Three women walk into a hospital.....

Three women walk into a hospital......

 

Irene Irishwoman, Polly Polish woman, and Lisa Lithuanian woman.

 Irene the Irishwoman says "I'm a first time mum I need to see a consultant"   

 Polly the Polish woman says 'I'm a healthy first time mum - why do I need to see a doctor?”

and Lisa the Lithuanian woman says “why am I in hospital?” 

 
Who ends up with the unnecessary caesarean section?   

 

 

AIMSI have just been sent some new research called:

"International variation in caesarean section rates and maternal obesity".
V. O’ Dwyer1 , R. Layte2 , C. O’ Connor1 , N. Farah1 , M. M. Kennelly1 & M. J. Turner 1

Study Purpose:

"This study examined variations in caesarean section (CS) rates associated with a woman ’ s birthplace and differences in maternal adiposity. Women were enrolled in the 1st trimester. Maternal adiposity was assessed by body mass index (BMI) and bioelectrical impedance analysis (BIA). Irish women were compared with women born in the 14 countries who joined the European Union (EU) before 2004 (EU 14), and with those born in 12 countries who joined following enlargement (EU 12)."

"Based on place of birth, the women in this study were grouped

into Irish women, those from all the other 14 European Union
(EU) member countries before EU enlargement in 2004 (Austria,
Belgium, Denmark, Finland, France, Germany, Greece, Italy, Luxembourg, Netherlands, Spain, Sweden, Portugal, UK) and those from the EU 12 countries that joined the EU aft er 2004 (Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia, Bulgaria and Romania)."
 

 Findings:

"We found that the emergency CS rate in primigravidas was increased in Irish women compared with the rate in women born in the countries admitted to the EU since 2004. The increase in CS rate was associated with increased maternal obesity in the women born in Ireland."
 

"There was no difference in the rate of pre-eclampsia between the three groups (Table I). There was a higher rate of gestational diabetes mellitus (GDM) among Irish and EU 14 women compared with EU 12 women (Table I). Of the women with GDM, nine had a normal BMI, 13 were overweight and 40 were obese. Labour and delivery details are shown in Table III.

There was a higher rate of induction of labour among the Irish compared with the EU 12 primigravidas (p 0.05).

The emergency CS rate was higher in Irish primigravidas compared with EU primigravidas (p 0.001).

The main indication for CS was fetal distress in labour (54.0%).

There was no difference in the CS rate between multigravidas from Ireland and multigravidas from other EU countries.

There was no difference in the mean gestation at delivery, mean birth weight or number of babies born weighing 4kg between the three groups.

There was no difference in the mean age between the three groups. Irish women were more likely to smoke than other EU women. However, the CS rate was not affected by smoking status."

 

 AIMSI Thoughts:

 AIMS Ireland fully accepts that maternal obesity is a growing concern in relation to perinatal and maternal health, however, previous studies may suggest other factors which could have affected outcome.

 * First time Irish mothers are more likely to have private health insurance and attend a private obstetrician compared to non-nationals. As we have seen from several studies, attending a private obstetrician increases the risk of Caesarean Section significantly, this Irish Times article suggests as much as 74%

Caesarean rate higher in private care http://www.irishtimes.com/news/health/caesarean-rate-higher-in-private-care-1.1403506

* Non-Nationals are less likely to use epidural in labour. The epidural means that your labour is considered 'high risk' and will require different management to 'low risk' labours. This includes the use of continuous monitoring (CTG) which is shown to have high rates of false positives, increasing a women's risk of intervention and caesarean section.

"Three quarters of non-national women have a normal vaginal birth rather than a caesarean section or vacuum birth. This is far higher than the rate for Irish women of 65%. A fifth of non-nationals (23%) had induced labour, a third lower than the Irish rate of 31%. "

29% of non-nationals used epidural compared with 42% of Irish women.

Non-nationals opt for natural births http://www.irishexaminer.com/archives/2006/1025/world/non-nationals-opt-for-natural-births-16606.html

* This study was done in the Coombe, which follows an induction policy of term+ 10 days. Private Patients often have a shorter post dates period.

If you look at the results for this study Irish while Irish first time mothers had higher Caesarean rates than their EU counterparts. Interestingly, the results between Irish and Non-national women appear to be the same if they have given birth before. AIMSI feels this illustrates the point that the cultural beliefs of Irish women put them at a greater risk of Caesarean Section by going private as first time mothers.

It would be interesting to see the results of a similar study with public patients within a unit of term+14 days induction policy.

 




 



 

AIMSI points to consider - discussion of High Court Case - Aja Teehan vs HSE

There has been much discussion following yesterday's High Court case of Aja Teehan vs HSE, much of which is uninformed, incomplete, and one-sided.

AIMSI would like to put forward the following points to this discussion.

1. This is about the right to self determination on the circumstances of becoming a parent - hospital or home, with a doctor or midwife, with pain relief or not - every woman must make the choices which she feels is best for her and her baby. The HSE can provide guidance and recommendations, however the ultimate decision must be the woman's.

2. In the discussion thus far, "risk" has played a heavy focus. There are no absolute risks in childbirth and each care option poses specific, individual risk potential. Informed choice means women understand the benefit and risks of each care option, selecting the care option that she feels most comfortable with.

The risks cited have been only with regards to giving birth at home after a previous Caesarean Section (HBAC) - mainly to do with uterine rupture.

Points:

* The rate of uterine rupture in Ireland is low. The rate is 2 per 1000 women overall, or 1 per 1000 for women in spontaneous labour who did not receive oxytocin augmentation (Turner et al, 2006). That means that 999 women will not rupture out of 1000.

* Of the small percentage of women who do rupture, even a smaller percentage of women will lose their baby or require a hysterectomy. In the rare instance of rupture, 94% of babies survive. Guise et all 2004 via Midwife Thinking

* Uterine rupture is associated with women whom have had a previous caesarean section, however, uterine rupture can occur with women with no previous Caesarean history.

* The risk of uterine rupture during a VBAC is actually lower to those of other possible birth complications of which are present in all vaginal births. First time mums are at risk for complications that are equally serious to uterine rupture and occur at a similar rate.  For example, placental abruption, (Deering 2013) cord prolapse, (Beall 2012) and shoulder dystocia. (Allen 2011)

* VBAC is safe. Overall,  around 70%  or more of women who try VBAC will give birth vaginally. If a woman has given birth vaginally previously, this rises to 90% (9 out of 10 VBAC women will birth vaginally)

* None of the risks cited above are reasons to undermine a woman's right to choose how or where she births.

3. The discussion of risk has been incredibly one-sided. The risk of going to hospital and/or the risk of a repeat Caesarean Section are real and substantial.

Points:

* Risk of hospital - Kilkenny is a maternity unit which has been flagged as having a disproportionate rate of Caesarean Section.

Kilkenny has a VBAC rate of only 2% (best practice recommendations is 70%)
43% of first time mothers in Kilkenny have a Caesarean Section
32% of second+ time mothers in Kilkenny have Caesarean Section
These rates are well above the National average and recommendations for best practice.

Hospital care in Ireland is obstetric led in practice and policy and include many routine interventions which increase distress to babies in labour and increase the risk of  adverse affects with women - intervention, assisted delivery, or caesarean section. Routine means that the practice or procedure is done as a normal practice on every woman, not down to medical necessity or evidence. Other practices may not be routine for every woman, but are frequent in use despite risks. For example recent research by the ACOG has shown the use of oxytocin - for induction of labour or to 'speed up' labour - is an independent risk to babies and increases NICU admission.

 * Risks of Repeat Caesarean Section - the risks associated with Caesarean Section increase with each section. They include:

~ increased risk of ectopic pregnancy in future pregnancies
 ~ increased risk of placenta previa (when the placenta covers the cervix)
 ~ increased risk of placental abruption (when the placenta comes away from the uterus before the baby is born)
 ~ increased risk of placenta accrete (the placenta grows into or through the wall of the uterus)
 ~ increases likelihood of problems for women – haemorrhage, blood clots, infection, scar pain
~ increased risk of severe complications - severe morbidity - such as hysterectomy
 ~ increases time of hospital stay and the instances of re-admission
 ~ longer recovery period
 ~ increases the likelihood of problems for babies – admission to NICU, breathing problems, cuts from incision

* Death - while the risks are relatively small, as with all major surgical procedures, there is a risk of death. The risk of death in a woman following a Caesarean section is believed to be less than 1 in 2,500. The risk of death in a woman following a vaginal birth is believed to be less than 1 in 10,000. There is a higher risk for emergency Caesarean Sections vs planned Caesarean Sections.  Cunningham FG, et al. (2005).

* Severe Maternal Morbidity Audit report from Cork's National Perinatal Epidemiology Centre took a national audit of Irish maternity units looking for instances of  severe maternal morbidity (complications). Severe maternal morbidity is essentially the 'near misses'. The audit found that the most instances of severe maternal morbidity in Ireland was postpartum (after the birth) and the main mode of birth was by Caesarean Section.

Despite the substantial increased risks of repeat Caesarean to mothers and babies the HSE recognize the mother's right to self determination in these cases - women are not denied repeat caesarean where requested by the mother. The risks of going to hospital for a VBAC is an increased likelihood of a repeat Caesarean, and the implications this has on mothers and babies. Given Kilkenny's rates of Caesarean and VBAC, this risk is magnified.

It is up to each woman to weigh the risks of HBAC, VBAC in hospital, repeat Caesarean Section comparatively in order to decide what is right for her.

4. It has been suggested that a woman should not expect the HSE to pay for a Homebirth.

* This woman has secured a private midwife and is willing to pay for a homebirth. She is not legally allowed to. The State has made it ILLEGAL for a midwife to attend a woman outside of criteria (VBAC one of many) as the midwife is not insured to do so. Midwives who attend women without insurance  are punishable by law with a €60,000 fine and/or 10 year prison sentence.

* The HSE has said women who fall outside criteria still have the right to have a homebirth, they just can't have a midwife attend them legally. What are the HSE advocating exactly? Homebirth has been shown in many studies to be as safe as hospitals when the woman is attended by a professional midwife and a good transfer system is in place. Unassisted homebirth is associated with more risks.

* In terms of cost, a Caesarean Section is believed to cost the health service double that of a vaginal birth (Turner), yet the public, State, HSE do not put barriers up for women in this mode of birth.

* women can access public or private obstetric led care in every region and maternity unit. The same choice should be afforded for midwife led care - MLU, DOMINO, Homebirth

* The Mid-U study found that the same birth, for the same woman, costs over €300 more for women in a consultant led unit (CLU) vs a midwife led unit (MLU). But women in the MLU had less intervention, less adverse effects, and higher satisfaction rates.

* In a 2007 case study at NMH’s DOMINO scheme 5,500 bed days were saved by Community Midwifery Services in NMH Holles St. (Early Transfer home and DOMINO). The study also found Caesarean rates are significantly lower e.g. 2007 LSCS in NMH 18.92%, LSCS in DOMINO NMH 5.86%

5.  An Equitable system means that women have access to all care options and equal care regardless of where they live or ability to pay. If we are happy to support the cost and choice of women having consultant led care and surgical modes of birth, interventions (despite added cost and risk), then we also support women who decide to have midwife led care options in hospital or the community.

6. The HSE are stating that the criteria created for homebirth eligibility is based on evidence and practice in other jurisdictions. AIMSI would like to know what jurisdictions.

* The HSE criteria appears to be directly pulled from NICE in the UK with one difference, NICE recognizes informed choice and specifically states the final decision is with the woman and must be respected.

* When querying the HSE eligibility tables, AIMSI directly cited this point. The HSE directly stated that the tables were not based on NICE.

* Best practice clearly states that patients should be assessed on an individual basis on their current health, current medical conditions, as well as their previous history. The HSE are not providing women with individual assessment, a fundamental principal in evidence based care.


7. The ECHR (European Court Of Human Rights) found that it is a human right to  privacy, and the human right to privacy encompasses the right to choose the circumstances on becoming a parent. Any State which has signed up to the European Convention, has agreed to be bound by the judgement of the court. However, as Ireland has slightly different legal agreement, the Constitution rises above the European Convention in Irish law.

The HSE have invoked article 40.3.3 in their argument to argue that the State has an obligation to protect the life of the woman, as well as the foetus. 

 We have seen the HSE invoke the Constitution in maternity care before, including recently circulated guidelines for consent which state:

* Draft Guidelines on consent for pregnant women state: "The Consent of a pregnant woman is reqired for all health and social care interventions. However, because of the constitutional provisions on the right to life of the 'unborn', there is legal uncertainty regarding whether a pregnant woman's right to refuse treatment extends to the refusal of treatment which puts the life of the foetus at serious risk. This matter can ultimately only be decided by the Courts. Thus, where a pregnant woman refuses treatment and this refusal may impact on the life of the foetus, it is essential that the consequences of the refusal are fully and clearly explained to the woman, and legal advice should be sought if she persists in the refusal"

8. There is an assumption that this case has been taken to force the HSE to grant a request for homebirth. It is not. From Aja Teehan " I'm looking to have their decision to deny me a homebirth quashed, and retaken again in accordance with law."

References and further information

VBAC Facts: More VBAC Facts: http://vbacfacts.com/13-myths-about-vbac/
Cuidiu Birth Statistics per unit in Ireland: http://www.bump2babe.ie/statistics/
Midwife Thinking: VBAC: Making a Mountain out of a Molehill: http://midwifethinking.com/2011/02/23/vbac-making-a-mountain-out-of-a-molehill/

1. Deering, S. H.; Smith, C. V. Abruptio Placentae, 2013. Medscape. http://emedicine.medscape.com/article/252810-overview#a0199.
2. Beall, M. H.; Chelmow, D. Umbilical Cord Complications, 2012. Medscape. http://emedicine.medscape.com/article/262470-overview#a30.
3. Allen, R. H.; Chelmow, D. Shoulder Dystocia, 2011. Medscape. http://emedicine.medscape.com/article/1602970-overview#a03

Update: Woman Forced to travel for D&C interviewed in Sunday Times

In March this year, AIMS Ireland was sent a story by a woman who was forced to travel for a D&C - we shared her story here: http://nocountryforpregnantwomen.blogspot.ie/2013/03/womans-story-uchg-denies-d-for.html

This woman decided to come forward and was interviewed in this past Sunday's Irish Times. The link is not available online, however, the woman has forwarded the text.

See below:

The Sunday Times, 14th July,

Justine Mc Carthy

A SPANISH woman who was refused surgical help after a miscarriage says she and her husband are leaving Ireland because they have no faith in its maternity services.

Lupe Royan, a mother of one, was almost 14 weeks pregnant when a scan taken at University Hospital Galway (UHG) on February 22 showed the absence of a foetal heartbeat. She claims that when she asked for the foetal remains to be removed from her womb, her request was refused.

“I told [the doctor] I was devastated by this loss and that I was aware there was a risk of infection,” Royan said. “Because the embryo only measured 7mm, she said she would have to book another scan for me in a week’s time and I would have to come back then. It was very cruel. I was thinking about what happened to Savita.”

Savita Halappanavar from India died at UHG last October following a miscarriage in the 17th week of pregnancy.

An inquiry report commissioned by the HSE was critical of her treatment in the days leading up to her death from sepsis.

Royan was referred to UHG by a Galway GP when she had a bleed at 11 weeks.

Following an inconclusive vaginal examination, an appointment was made for an ultrasound scan two weeks later, but she was not prepared to wait that long.

She paid €100 for a scan on February 16 at the Terryland Medical Centre in Galway, a private clinic that specialises in early-pregnancy ultrasound. The scan showed no foetal heartbeat and the clinic referred Royan back to UHG.

“I went to the hospital the following Monday and gave them the scan images and the report from the clinic,” Royan said.

“The doctor said they would have to do a second scan to make sure there was no mistake with the dates of my pregnancy. I understood that.”

The second scan on February 22 again failed to detect a foetal heartbeat. It showed an embryo of a size normally equivalent to about four weeks of pregnancy.

“There was no life there. This was clear,” Royan said. “The doctor said they would have to wait a week to do another scan to make sure it was a miscarriage. I asked her, ‘How can the embryo grow if it is dead?’”

Royan says two other doctors told her and Gonzalo Matanala, her husband, that medical protocol required that the hospital do its own second scan to confirm the miscarriage. Royan phoned a doctor in Valencia, Spain, whom she had attended during her first pregnancy. The doctor, she says, advised her to return to Spain where she would undergo a scan and a procedure known as “evacuation of retained products of conception”.

Royan, Matanala and their three-year-old son set off for Valencia on February 24 but she suffered a natural miscarriage en route.

“I don’t feel safe here [Ireland]. I would never try to get pregnant again in this country,” said Royan, who is moving with her family to Luxembourg.

“Ireland is very proud to be Catholic but it lacks compassion.”

The HSE does not comment on individual cases but it said: “Galway University Hospital adheres to the national clinical guideline on the management of miscarriage which was formulated by the National Clinical Advisory Group in Obstetrics and Gynaecology.

“This guideline recommends waiting a week or more between doing a first and second scan before intervention.”

In its section on the treatment of miscarriage, the guideline states: “Follow-up scans may be arranged at two-weekly intervals, until a diagnosis of complete miscarriage is made.

“However, if the woman requests a surgical or medical approach to their management at any stage, it should be arranged.”

Fionnuala McAuliffe, a professor of obstetrics and gynaecology, said: “Certain criteria have to be met to diagnose a miscarriage. We would err on the side of caution. I understand how this woman must have felt, but it is important to be sure. A foetal heartbeat only comes at about 6½ weeks and sometimes a woman can be less pregnant than she thinks she is.”

Thank  you to Guatelupe for coming forward and sharing her story.

AIMS Ireland support services: support@aimsireland.com 

Irish Inquests - Jo Murphy-Lawless looks at the inquest into Savita Halappanavar’s death and its aftermath

Irish Inquests - Jo Murphy-Lawless looks at the inquest into Savita Halappanavar’s death and its aftermath

The full inquest on the death of Savita Halappanavar opened on 8 April 2013 and concluded on 17 April, with the jury returning a unanimous verdict of medical misadventure. The jury also endorsed nine recommendations for fundamental change. Two of the recommendations alone reveal the
utter clinical impoverishment of Irish maternity services:

• that protocols on the management of sepsis along with ‘proper training and guidelines for all medical and nursing personnel’ should be instituted;
• that a protocol for sepsis be written for each individual hospital by its microbiology department and be applied nationally.(1)

University Hospital Galway is a third level hospital meant to provide comprehensive acute services for the western region of Ireland. It is beyond the bounds of understanding that a third level hospital had insufficiently clear protocols in place for the management of sepsis, including training, that were reliable, evidence-based, and above all, with all staff up to date on their use. It is beyond belief that the many clinicians involved in Savita’s care from Sunday 21 October 2012 to Wednesday 24 October were so hapless as to be unable to try to discern warning signs in her condition during that period and take swift action; or even to ask themselves what substantive risks there might be for a woman in the process of an inevitable miscarriage and proactively look for warning signs.
We know that obstetric clinicians, driven by interventionist imperatives, are quick enough to imagine the worst of outcomes for pregnant and labouring women in ordinary circumstances and react accordingly, very often to the detriment of women’s well-being. Why, when this woman’s condition did point to genuine risks, was she not strictly monitored? The inquest revealed that the confusion arising from the 1992 constitutional ruling on the X case, that a woman whose life is at risk can be given a termination, formed only one strand, if a significant one, in the appalling lapses of care Savita endured.

It is even more distressing to read a recommendation that calls for ‘proper and effective communication between staff on-call and a team coming on duty’.(1) Surely this is what comprises basic clinical care that people expect as a matter of course when entering hospital, that clinicians communicate effectively with one another?

The inquest explored a terrible catalogue of errors: the blood sample taken on the Sunday evening which was never followed up or noted again, which would have shown an elevated white blood cell count; an examination by the obstetric consultant on Monday morning, over eight hours after the membranes had ruptured fully, showing ‘no infection’, but a full blood screen and c reactive protein test were not ordered to confirm that; instead, a clinical decision to ‘await events’ was taken; readings showing an elevated pulse which were taken on Tuesday evening by an alert student midwife were not picked up by senior clinical staff; then a large gap of time when vital signs were not taken; Savita’s shaking with cold in the early hours of Wednesday morning was attributed to a cold room, with an extra blanket brought in for her, while paracetamol was given for her raised temperature, her pulse and blood pressure not recorded, and no alarm bells sounded; the note made by a junior doctor about a foul-smelling discharge from a vaginal swab taken some hours later at 6.30am, which was not picked up by the consultant obstetrician at 8.30am; bloods taken at 7am that Wednesday morning did not reach the laboratory until three hours later.(2) In his summing up, the Galway Coroner, Dr Ciarán MacLoughlin, said that by 1pm, when the consultant obstetrician was contacted again, Savita ‘was in peril of her life’.(3)

A microbiologist called in as an expert witness by the Coroner noted that on the Sunday she was admitted, Savita was not given a vaginal examination nor was she checked for leaking amniotic fluid. This consultant also took issue with the type of antibiotics finally prescribed on the Wednesday, the wrong drug for the extent of the sepsis and the E. Coli ESBL, and the lack of ‘prompt attention’ to deliver the fetus.(4)

What was perhaps even more unbearable to hear was how Savita, in tears, was subjected to an ultrasound on several occasions to determine if there was still a fetal heartbeat. This surveillance related to a possible decision about a medical termination by Dr Katherine Astbury, the consultant obstetrician in charge of Savita’s case, in accordance with that consultant’s interpretation of what constituted a risk to the life of the woman.

In February 2013, there was a series of hearings before the Oireachtas Health Committee, a joint parliamentary committee, in which obstetric consultants from the Dublin maternity hospitals stated that six terminations had taken place in the Rotunda Hospital and three in the National Maternity Hospital in 2012. They were taking their lead from guidelines published by the Irish Institute of Obstetricians and Gynaecologists which is all consultants have to rely on, given the current legislative vacuum. They estimated that the numbers of terminations nationally to save women’s lives ‘could be as low as 10 or as high as 30’ in any given year.(5) Is it really conceivable that these same obstetricians wait on all similar occasions to perform a medical termination when there is no fetal heartbeat, until severe chorioamnionitis has set in, until the delay most certainly puts a woman’s life in the balance?

The barrister for the hospital and the Health Services Executive maintained an aggressive presence throughout the inquest. In respect of the nine hours between Tuesday night and Wednesday morning when there was no regular recording of vital signs, this barrister argued that it would be incorrect to say that no vital signs had been taken as Savita’s temperature had been taken on two occasions. If that passes for good-quality clinical care, women in Ireland should feel a sense of dread in having to enter a maternity unit at all.

In the wake of the inquest, those who carry the principal responsibility for the poor quality of our maternity services, namely the community of consultant obstetricians who stand at the apex of this system, continue to dodge that responsibility. They appear to prefer splitting hairs and defending their own positions with their considerable egos. Peter Boylan, former Master of the National Maternity Hospital, who was an expert witness at the inquest at the Coroner’s request, tried to argue that given the current legal vacuum, Savita was not ill enough and therefore not enough at risk of losing her life on Monday or Tuesday to justify a termination, whereas by Wednesday morning she was, but it was too late to carry it out in order to save her. His focus was not the clinical care and he effectively exonerated the consultant obstetrician in charge of Savita’s case about that dimension. Boylan is determined to get legislation in place on the X case so that clinicians will have some legal safety in the decisions they must take on medical terminations. Yet he gave no indication at the Oireachtas hearings in February that women were literally at death’s door before he intervened in the National Maternity Hospital. On the other hand, in a recent letter to the Irish Times, some of his obstetric colleagues including two consultants from Galway, one the professor emeritus of University Hospital Galway, objected to Boylan’s position about termination. They argued variously and confusingly, that maternal mortality is on the rise in developed countries, that this was one of the worst cases of sepsis ever seen, that E. Coli ESBL is extraordinarily virulent, and that hospitals must reflect on the lessons from the inquest.(6)

The battle lines now dividing Irish obstetricians on the need for legislation for the X case do not get us to the heart of the matter. Despite their speeches and positions about how they care for women, what neither side is doing is stepping forward to say that our services are in need of urgent reform from the top down, starting with the consultants themselves. Many of the 125 consultants in Ireland are very wealthy indeed as a result of their generously paid public contracts which historically have left considerable scope for a lucrative private practice. Yet it is as if the standards of care have little or nothing to do with them, even though it is their interests and their decision-making which most determine our services. This is the same professional group which has consistently blocked any wide-ranging initiative to establish midwifery led care.

At the conclusion of the inquest, Praveen Halappanavar, Savita’s husband said: ‘She was just left there to die. We were always kept in the dark…It’s horrendous and barbaric and inhuman the way Savita was treated in that hospital.’(7) We are now in the midst of the inquest for Bimbo Onanuga, an impoverished Nigerian woman who died in the Rotunda in 2010 from a ruptured uterus leading to DIC and cardiac arrest, after she had come into the hospital for treatment for a late intrauterine fetal death. An inquest has been urgently sought about Dhara Kivlehan, an Indian woman married to an Irish man, who developed pre-eclampsia and died from HELLP syndrome after a caesarean in Sligo General Hospital in 2010. What may be the lessons from the deaths of these three young, healthy women? That fragmented care on top of unaccountable obstetric practice kills. Our overriding problem continues to be how to make the Irish obstetric community truly accountable for its work.

Jo Murphy-Lawless

References
1. Irish Times (2013) Recommendations. Irish Times Saturday, 20 April, 2013.
2. Sheehan, M. (2013) Shortcomings in care of Savita have ramifications for all State hospitals: Inquest shows litany of mistakes caused fatal infection to be missed. Irish Independent, 14 April 2013.
3. Holland, Kitty (2013) Death by Medical Misadventure. Irish Times, 20 April 2013.
4. Cullen, Paul (2013) The systems, not individuals, to blame? Irish Times, 19 April 2013.
5. Kennedy, Geraldine (2013) Valuable debate complete with medical facts, figures. Irish Times, 19 February 2013.
6. Monaghan, John et al (2013) Letter, Irish Times, 30 April 2013.
7. Irish Daily Mail (2013) The Inquest’s Key Quotes, Irish Daily Mail, 20 April 2013.

This article first appeared in the AIMS UK Journal (Volume:25 No:2, 2013) and is reproduced here with their kind permission.

Full copies are available from www.aims.org.uk/ or by emailing publications@aims.org.uk

Your Service, Your Say?

 

Your Service, Your Say?
by Breda Kerans

I’m sure you are all too familiar with this, favoured phrase of the HSE “Your Service Your Say”. What exactly does it mean? Well firstly it does not mean that “your” service allows you to access any information on how well it delivers “your” service. You might think that is the most basic of rights, in Ireland you would be wrong.

In 2007 AIMS Ireland was formed, by women, who wanted to see the service user have some say in their maternity service. I was one of those women. We quickly realised that in order to effect change we needed some basic information. We also found that we, as service users were not entitled to this information. I can access arrogated national data, but not information on individual hospitals.

In the Spring of 2013, following a tip-off from a member of staff in one of Ireland’s maternity units of rising rates, AIMS Ireland decided to look into rates of certain procedures and request the birth statistics in each maternity unit to publish for women to use when deciding on their birth options.

What kind of information did AIMS Ireland want to find out and why?

AIMSI requested birth statistics for several key interventions which have short and long-term affects on women. We wanted to know how many labours were induced, the current C-section rate per unit, the episiotomy rate, rates for forceps delivery, and how many women were breastfeeding on discharge, and more.

AIMSI requested this information because we knew from the hospitals who do publish annual reports that the rates of various interventions do vary, sometimes quite a lot.  Women have a right to this information. They have a right to know in order to make informed decisions about their care. If for example, breastfeeding support is really important to you, you might like to know what percentages of women are breastfeeding on discharge from the hospital you are considering.

This information should be openly transparent and easy to access within the public domain. This is important for several reasons (i) women cannot make an informed decision if they do not have access to all the information (ii) ensuring full transparency of birth statistics per unit and per individual health care provider holds units and health care providers accountable for wide variations of care (iii) If this information was readily available, it would protect women from individuals or units whom do more harm than good – exposing these inconsistencies quickly. For example, following the Cuidiu publication of birth statistics, a review* was promised by the HSE to look at why first time mothers in one maternity unit had a 50% Caesarean section rate – a huge variation from other units.  Another unit showed 43% of first time mothers will have an episiotomy.

Are we to believe that first time mothers in these particular areas are more likely to require an episiotomy or Caesarean?

Or does the local practice and policy within a particular unit or with a specific health care professional increase the likelihood of a woman having these procedures.

*While the review was promised, we are still awaiting the findings

Cuidiu Birth Statistics

Irish organization, Cuidiu, painstakingly wrote to each of the country’s 22 maternity units, (19 public consultant led unit (CLU), 2 midwifery led units (MLU) and 1 private maternity unit) asking for their rates of various procedures. Some hospitals promptly replied with all of the relevant information. A few did not reply at all,  and many others gave very incomplete or partial information. As there is no official duty to supply this information, it is solely at their discretion.

 Ironically, 20 of these hospitals, along with 20 Self Employed Community  Midwives*, collect all the data required and send it annually to the ESRI, who run the National Perinatal Reporting System (NPRS). The ESRI are not allowed to make available information on individual hospitals.

The question has to be asked, why do some hospitals choose to leave some questions unanswered in their response to Cuidiu, when it is clear that they already collect this information for the NPRS?

 

 

* Self Employed Community Midwives (SECMs) are required to provide birth statistics for every woman booked, events in pregnancy, labour, birth, outcomes, morbidity, etc, including transfers, however, the same is not required for each individual consultant obstetrician.

AIMS Ireland's Requests

AIMS Ireland has recently made a Freedom of Information Request to the HSE to try obtain this information for the public.  Our request was denied. We were informed that the HSE did not hold this information centrally, and as such the information does not exist. Individual member hospitals under the control of the HSE do however hold this information. We were informed that the NPRS does hold this data, but they are not allowed to produce data on individual hospitals, in order to protect patient confidentiality.

This is a new one. Transparency = violations of patient confidentiality?

How exactly does informing the public about the number of C-sections or episiotomies performed in each maternity unit affect a patient’s confidentiality?  

 The plain unvarnished truth is that many hospitals produce annual reports, which contain this data and AIMSI commend the hospitals who publish these figures. And the others, who choose not to publish this data, are protected by the HSE.

In summary:

• 20 of our maternity units collect a lot of data
• These maternity units send this data to NPRS
• The NPRS is not allowed to tell you about the data that Your maternity unit has sent them
• Your maternity unit is not obliged to let you see this data.
• Your HSE prefers to step aside and abdicate its responsibility in ensuring You have any right to see information about Your maternity unit.

How can You have a Say in Your Service if you have no information with which to inform Your Say?

Severe Maternal Morbidity Audit report - Points to consider before we start Congratulating ourselves.

This week, an audit report of severe morbidity in the Irish maternity system, carried out by the National Perinatal Epidemiology Centre in Cork in 2011, was published. This report was eagerly anticipated by AIMS Ireland and we have been quoting the need for such an audit for some time.

The reasons for a need to audit morbidity in maternity care are outlined in the AIMSI 42 weeks campaign aricle,  "Healthy Births for Healthy Mothers and Babies"

For a long time, the quality of maternity care has been measured by the rate of deaths to mothers and babies. But, many now argue that this is not a true reflection of care as technology, nutrition, disease control, and hygiene have reduced the rate of deaths drastically. Instead, a way of measuring care is to look at the rates of complications that arise in pregnancy, and during labour, birth, and the postpartum period. These complications are called morbidity and can affect the health of mothers and babies ranging from moderate to severe harm. Some procedures and care increase the chances of these complications and, as a result, morbidity is on the rise in Ireland.

“Results have shown that maternal morbidities in Ireland are common and changing. Analysis of national trends in maternal morbidities from 2005-08 show a statistically significant increase in rates of postpartum haemorrhage (PPH), pelvic and perineal trauma, and gestational diabetes.Over an 11 year period (1999-2009), the overall PPH rate increased from 1.5% to 4.1%, with a significant increase in the rate of blood transfusion co-diagnosed with atonic PPH.....Further increasing rates of Caesarean section have led to an increase in the incidence of peripartum hysterectomy for morbidly adherent placenta. Such findings stress the need for continued surveillance of maternal morbidities to guide clinical practice, focusing on aetiological factors, preventative measures and quality of care.” Measuring maternal morbidity, Edel Manning

AIMS Ireland are concerned about rising intervention rates, which can vary greatly between hospitals and even between individual health care providers. Interventions are known to increase the chances of harm to the physical and psychological health of mothers and babies. We all want mothers and babies to come through birth feeling healthy and emotionally complete.

Severe Maternal Morbidity Report

For the purpose of this report, only severe maternal morbidities were collected. To you and me that means the NEAR MISSES.

The 20 maternity units in Ireland (19 public units and 1 private) were asked to provide data on instances of severe maternal morbidity.

What is 'severe morbidity'?

According to the report from UCC its:

" 15 categories of maternal morbidity including: major obstetric haemorrhage (MOH), eclampsia, renal/liverdysfunction, cardiac arrest, pulmonary oedema, acute respiratory dysfunction, coma, cerebrovascular accident, status epilepticus, septicaemic shock, anaesthetic complications, pulmonary embolism, peripartum hysterectomy, admission to intensive care and interventional radiology. Major obstetric haemorrhage was defined as an estimated blood loss of ≥ 2,500ml, and or a transfusion of ≥ 5 units of blood and or documented treatment for coagulopathy."


Key Findings of Severe Maternal Morbidity Report

 

"Overall, 260 women were reported as experiencing at least one severe maternal morbidity, which translated as a national morbidity rate of 3.8 cases per 1,000 maternities or 1 in 263 maternities."
 "The majority of women (57.7%) were diagnosed with one severe morbidity and one third (32.3%) were diagnosed with two severe morbidities. A small proportion was diagnosed with three or four morbidities."


"The perinatal mortality rate among women experiencing severe maternal morbidity was 32.6 deaths per 1,000 births. This was substantially higher than the national rate, which was estimated recently at 6.6 per 1,000 births." "Key findings and rates of women experiencing MOH mirrored findings from successive SCASSM reports. These include: Uterine atony was the most frequently reported cause of MOH, followed by: other specific causes; retained placenta; and placenta praevia. The majority of cases of MOH occurred in the postpartum period, with Caesarean section the most common associated mode of birth. MOH was also the most common morbidity associated with ICU admission."

With Ireland's rising Caesaeran Section rates, the rates of severe maternal morbidity look set to rise also.

And finally:

 "The incidence of severe maternal morbidity was disproportionately higher among ethnic minorities."

Does this send a red alert? It should.

AIMS Ireland has been highlighting concerns regarding care received by ethic minorities for some time. Clare Daly has put in numerous Parliamentary Questions from AIMS Ireland on the disproportionate instances of maternal mortality and morbidity among women of ethic minority backgrounds.

According to UK and Irish data, maternal deaths, while a rarity, nonetheless  statistically affect non-national emigrant women almost twice as frequently as women born in either the UK or Ireland (CMACE, 2011; MDE, 2012).  

Maternal Death Enquiry Ireland (2012) Confidential Maternal Death Enquiry in Ireland, Report for Triennium 2009-2011, Cork: MDE.
http://www.mdeireland.com/

This report adds to concerns that ethnic minority women are not receiving appropriate, safe maternity care.

Limitations of the Audit

Unfortunately, there are limitations to this audit which result in unknown and misleading results.

1) Only 19 of 20 maternity units participated in the audit, the unit which did not participate has not been named. Transparency and availability of information have been issues raised by AIMSI to the Minister for Health (twice), and HIQA. This is a 'National Audit' - every unit must participate and those who do not, should be named so that women know that their maternity unit has (i) not been included in the findings (ii) has chosen not to participate  (As an aside, AIMSI have been campaigning for the full disclosure of annual audit reports of birth statistics per unit available to the public online in order to aide informed choice. Information such as episiotomy, caesarean section rate, assisted delivery, induction rates, pph, etc should be available per unit and per individual health care professional so that women can decide which units and professionals they choose to attend for their care.)

2) AIMSI have been informed that only 6 (yes 6) of Ireland's maternity units has an electronic record system, such as the MIS system. Relying on handwritten records increases the risk of unreliability and quality of the data available to audit.

3) Some of the records from units within the audit were only partial. When looking at the audit report, we see in the 'maternal characteristics' that 2 cases did not provide maternal age and 54 cases did not provide data on ethnicity. 71 cases were missing data on smoking habits and 93 cases had no background data on alcohol habits. BMI data was missing for 1/4 of women's cases. When reports from units are based on partial recording, it is difficult to (i) have a clear understanding of the true extent of instances (ii) some of the missing data would be important to draw conclusions to risk factors contributing to rising rates of severe morbidity (iii) the integrity of the information is put into question - if data is missing or only partially recorded, can we trust the data provided is accurate?

4) Most women with severe maternal morbidity had Caesarean sections. However the report says that 1/5 of women with severe maternal morbidity had spontaneous vaginal deliveries (SVD). However, in this report, SVD is defined in terms of mode of delivery, not mode of management in labour. This is incredibly significant. It means that all vaginal births are being classified in the same way, regardless to how the labour has been managed. Evidence has shown us that some interventions used to manage labour significantly increase the risk of maternal morbidity, such as PPH. To categorize all vaginal births together, regardless of intervention, is misleading.

5) This audit, while welcomed, only measures severe maternal morbidity; the near misses, within the definitions of the classifications. A woman with a PPH of 1500ml, which is still a significant bleed, has not been included in this report. Also, everyday maternal physical and psychological instances of maternal morbidity have not been measured. AIMS Ireland has seen an increase in these types of morbidity and they have a huge impact on the physical and emotional short and long-term health of mothers and babies.

Maternal morbidity is an important aspect in measuring the quality of care within our maternity services and the care we provide to women and babies. In many instances, less severe classifications of maternal morbidity are not considered as significant as a medical means of measuring the safety of maternity care, yet, the impact on women can be lifechanging. Injury from episiotomy, for example, can lead to chronic pain, urinary and fecal incontinence, and can greatly impact on women's self esteem, ability to be active/sport, and maintain a healthy sex life. Women can also suffer from psychological morbidity - depression, PTSD, anxiety - following such interventions.

Before we start congratulating ourselves on our low rates of maternal mortality and severe maternal morbidity in Ireland, we must look at the whole picture. Recording deaths and near misses is not enough - the health of mothers and babies, in the short and long-term must be protected.



Read More:

Just one-in-263 pregnancies has severe difficulties http://www.independent.ie/lifestyle/mothers-babies/just-onein263-pregnancies-has-severe-difficulties-29369343.html

Full Report: http://www.ucc.ie/en/media/research/nationalperinatalepidemiologycentre/NPECSevereMaternalMorbidityReport2011.pdf

AIMSI and NWCI - Working Together to Improve Maternity Services

AIMSI motion voted on and passed at NWCI AGM

The National Women's Council of Ireland (NWCI) held their AGM on June 14th, 2013 - their 40th anniversary - in the Clarion Hotel (IFSC), Dublin. The diversity of members at the AGM was a stark reminder of how women from all over the country - and all over the world - have converged into this one organisation so that they have a platform from which they can stand strong together and call for changes to women's rights in Ireland. With the support of these members, AIMSI submitted a motion at the AGM that calls for changes to maternity services that will ensure women are treated with the dignity, respect and equality of health that is inherent in a woman's basic and inalienable human rights.

The motion was voted on by the NWCI members and passed, meaning that AIMSI will be given the support as well as the extensive knowledge and experience of the NWCI in seeking to improve Irish maternity services. 

The day was inspiring as it gave NWCI members a chance to vote not only on the motion submitted by AIMSI, but also on other motions put forward by fellow members. The issues ranged from a call to influence and broaden the inclusion of women in school history books to combatting domestic violence against migrant women. The calls were passionate and articulate - each one presenting a worthy and just case for support and action. In the true spirit of democracy, each motion was voted on and each one  passed. 

Here is an excerpt from the AIMSI motion:

"Ireland has the highest birth rate in the EU yet our maternity system is primarily focused on one patriarchal model of care, in which women have limited choices and a limited voice. On an administrative level this has fostered a grave lack of accountability and transparency, and a lack of equity in access to care based on geography, ethnicity and wealth.  The media rarely picks up on the extreme cases of violations to women’s autonomy and human rights in maternity services and the HSE does not investigate unless they are forced to do so. Recent years have seen maternal deaths, forced c-sections and hundreds of other cases of maternal morbidity go almost completely unnoticed. Disturbingly it would appear that these affect non Irish and disadvantaged women disproportionately. Other less extreme cases, but equally as damaging, may involve restricting or ignoring a woman’s choices in childbirth or forcing certain procedures on women in this setting without seeking informed consent/refusal. The common thread in all of these cases is that the maternity units will ultimately put the rights of the unborn child before the life and health of the mother, sometimes with fatal consequences. AIMSI believes that a woman’s human rights should not be compromised in pregnancy, labour and birth or, indeed, at any other  time in her life."

So what does this mean for AIMSI?

The NWCI encourages its members to put forward motions at the AGM that are in line with the Strategic Plan of the organisation (see here). In their guidelines on motions, the NWCI states that "this will ensure that the work of the NWCI is carried out in a focused and strategic manner; resources are used efficiently; and the best interests of the affiliates are served".

When a motion is passed by the majority of members at the meeting, it informs the policy work of the NWCI and will be acted upon within the resources of the strategic work plan. Essentially, it is an opportunity for members to put their issues forward and to gain support for their work.

This means that AIMSI will have the extensive support and invaluable resources of the NWCI to progress our mandate of improving maternity services in Ireland - with a particular focus on lobbying and campaigning for clear guidelines and legislation that uphold women's rights in maternity services. AIMSI looks forward to working with the NWCI to further our work in making improvements in Irish maternity services.

For more information on the NWCI, see http://www.nwci.ie/