Survivors of Symphysiotomy: "No introductions, just lots of aggressive staring, and plenty of emotional blackmail"

No introductions, just lots of aggressive staring, and plenty of emotional blackmail

Our recent meeting with the Minister for Health was not 'a bid to find a satisfactory resolution', to quote a Government deputy, it was, rather ironically, an all out attempt by his allies to coerce our members into an ill-defined mediation process that aims to buy them off. 

(There were no introductions, just lots of aggressive staring, and plenty of emotional blackmail at this meeting involving top officials and highly paid advisers. One of them sat behind me, while a government ally stared non stop for 2 hours, creating a tunnel of negative energy! At one point, at a signal from that adviser, 2 of the allies suddenly left the room with him: the 3 could be seen having a lengthy confab through the glass door...) 

That bizarre meeting was not about resolution, it was about re-victimisation. Being economical with the truth can be a cost saver for governments.  At no point did the Minister condemn the practice of symphysiotomy: to do so might mean survivors would have to be treated as victims of medical negligence. 

The government has other plans, plans that involve a so-called redress scheme.  

'Compensation', to use the Deputy Regina Doherty's word for redress, is not the same as redress, however, any more than mediation is the same as negotiation. Word do not mean what we say they mean, unless we are Alice in Wonderland. Compensation is generally based on a finding of wrongdoing, and aims to make up to the victim for the loss s/he has suffered, insofar as that can be done, while redress is a token for pain and suffering, with no admission of liability or wrongdoing. 

The Minister expressed a wish to find a quick way forward but showed no interest whatsoever in the fastest way forward of all, a negotiated settlement on foot of the legal actions being taken by our members. Based on an acknowledgement that these operations were wrongful, such a settlement would offer both truth and justice and could be hammered out in weeks, if the political will existed. 

The redress road has been chosen as the preferred solution to the 'problem' of survivors of symphysiotomy. This will take several years and fits perfectly with the 'delay until they die' strategy adopted by the Department of Health 14 years ago.  

There are, of course, different models of redress. The Hepatitis C scheme was exemplary. However, the authorities appear to have chosen the shabbiest one of all. Instead of dealing with survivors of symphysiotomy as victims of medical negligence, the government seems bent on treating with them as though they were Magdalene detainees. This is patently wrong. 

This is a formula that enables the government to deny survivors their rights. The Magdalen women are being forced to sign away their legal and constitutional rights as a condition of entering their scheme.  They are also denied the right to legal representation. This is grossly unfair and manifestly unjust. 

When the Minister talks about 'money going directly to the women', he is implying that money paid to lawyers comes out of the awards made to victims. Nothing could be further from the truth. Every redress board until now has offered access to independent lawyers and independent doctors paid for by the state over and above any awards made to victims.  

The Magdalene model has set the bar at a new low.  The government is simply not prepared to pay for independent legal representation. (Access to independent doctors is also off limits, presumably. But then, why would you need them if you are not a victim of medical negligence?) 

The Government is already set on denying as many women as possible access to justice by blocking our Bill setting aside the statute bar. Whatever scheme is in the pipeline will also likely deny survivors access to the courts, as the Magdalene scheme does.

Survivors will also be offered levels of restitution far below their entitlements. The Minister made it clear that €250,000 was completely out of the question, even for a woman who has had to have 20 operations, including a colostomy, and four colostomy reversals, a woman who has missed communions, confirmations, weddings and christenings, a woman who has all but lost her life as a result of that barbarous surgery, who would undoubtedly be awarded well over €600,000 by a judge for her injuries, yet the Minister deems them to be insufficient to merit one third of that amount. 

He also made it clear that he wanted to see money paid across a woman's lifetime: this suggests weekly instalments, as per the Magdalenes. Their financial entitlements have been shamefully downgraded: any award in excess of 50,000 is paid at a rate of €9 per week. What a cynical scheme to offer 70 and 80 year olds!   

Survivors may be advancing in age, but they are also advancing in determination. After so many years spent fighting for justice, our members will not be fobbed off with this blatant denial of their legal and constitutional rights, which is founded in the fiction that the practice of symphysiotomy was medically acceptable, a fiction that the Institute of Obstetricians and Gynaecologists and its members have nurtured since 1999. 

While government allies may witter on about the 'healing' that comes from 'telling your story' in mediation-manipulation, closure cannot come from a lie. 

 

Marie O'Connor
Chairperson Survivors of Symphysiotomy (SoS) 

Author: Bodily Harm: symphysiotomy and pubiotomy in Ireland 1944-92

AIMS Ireland Statement on " Midwifery-Led continuity models versus other models of care for childbearing women", Cochrane Review August 2013

 

 

AIMS Ireland Statement on Midwife-led continuity models versus other models of care for childbearing women, Cochrane Review (August 21, 2013) 

A research review of over 16,000 women, in different jurisdictions, was released on August 21, 2013 concluding that women who received midwifery-led care from a small group of midwives had healthier births than women receiving traditional consultant led care. Women of both low risk and high risk status participated.

 

The study, published by the Cochrane Library, showed that women receiving midwife-led care had higher satisfaction ratings of their birth experience and were less likely to require an epidural, had less instances of assisted instrumental delivery and less episiotomies than women in obstetric-led care. Babies of women receiving midwife-led care also fared better as there were less instances of birth before 37 weeks and less instances of miscarriages in the midwife-led group.

 

AIMS Ireland Statement

 

This research comes at a pivotal time for Ireland. This year has seen obstetric negligence claims that are projected to exceed €100 million and the recent High Court ruling in the Aja Teehan v HSE case, which has instigated discussion not only on the safety of home birth vs hospital practice but also on the strict HSE criteria. This discriminatory criteria prevents women from accessing services outside of traditional obstetric-led care and it does not allow for individual assessment.

 

Hospital care in Ireland is obstetric-led in practice and policy and includes many routine interventions which increase distress to babies in labour and increase the risk of  adverse effects on women, for example: higher rates of induction, amniotomy (breaking the waters), epidural analgesia and use of oxytocin. Routine means that the procedure or intervention is standard practice for every woman with no individual assessment and regardless of medical necessity or robust and reliable evidence. Some practices may not be routine for every woman, but are frequently 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 - poses an independent risk to babies and increases NICU admission.

 

It is noted with great interest that this review included women of both low and high risk status and that there were no adverse outcomes. In Ireland, women are prevented from midwife-led care on very tight exclusion grounds. Many are women who would otherwise be considered low risk in other jurisdictions. Women perceived or deemed to be moderate or high risk are also excluded.

 

 

AIMS Ireland welcomes the rigorous methods, the impartiality and the independence of this Cochrane Review as it confirms what we already knew: that midwife-led continuity of care options provide safe, cost effective care for mothers and babies and have significantly fewer interventions. The other important result of this research shows that “midwife-led continuity models of care are associated with a reduction in overall fetal loss and neonatal death by approximately 16%”. This research is supported by countless previous research studies that have all had similar conclusions to the Cochrane Review. These include:

 

• In 2008 KPMG reviewed Irish maternity services and recommended the implementation of Midwife-Led care options to be rolled out nationally.

 

• The HSE’s Mid-U study found that the same birth, for the same woman, costs over €300 more for women in Consultant Led Care (CLU) as compared to a Midwife-Led Unit (MLU). Women in the MLU had less interventions, less adverse effects and higher satisfaction rates than the women in the CLU.

 

• In a 2007 study at NMH’s DOMINO scheme 5,500 bed days were saved by Community Midwifery services in NMH Holles Street (Early transfer home and DOMINO home birth). The Study also found Caesarean Section rates are significantly lower LSCS in NMH 18.92% vs LSCS in DOMINO NMH were 5.86% - however this is not reflected in the results of this Cochrane Review.

·        

• There have been countless international studies with similar results.

 

 

Obstetric-led care has a very important place in Irish maternity services and should be available for women who want or need this type of maternity care. In Ireland, 90% of women will have no access to midwife-led care even though it is deemed to be the most appropriate model of care, it is safer and it is less expensive for the majority of women. Failing to provide appropriate care options affects all women. Our two tiered obstetric base system means that: 

1. no choice is afforded to women who prefer to birth under a midwifery-led continuity of care model and
2. women who do not want or need obstetric led care are using valuable resources and are taking up time and beds from women who want or need a consultant led care model.

 

This current study shows that, once again, reliable and valid research stronlgy suggests that Ireland's obstetric-led model of care is outdated and is of very little benefit to the majority of women. While there may be an estimated 10% to 15% of women and babies who are in need of obstetric-led care, the Cochrane Review on midwife-led care shows that the large majority benefit from the Midwifery-Led care model.

 

The majority of regions in Ireland have no choice of midwife-led services. 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 options in the community or hospital based. Where midwife-led care is available, the HSE has placed highly restrictive criteria and/or catchment areas that exclude access to a great number of women . As in the case of Aja Teehan v HSE, the HSE have developed restrictive criteria - that is not evidence-based - to determine access to midwife-led options (home and hospital based) There is no provision for individual assessment based on current pregnancy or previous birth experience nor is informed choice given any consideration. Women who would have access to midwife-led care in the UK, the EU and even the North of Ireland are blocked from accessing midwife-led care due to the ambiguous and discriminatory HSE blanket bans.

AIMS Ireland assists in many complaints regarding blanket bans on hospital based midwife-led care options in Ireland. Women are excluded for arbitrary criteria, such as: a BMI over 30 at the  time of booking, age 40 or over at time of birth, IVF, LETZ procedure, VBAC, and transfer from MLU to CLU on suspected ‘big baby’. These women are denied hospital based midwife-led care without individual assessment or discussion and, most importantly, without their informed choice.

 

 The expert who provided evidence against Aja Teehan is also one of the policy makers who created the HSE criteria for homebirth in Ireland. He also published an article in the BMJ supporting a mother’s right to choose a non-medically indicated Caesarean Section, citing directly the right to informed choice despite the associated risks. So, why are women who choose to birth outside an obstetric care model (home or hospital based Midwife-Led care) not afforded the same right?

 

AIMS Ireland Conclusions

 

Removal of choice is never best practice. Women should be assessed on an individual basis on their current health and their current medical conditions in addition to their previous history. The HSE are not providing women with individual assessment - a fundamental principle in evidence-based care.

 

Obstetric-led care is defensive practice that has high medical intervention rates and lacks the continuity of midwife-led care. Obstetricians in Ireland use outdated routine practice such as continuous electronic fetal monitoring (CFM), artificial rupture of membranes (ARM) and Active Management of Labour - all practices that robust and reliable evidence-based research shows to increase risks of unnecessary interventions and adverse outcomes to mothers and babies.  

 

Research studies over the years, including the most recent Cochrane Review, categorically state that best practice in maternity care is to provide a midwife-led continuity of care model in every maternity unit in Ireland with appropriate inclusion criteria, individual assessment and the right to informed choice. The failure to implement policy that supports this robust research means that the HSE are putting mothers and babies at risk.

 

AIMS Ireland

 

ENDS

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?