ANALYSIS - NEW STUDY: Private Health Coverage is an Independent Risk factor for Caesarean Section

Last week, an important new study was released: "Private health care coverage and increased risk of obstetric intervention"


AIMS Ireland examines the new study and key points.


What was the study looking for?


When complications arise during pregnancy, labour, or birth interventions are often necessary to improve the health of women and/or babies. This medical need is often called clinical or medical indications. Appropriate use of intervention is necessary and important to ensure that women and their babies are safe.


In Ireland there are wide variations in rates of interventions. Rates can vary significantly across the 19 public maternity units. This suggests that practice in maternity units is not standardised and that interventions may not be used appropriately - based on medical need.


Previous studies have shown that women who choose obstetric led care and private obstetric led care have higher intervention rates than women who attend midwife led care or public obstetric led care. Discussion following these studies often focused on risk factors between the two groups - that women who opted for private obstetric led care were of higher risk groups (have more risk factors) than women who did not.


This study wanted to see if there is a difference in interventions used in Irish maternity hospitals between women who book into public maternity care (without using private health insurance) vs women who book into private maternity care (with private health insurance).


This study is significant as researchers controlled for relevant risk factors between public and private patients.

* Obstetric Led Care is hospital based care where a consultant obstetrician is the lead clinician. The policies, practice, and guidelines in the maternity unit are based on a medical care model.

What are "obstetric interventions"?


This study looked at the outcomes of 403, 642 births across Ireland - a third of which were private consultant led care - and examined the births WITH and WITHOUT the following:


* Caesarean Section

* Operative Vaginal Delivery (some times called   'assisted  delivery' - use of forceps or vacuum)



* Induction of Labour


* Episiotomy





Why is controlling for risk factors significant?


When we talk about "risk factors" this is a way of estimating the odds of a woman requiring intervention during her pregnancy, labour, or birth. Some risk factors suggest that a woman is more likely to require an induction of labour, episiotomy, emergency caesarean, or planned caesarean.


Sometimes risk factors can be conditions occurring in a pregnancy, like gestational diabetes or placenta previa. Others can be age (we hear a lot of older mothers), previous births, epidural, or if you are having multiples.


 This study isolated known risk factors for each obstetric intervention, in order to compare like with like.


The following risk factors were adjusted for each intervention group:


Induction of Labour

* Age

* heart disease

* diabetes

* placental disorders

* previous caesarean section

Planned and Emergency Caesarean Section

* age

* heart disease

* diabetes

* placental disorders

* previous caesarean section

* multiple births

(Due to recent evidence, use of epidural and induction of labour were not considered risk factors for Caesarean Section)

Assisted/operative Vaginal Births (Forceps and Vacuum)


* age
* heart disease
* diabetes
* previous caesarean section
* multiple birth
* induction of labour
* epidural




Episiotomy


* age
* multiple birth
* assisted/operative vaginal birth (forceps or vacuum)

What did the study find?


After controlling the public and private groups for relevant risk factors, the study looked at the birth outcomes between women who chose public vs private health coverage. The study found:


* women with private health coverage were more likely to have a planned caesarean section


* women with private health coverage were more likely to have an emergency caesarean section


* in vaginal births, women with private health coverage were 40% more likely to have an episiotomy




Key Points: Quotes from the full study which AIMSI feel are of significance.

"Irrespective of obstetric risk factors, we found that women who opted for private maternity care in Ireland were significantly more likely to have an obstetric intervention than women who opted for public care."

"assessing the influence of health care coverage status in a variety of health care settings is critical given that rates of obstetric intervention are likely impacted by a country’s prevailing model of obstetric care (i.e. midwifeled, obstetrician-led or shared care models) and health care system (i.e. socialised medicine or fee-for-service).

"health care coverage status is part of a broad spectrum of non-clinical reasons, including obstetrician preference [27,28], litigation fears [29-31], maternal preference [32,33], and fewer women attempting a trial of labour after previous caesarean [34,35]. For this reason, to better understand both clinical and non-clinical dynamics, in future studies of health care coverage status and caesarean delivery, mixed-method research would be a clear advantage."

"We are unable to confirm why differences in episiotomy rates were observed in this population. Speculatively, however, uncomplicated deliveries in the public scheme are largely attended by midwives, who may be less likely to carry out an episiotomy [44]."

"residual confounding is of concern as we were not able to adjust for all maternal (e.g. parity, obesity, assisted conception, ethnicity and socio-economic status) and fetal (e.g. position, intrauterine growth restriction, macrosomia, heart rate) risks factors which may have increased risk of obstetric intervention."

"Data extracted from hospital records may underreport the true extent of covariates and outcomes of interest in this population."

AND FINALLY AND MOST SIGNIFICANTLY,

In relation to increased C-section rates:

"While undoubtedly such trends are impacted by differences in obstetric profiles, our study suggests that health care coverage status is likely an independent risk factor for caesarean delivery."

The National Committee for the Elimination of Home Birth (NCEHB)

This National Committee has been in existence for several decades. It came into being some time in the 1960s when Ireland first bought into the medicalisation of childbirth and the only acceptable birthplace became a centralised obstetric-led maternity unit. Control over birth started to move into the domain of the obstetrician; a specialist in abnormal labours and birth. Traditionally, normal births had been attended in the community by midwives; the specialists in normal birth. Their place of work was either in local maternity homes or in the women’s home. The BBC TV series “Call the Midwife” captures the spirit of these times well

Membership of the Committee.

The Committee has had many members over time, and membership changes as and when demand arises. So for example, sometimes it would appear that the committee is only made up of HSE personnel, whereas other times it would appear that the judiciary, social services, regulatory bodies and the media are also opted into the committee as ad-hoc members.

Some members have of course been given honorary life membership for their great and tireless devotion to Committee business. They have been outspoken on home birth within their hospital units, within the media and even sometimes as expert witnesses in the country’s Coroner’s Courts or High Courts.

Accessing the Minutes of the Committee.

In true HSE style the Minutes of NCEHB meetings are difficult to access or find and may require an FOI. Sometimes when Minutes are found they bear no real reflection of what actually happened at the meeting, with meeting events spuriously added in by key individuals to suits the Committee’s central agenda. As with all committees the real work is done is secret working groups and subcommittees that do not maintain minutes, so the best stuff is probably recorded on someone’s mobile phone!

Furthermore, since the Committee’s membership is so fluid and not officially noted anywhere it is hard to know how often they meet and who attends never mind what decisions have been reached. It is assumed that these meetings take place in the dark corners of the HSE, in Department of Health corridors and in the by-ways of the nation’s Maternity Units, not to mention golf clubs and dinner tables of the medico-media-legal triumvirate. Some Committee members do not even realise that they are members of the Committee believing themselves to actually be part of the home birth supporters club.

Key achievements of the Committee

1. Eliminating the term independent midwife.
2. Removing autonomy from the midwife to make clinical assessments and judgements for their client
3. Insisting on indemnity insurance for midwives in the cynical knowledge that this was not available on the open market yet legislate that other medical professionals can attend childbirth without such indemnity
4. Creating a set of exclusion criteria that eliminates the choice of home birth for women without even allowing them individual assessment
5. Requiring that obstetricians who are not experts in the field of home birth decide on whether women can avail of a home birth service or not
6. Insisting that women whose babies are not in clinical distress transfer to a hospital setting in labour where they will probably be subject to a rigorous set of interventions
7. Ensuring that women transferring from a home birth to a hospital setting do not get to transfer with their primary care giver.
8. Insisting on two midwives present at every birth, in the cynical knowledge that there are not enough second midwives available in certain areas to perform this role.
9. Refusing to engage in the recruitment of more midwives in order to provide midwives for the second midwife service. This is a particularly notable achievement of the NCEHB as there is no evidence anywhere to show that having a second midwife present at the birth improves outcomes for mother or baby.
10. Tell women who are booking into hospitals for their bloods and scans that there is no national home birth service
11. Ensure that the wage paid directly to self employed community midwives is very low and ensuring that any unaccompanied transfer to hospital, even in the woman’s best interests incurs a reduction of up to €1000
12. Ensuring that newly qualified midwives cannot act as second midwives in a community setting until they have had three years experience in a maternity hospital. This is a great committee achievement especially considering that there is absolutely no evidence anywhere to suggest that second midwives improve outcomes for mothers and babies at all, neither is there any evidence to suggest that experience in an obstetric dominated maternity setting prepares newly qualified midwives for work in the community. Leaked Subcommittee Minutes tell us that this particular decision was based on a number pretty much plucked out of thin air and agreed upon based on the personal experience of individuals present in the room at the time.
13. Striking independent midwives off the register following in-camera hearings in which it would appear evidence from midwifery professors currently practising in home birth is ignored in favour of evidence from those not currently involved in home birth.
14. Subjecting SECMs to a different set of professional practice evaluation criteria than those reserved for other maternity care professionals. The country has been shocked in the last year by so many revelations of failure in our hospital maternity services, but so far none of the individuals involved have been subjected to any disciplinary action blame or reproach. In fact do we even have a guarantee that they are not still doing the same thing? Thankfully, due to the Committee’s ever vigilant and tireless pursuit of self employed midwives they get a public lambasting at best should they merely be within a whiff of an event the Committee doesn’t like, and if they were present at such an event the FTP card pops up like a jack in the box..
15. Ensuring that mothers who disobey the Committee’s rules are punished. What is the best way of punishing a new mother? The best possible way of torturing a new mother is to take her baby way from her. The NCEHB have been carrying out some interesting experiments in this area by suggesting to social services that mothers who insist on birthing at home are unfit or unsafe parents, who therefore need to have their newborns removed from them.
16. Forbidding midwives to attend women who do not wish to transfer to hospital care, thereby putting the woman her baby and her family at greater risk and putting midwives in the invidious position of having to relinquish their commitment to duty of care.
17. Refusing to acknowledge the woman’s right to choose the circumstances by which she becomes a parent. This is carried out despite a European Court of Human Rights ruling to the contrary.
18. Creating research that is deliberately statistically biased to try and prove that home birth is dangerous. The committee is aided and abetted in this regards by journals, which the committee control, that are willing to print such poor research.
19. Citing the 8^th amendment as a justification as to why a mother should not be permitted to proceed with a home birth.
20. Eliminating home birth as an option for women who have had previous cesarean birth. This, despite the fact that she may have had previous babies at home in Ireland. Given the country’s extremely poor VBAC rates (despite the existence of national guidelines too promote it) this means that such women are basically being forced into repeat sections even though this is not in their baby’s or their best interest and is not best practice.

Congratulation to the NCEHB, you are doing a great job. The only fly in the ointment are the women’s advocacy groups that seem to be opposing Committee business; harping on about such irrelevant issues as human rights in childbirth, the right to choose, evidenced based care and the right to bodily self autonomy. Some of these groups have even exposed the high quality research that shows home birth to be safer than hospital birth in an obstetric unit, with both mothers and babies having better outcomes and fewer interventions. Whilst the Committee are aware of such evidence, the general modus operandi (as with any other evidence that does not align itself with any accepted clinical practice in our maternity system) is to simply ignore it.

AIMS Ireland shocked to learn that obstetrics has been reclassified as Arts subject

AIMS Ireland shocked to learn that obstetrics has been reclassified as Arts subject

Wednesday, March 26, 2014 The Association for Improvements in the Maternity Services Ireland (AIMS Ireland) today expressed bemusement over comments from the HSE that the obstetric led Irish maternity system is not based on Science as previously thought, but is an Art form.


AIMSI Statement: AIMS Ireland campaigns for evidence based, safe, and appropriate practice and care options for women accessing Irish maternity services. The obstetric care model is the only care option available for the majority of women in Ireland.


A spokesperson from AIMSI states, "AIMS Ireland has long had concerns on the appropriateness of the obstetric care model given findings from high quality, robust science. To be informed by the HSE today that obstetrics is indeed an Art form, and not a science, raises new and serious concerns. Women and their babies deserve the best care possible for themselves and their babies. Science provides us with the answers we need to make best practice recommendations. To learn that maternity care in Ireland is not based on a scientific basis is surprising to say the least. Many women pay significant sums to be provided with private obstetric led care under the pretence that their care is being provided by a highly qualified medical professional, not an Artist. We wonder also are obstetricians eligible to apply for an Arts Council Grant and perhaps they could pass on the savings to their clients? We advise women to consult the most current scientific data, which concludes that for the majority of women, midwife led care is the recommended professional medical, science-based care option.”


ENDS


Reference:








The HSE spokesperson, based in Kilkenny, is quoted as saying "The art of obstetrics is getting the balance right." http://www.independent.ie/irish-news/health/new-mums-more-likely-to-have-a-csection-in-some-units-30125330.html

Legendary Beverley Beech to close AIMSI's 42 Weeks Campaign

“The way a woman gives birth can affect the whole of the rest of her life. How can that not matter? Unless the woman herself does not matter”” ~ Beverley Beech

Beverley Laurence Beech "is a freelance writer, researcher, campaigner and mother of two who has campaigned to improve maternity care since the birth of her second child in 1976. For six years she was a lay adviser to the National Perinatal Epidemiology Unit at Oxford and was for seven years a lay member of the Professional Conduct Committee of the Nursing and Midwifery Council (NMC) and a member of the Midwifery Committee of the NMC. She was also a lay member of the Royal College of Obstetricians and Gynaecologists Maternity Forum, and a founder member of CERES (Consumers for Ethics in Research).


She lectures, both nationally and internationally, on consumer issues in maternity care and the medicalisation of birth. She is the honorary chairman of the Association for Improvements in the Maternity Services (UK)."

                           42 Weeks Campaign Closing Ceremony

What is the 42 weeks Campaign?


AIMS Ireland invites you to attend the closing ceremony of our 42 weeks campaign on March 29, 2014.


42 weeks is a public information campaign for women giving birth in Ireland. 42 weeks began on Sunday 9 June 2013 and ran for 42 week closing Mother’s Day 2014, Sunday 30 March, focusing on healthy positive birth for healthy mothers and babies through positive Irish birth stories, a gallery of beautiful birth photography, and articles to help women make the best choices for themselves and their babies.


Why 42 weeks? Most pregnancies go to full term, which means that a woman will go into spontaneous labour some time between the 37 and 42 week mark. Our campaign is called 42 weeks to reflect that the vast majority of babies will arrive when they are ready – not on an Estimated Due Date (EDD) but some time during this 5 week window – up to and including 42 weeks gestation.


Closing Ceremony: March 29th at 1pm - Cassidy's Hotel in Dublin


Keynote Speaker: Beverley Beech, 'Informed Choice - an Irish illusion?'


Special Guests Presentations:


AIMSI member Nuala Hoey, shares her personal experiences of self advocacy: "Birthing Decisions - A Positive Choice"

Krysia Lynch: " 42 weeks in the Irish maternity system; the rights, the wrongs, and the going forwards"


Angela Martin, 42 weeks photographer, on birth photography

 A 42 weeks slideshow over-view of the campaign


And MORE!




Admission is €5 per person


Doors open at 12:30, with presentations beginning at 1pm.


Cassidy's Hotel: http://www.cassidyshotel.com/?gclid=CKHQoOTSmb0CFYRf2wodOI4AVg




















Reference:


Beverley Beech Biography: http://www.zoominfo.com/p/Beverley-Beech/34783645

Portlaoise: "ground zero" of a failing maternity system?

AIMSI are horrified to hear of the recent death of a baby in Portlaoise over the weekend. Our thoughts are with the family and also the women who are booked into Portlaoise hospital and may be feeling scared, concerned, or anxious following the events of the past few weeks.

It is unclear as to if the baby died from natural causes or if the care/practice was a contributing factor. The results of the post mortem will tell us more.

The hospital is under new management, lead by the Coombe. AIMSI have been informed (unverified) that the former lead consultant from OLOL Drogheda - Maire Milner - has also been transferred to Portlaoise. So there has been a changing of the guards so to speak.

However, questions still remain on some of the findings from the Holohan Report and contributing factors:

Is Portlaoise a case of a few bad apples practicing individually unsafe care? A single maternity unit with an underlying culture of inhumane and detached care?

OR Is Portlaoise the "ground zero" for a maternity system with systematic failures and a culture of indifference to those working in and accessing services from management, policy makers, and the Department of Health? An under-prioritised branch of the health system which lacked provision for care options and was overlooked for investment by the current and former health ministers. A maternity system which is the result of years of over-stretched services, lack of choice, poor moral, and reports of bullying and fear hidden by a complete lack of transparency.

A maternity system which is:

* centred around a care model which is inappropriate for the majority of women - obstetric led vs midwife led

* routinely practices interventions without medical indication which are shown to do more harm than good for the majority of women - CTG, Syntocinon, ARM, episiotomy, caesarean section

* women and midwives report bullying and coercion

* local policy does not reflect evidence or best practice

* evidenced based care options, midwife led care (where available) is not self selecting and does not allow for individual assessment or informed choice

* informed consent/refusual is not recognised in the National Consent Policy

* local policy is not obligated to implement National Clinical Guidelines

* the system lacks transparency and accountability - no watchdog which enforces evidence based practice, guidelines

* the complaints system is grossly inadequate - women regularly report that complaints are not dealt with within the time frame of the HSE's own guidelines, replies are inadequate and do not address concerns, women are fobbed off with consistent replies stating that the unit needs more time to look into her complaint, leading to long time periods with no resolution, responses often provide little or no resolution or validation into the nature of the complaint "we are sorry you feel that way, our unit boasts a high maternal satisfaction percentage"

* large numbers of women contacting AIMSI report that notes have been changed retrospectively or are inaccurate

* maternity system is over-seen by a Department and Health Service Body who puts maternity services and choice low on the list of priorities and does not consult the concerns/opinions/interests/needs/desires of service users, midwives (obstetricians consulted but not midwives), and maternity advocacy groups representing service users which do not hold a conflict of interest. Instead, consultancy and reviews should be open - not by invitation - to all service users as well as advocacy/support organisations, health care providers, and policy makers. Anyone who wants to lend their voice to the discussion should be welcomed, not shut out.

 

* a system in which a HSE risk manager argues that he does not see how refusing women individual assessment or informed choice/consent on their care options is a human rights violation

 

The Irish Maternity system has been neglected for decades and as a result is imploding.

We need an urgent investment in healthy care options for women & babies with immediate implementation of self-selecting, evidence based care, midwife led birth options - MLU, Birth Centres, Homebirth. There must be an immediate over-haul of the current obstetric led care options, so that women who need or choose this type of care receive the highest quality of services possible. Individualised healthy and positive birth - not birth high in morbidity, intervention, and over-crowded conditions. Women deserve time with their chosen care provider. Women and babies DESERVE to be invested in. Women must be supported to make the best decisions for her and her baby - treated with dignity and respect. Midwives must be respected to practice with autonomy - recognising their skills and qualifications. Not bullied into complying with routine intervention or demoralised by having to few colleagues to provide safe and evidence based supportive care to each woman.

 

There must be repercussions for individuals and maternity units who fail to provide evidence based care and healthy working environments for HCPs. There must be repercussions for units using inappropriate rates of intervention, units with large regional variations, who actively manage women in labour with sytocinon, who use episiotomy or refusal of choice inappropriately, who devalue midwives, - a demand for accountability and investment NOW.

 

There must be a change of culture. A change of priority. The Department of Health, Minister, and HSE must stop lying to women - to the public. Hold your hands up. Tell the truth. Stop firefighting.

 

The only way to prevent next week's tragedy is to be open, listen, and invest.

Revealed: Midwifery Staffing Levels for 19 public units (Feb 2014)

Revealed: Midwifery Staffing Levels for 19 public units (Feb 2014)

February 2014 the INMO (Irish Nurses and Midwives Organisation) took a survey of clinical staffing levels of the 19 public maternity units in Ireland. The results highlight grossly inadequate & unsafe staffing levels in Irish units.

These are the findings of the survey:

Irish Nurses and Midwives Organisation

Ireland - Midwifery Staffing (Public Hospital/Unit)

Survey of Current Clinical Staffing Levels - February 2014

Hospital/Mat Unit          No of Midwives     No. of Births       Ratio Midwives/Births      Shortage

Holles Street                         303                          9142                              1:30                          7
_______________________________________________________________________________________

Mayo                                     55                            1785                              1:32                          5
________________________________________________________________________________________

South Tipp                            34                             1167                              1:32                          6
________________________________________________________________________________________

Limerick                               144                           4950                              1:34                           24
________________________________________________________________________________________

Sligo                                      46                             1660                              1:36                          10
_________________________________________________________________________________________

Waterford Regional               63                             2250                             1:36                           13
_________________________________________________________________________________________

Cork                                       243                           8900                             1:37                           59
__________________________________________________________________________________________

Kerry                                     45                             1676                              1:37                           12
___________________________________________________________________________________________

OLOL Drogheda                   99                             3654                              1:37                           24
___________________________________________________________________________________________

Kilkenny                               50                             1907                               1:38                           15
___________________________________________________________________________________________

Portiuncula                           54                              2055                               1:38                            16
_____________________________________________________________________________________________

Coombe                                215                            8586                               1:40                            76
___________________________________________________________________________________________

Galway                                 82                              3377                               1:41                            32
___________________________________________________________________________________________

Letterkenny                          46                              1881                                1:41                            18
______________________________________________________________________________________________

Cavan                                   45                              1897                                1:42                             19
______________________________________________________________________________________________

Wexford                               46                               2180                                1:47                             28
______________________________________________________________________________________________

Rotunda                               188                              9041                                1:48                            118
______________________________________________________________________________________________

Mullingar                             54                                2712                               1:50                            38
______________________________________________________________________________________________

Portlaoise                            37                                  2059                               1:55                           33
_____________________________________________________________________________________________

Total:                                 1804                                70879                            1:39 (average)    

___________________________________________________________________________________

Internationally Recommended Midwife: Birth Ratio:                                   1:29.5
(Birthrate Plus UK)
______________________________________________________________________________________

Total Number of Midwives (Clinical Areas) in Ireland:                               1821
___________________________________________________________________________________

Total Number required to reach ratio and safe standards:                             2403
__________________________________________________________________________________

Shortfall:                                                                                                         582

__________________________________________________________________________________

    

* Safer Childbirth Recommendations (2007) from RCOG and RCM recommend that the midwife to woman ratio should not exceed 1:28 for the majority of women, and for women with complicated case loads, the ratio is recommended at 1:25

Ireland's Maternity Staffing Levels are an Epic Safety Failure

 Ireland's Maternity Staffing Levels are an Epic Safety Failure

On Friday we saw yet another damning report into unsafe clinical practices and an underlying culture within the HSE which has contributed to deaths in Irish maternity hospitals. This was not the first report of its kind. In fact, it has only been a matter of months since the last. What was interesting in the report was that while there was recognition to the grave failures to provide safe clinical care, an underlying culture which lacked accountability and humanity, and serious concerns over communication and transparency.... the report failed to cite staff levels as a contributing factor.

This was a big surprise.

While AIMSI are delighted to see that communication failures and transparency are cited within the report from Portlaoise, it seems to be an over-sight that the reoccurring complications of an over-stretched and under-staffed system have not been taken into account.

 

Here's a few reasons why. 

 

Safer Childbirth Standards - RCOG and RCM - 2007

"Inadequate midwifery staff will lead to many women being left alone for long periods of time when they feel very vulnerable. Incidents like bleeding, drop in blood pressure or abnormality in the fetal heart rate may not be picked up in time to avoid morbidity."

Safer Childbirth standards (RCOG et al 2007
(Written evidence, RCOG)


"The minimum midwife-to-woman ratio is 1:28 for safe level of service to ensure the capacity to achieve one-to-one care in labour (BR+ evaluation  data).89,90 The midwifery total care ratios for services with more complex case mix must be determined locally after case mix (social and clinical determinants) and external workload assessment is done, this may mean a lower midwife to woman ratio up to 1:25. The recommended total care ratios indicate the maximum number of women that a midwife can provide antenatal, intrapartum, and postnatal care for within the service. "

Safer Childbirth standards (RCOG et al 2007)   
Irish midwife to woman ratios vary but we have heard consistent calls from Masters of the Rotunda, former Master of the Coombe, and others citing midwife to woman ratios in Ireland to be at desperately unsafe levels in Irish units. Numbers cited have varied from 1:47 in the Rotunda to 1:55 and 1:75 in Portlaoise.

In addition, the HSE has not chosen to establish any more midwifery-led units, in addition to the two pilot units in Drogheda and Cavan despite an extensive HSE-financed Randomised Controlled Trial of those units indicating (Mid-U study):

-better birth outcomes

-fewer interventions

-more cost effective births

For normal low-risk women

(SNM, TCD, MidU Report, 2009)

We know from the extensive 2011 National Perinatal Epidemiology Unit Birthplace Cohort Study in the UK that for low risk women, best, safest and most cost-effective results are obtained from midwifery-led units (Brocklehurst et al., 2011).

March 9, 2007 Tania McCabe and her son Zach died at Our Lady of Lourdes Hospital in Drogheda.

The Midwife to woman ratio at the time of her death was over 1:48

 
HSE Report: Tania McCabe:
 
"Maternity Services at Our Lady of Lourdes Hospital have been under increasing pressure, with a significant increase in activity. This has resulted in the Maternity, Paediatric and Anaesthetic services being significantly under-resourced to cope with the current demands. This had an impact on Tania’s care, with staff working long hours while carrying an excessive workload. Despite the good intentions of staff who were working in very difficult conditions, their practice and ultimately the care that they provided to Tania were compromised by their workload and the environment in which they were working."
 
High Priority Recommendation: Continual Assessment of staffing levels
 
"The Review Team recommends that the HSE in conjunction with the Clinical Networks’ advice would seek to urgently upgrade the medical and midwifery staffing commensurate with the recommendations from Safer Childbirth (2007)."
 
In 2008 Rosaleen Harlin wrote: "Significant investment in recruitment has resulted in all but 6 of these posts being filled. This brings the midwife to patient ratio to 1:48.There are currently 6 midwives vacancies in the Maternity Department in Our Lady of Lourdes Hospital, Drogheda and efforts are currently being employed to address this"
 

 

2008 KPMG Review of Dublin Maternity Services

 In 2008, the HSE-commissioned report, Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area, by KPMG, with each hospital THEN delivering over 8,000 births per annum, stated:

"Based on the current model of care, compared to standards set by BirthRate Plus, BAPM and the RCOG in the UK, the hospitals are understaffed, with an additional:

20 obstetricians,
221 midwives,
20 neonatal nurses
and 35 theatre staff required across the three hospitals"
 
The public service embargo along with the numbers of midwives who have retired from the system from 2010 onward, under the voluntary early retirement schemes, mean that on many shifts in our maternity hospitals, midwives are carrying double the caseloads they should be carrying. Staff sickness levels are high and staff are leaving.

 While it is true that the birth rate has dropped nationally by almost 3% between 2011 and 2012, that does not bring our maternity units anywhere near the numbers of births in 2007/8 when the KPMG report already stated that we suffered significant understaffing by best international standards.

  

Portlaoise Midwives

 In 2006, 32 midwives from Portlaoise wrote to the Minister for Health concerned with staffing levels directly citing fears that levels will result in the death of a mother or baby. The midwife to woman ratio in Portlaoise has been reported on twice with conflicting levels. One report of 1:55 and another of 1:75.


Neither are safe nor appropriate staff levels.

 

"Not enough people to look after you"An exploration of women's experiences of childbirth in the Republic of Ireland - 2010

Objective: women's experiences of childbirth have far reaching implications for their health and that of their babies. This paper describes an exploration of women's experiences of childbirth in the Republic of Ireland

Focus group interviews with women from units which were randomly selected.

Findings: three main themes were identified, ‘getting started’, ‘getting there’ and ‘consequences’. Women experienced labour in a variety of contexts and with differing aspirations. Midwives played a pivotal role in enabling or disempowering positive experiences. Control was an important element of childbirth experiences. Women often felt alone and unsupported. The busyness of the hospital units precluded women centred care both in early labour and in the period following the birth. Some women would not have another baby due to their childbirth experiences.

Key conclusions: the context within which women give birth in the Republic of Ireland is important to their birth experiences. Although positive experiences were reported many women felt anxious and isolated. Busy environments added to women's fears and participants appeared to accept the lack of support as inevitable. Midwives play a pivotal role in helping women achieve a positive birth experience.

 Midwives SHOUT BACK

At the start of February women and midwives started a SHOUTBACK campaign. To tell their examples of why care is unsafe in Ireland from a professional view and examples from women of unsafe care they have experienced. These are a few SHOUT BACK contributions from midwives and their experiences working in an over-crowded and understaffed maternity system with a fundamentally flawed system. These contributions are from units all over Ireland. Urban and Rural. All saying the same.

SHOUT BACK - YOUR SAY: Be 'With Woman'...a Midwife, its what I trained to do, this profession was a passion for many of us, and I see on a daily basis that constraints the system, the hierarchically environment, the lack of on the ground support has made us dispassionate and akin to robots. Everyday I hear stories of fellow midwives leaving the system, dispirited and unsupported they have reached ...burnout stage, no longer having the energy to fight the system, they go along with the diatribe, suppressing their natural instinct, afraid that if seen to be different as they will be blackballed, there is no joy going to work and feeling alienated, or the odd one out. Yet I know they do try everyday to try and make birth better for the women in their care, no matter how bad the day, that passion and the love of midwifery is still there, engrained in their core, we need as women and Midwives to work together, lets not accept this anymore, lets make changes, NOW, SHOUT BACK!

 

SHOUT BACK - YOUR SAY: As a midwife I can safely say the only reason more people aren't dying is because birth is normal for the most part. There are near misses every day, dreadful post natal care, cattle market prenatal care. Lack of evidence based care is rampant. Midwives are cracking under this broken system. I, myself have taken many sick days because I just can't cope. As a I frequently had 12 women and babies to care for. This level of stress can not continue. Midwives are flocking to other countries. Better countries to work and give birth in

 

SHOUT BACK - YOUR SAY: I am currently working as a midwife in the Irish maternity system. It seems redundant to say that I work in a very busy and understaffed hospital, however I feel that perhaps the government and a certain minister may need a little bit of reminding. When I began my training as a midwife I knew it would be hard work; I was never afraid of that. However, in the last few years I... feel that my role has shifted from advocate, educator and supporter of women and their families as they traverse the amazing road of parenthood to somewhat of a firefighter. It is a constant struggle just to provide the bare minimum of safe care (and even then it is not always possible).

It is unsatisfactory to say that Ireland is one of the safest places to have your baby. Of course safety is paramount but merely sending a family home alive and "safe" physically is not the only benchmark to which the maternity system should be held accountable.I work with some phenomenal people who try their best every single day to provide as much care to women and their families as they can but it's just not enough. The pressure on our maternity system caused by lack of staff and adequate resources to cater to the number of high and low risk women is having a detrimental effect on the experiences of the clients and the health and wellbeing of the staff.

 I love my job, but it breaks my heart to come home after a long and exhausting shift to feel that I just didn't get a chance to truly support anyone, to employ the skills I have worked hard to obtain. It's a terrible thing to know what you could do if you had just a bit more support, just a bit more time.... you could make all the difference in the world to someone. And as selfish as it sounds, it could make all the difference to me, to all of us working here. No midwife that I know pursued this career to feel like an unwilling abuser, we do it because we know how important this moment is in peoples lives, and we want to help!

Job satisfaction is a wonderful thing and drives us to continue to support and care with everything we have. We glean what we can from a spare ten minutes to give an extra helping hand to someone who is breastfeeding, rocking with and rubbing the back of a woman in labour or having a few precious moments to genuinely listen to a woman about her concerns or worries and give reassurances or education. So often however, Its just not feasible and those moments are considered a luxury for us and the women. I am truly sorry to all the women I have cared for who may have left feeling upset, scared or traumatised and no one had a moment to sit and talk to them. It weighs on me all the time.

So many of us are close to breaking point, so close to leaving the job we love because it's turning out to be unsustainable to continue with those levels of pressure and stress on a daily basis without turning into an apathetic or unhappy person. I sincerely doubt that any woman would want to be cared for by someone who is unhappy and exhausted physically and emotionally.

I wish I had the courage to post this with my name on it, but I am afraid. I am afraid that the foxhole mentality of the maternity system will come crashing down on me; that I will be accused of putting words in other peoples mouths even though I hear these sentiments every day. Or worse, that I will be seen as someone who just can't handle it. I can handle it. I just don't think it's enough to be able to merely 'handle' ones job, especially when that job is so importance and carries such gravitas and may have implications for the rest of a womans life.

I suppose it boils down to the fact that although I'm doing the best I can with what I have, I want the opportunity to be the best that I possibly could be for the families I care for. If we could have that opportunity it would certainly make this an excellent place to have a baby.... not merely an acceptable place.

Its not enough to make recommendations.

 

Report after report. Recommendation after recommendation. And no action.
 

  Recommendations and guidelines in the current system go unanswered with no obligation to implement them locally. AIMSI are aware of maternity units which are still failing to implement recommendations (Amnisure) from the Tania McCabe report.

Why have these units not been held accountable?
Why does Ireland have an extensive library of National Clinical Guidelines which have not been implemented into local policy or practice?

The HSE needs to be fully audited and held accountability for its own compliance in creating a culture in which these scandals have been allowed to flourish.

There is a serious need for investment in evidence based care in Ireland. Obstetric led hospital based care must be fully equipped - not only with up to date equipment but also the appropriate safe staffing levels to prevent adverse outcomes for women who chose this care setting. In addition, investment in care options must be available in all units - including midwife led units, birth centres, and homebirth services.


Continuous safety failures clearly illustrate that the current care model needs an urgent overhaul and that health care providers are working in environments without clinical support - just getting by. Women and babies deserve one-to-one care based on the highest possible quality and evidence.
 

Related Reading:

Baby deaths 'not linked' to hospital's staff levels: http://www.independent.ie/lifestyle/health/baby-deaths-not-linked-to-hospitals-staff-levels-30055895.html

Safer Childbirth 2007: http://www.rcog.org.uk/files/rcog-corp/uploaded-files/WPRSaferChildbirthReport2007.pdf

‘Far off’ level of care needed http://www.leinsterexpress.ie/news/your-community/far-off-level-of-care-needed-1-5899190

Portlaoise midwives wrote to Cowen and Harney over ‘fears that a mother or baby would die’ http://www.thejournal.ie/midwives-wrote-to-ministers-in-2006-expressing-fears-that-babies-would-die-1291780-Jan2014/

‘Not enough people to look after you’: An exploration of women's experiences of childbirth in the Republic of Ireland http://www.midwiferyjournal.com/article/S0266-6138(10)00186-5/abstract