claims, is that maternity care in Ireland is male dominated in terms of those providing it. "In the Coombe, the overwhelming amount of work is done by female midwives. Yes, in the past it would be safe to say there were very few women who went on to become consultants. However, now the majority of consultants in obstetrics and gynaecology currently being appointed are women and that is a good thing. We now have a woman Master of the National Maternity Hospital in Holles Street. My own experience is that hospitals function best where there is a good blend of female and male staff."

Is 'going private' worth it?

Again, Prof Turner says, this is a question of choice. "Women value continuity of care and if you have a doctor who has for example attended you with a gynaecology problem in the past, women may want the choice of staying with the same doctor for maternity, and this is easier in the private system. Also, you have the issue of having single rooms in private care, which some women may prefer. It's all down to choice."

"Some women would prefer to spend their hard-earned money on attending a hospital privately, others would prefer to attend publicly and perhaps save the money for a sun holiday. It would be hoped that the standard of care would be high no matter what option a woman picks."

Missed miscarriages

Prof Turner says following the miscarriage misdiagnosis scandal, where women were wrongly told their pregnancies were not viable, and the subsequent review of the issue last year, considerable progress has been made in improving the standard of early pregnancy care.

He said early pregnancy assessment units had now been established in all 19 maternity hospitals, all of which now have high spec ultrasound machines.

Other measure have included proper training for medical and other staff in ultrasound. National guidelines on ultrasound in pregnancy have also been drawn up and improvements in the service are to be audited, Prof Turner said.

"The fact that we had a national audit of missed miscarriage over five years gave us an opportunity, which was unique internationally, to study the problem and I think this has led to improvements in early pregnancy care, which I hope will reassure women and their families about the quality of ultrasound in our maternity services."

He said it should be emphasised that miscarriage misdiagnoses are extremely rare and were not unique to Ireland. "We only recently had a major controversy about this in Britain."




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