Second Opinion: Time to cut through the red tape for a better maternity service
It must be galling for the Masters/obstetricians who lead Ireland’s maternity hospitals/units to be told that women need “modern day” services, including changes in the consultant-led model of care. The HIQA report into the safety, quality and standards of services provided to pregnant women shows that they are not the often quoted “among the best in the world”. Dr Peter Boylan, Clinical Director at the National Maternity Hospital blames the Government, saying the report is “an appalling indictment of state failures over many years to provide a safe infrastructure” for maternity services. While the State must take its share of responsibility, the report identifies failures at all levels, including failure to address power imbalances.
In 1954 the State decided that obstetricians should make all decisions about the natural process of childbirth. Midwives were disempowered and relegated to the role of doctor’s assistant. This became the worst of all possible models: consultant-led and midwife delivered, leading to a huge imbalance of power between the two most important professionals involved in the care of pregnant women. Inevitable negative health consequences followed, including excessive medical interventions, rising caesarean sections, barbaric symphysiotomies, and unnecessary caesarean hysterectomies. The 2006 Lourdes Hospital Enquiry noted “there has to be a more constructive, complementary and fluid relationship between midwives and obstetricians which is patient-centred.”
The medical model of maternity care has been in place without a review for 59 years. The 2001 National Health Strategy, Quality and Fairness: A Health System for You recognised that a new model of maternity care was needed, that was “woman-centred, equitable, accessible, safe and accountable” and noted that “A plan to provide responsive, high-quality maternity care will be drawn up.” Twelve years later there is still no plan. HIQA found no “evidence of any national review.” There is no national maternity strategy. This is unprecedented. Every major health service has developed at least one strategy and some services have too many. The 19 maternity hospitals/units do their own thing, have a “myriad of governance structures”, as well as differences in models of care, such as a few hospitals having midwife-led units and a majority having consultant-led services. As a result “it is impossible to assess the performance and quality of the maternity services nationally”.
Complacency is another problem within Irish health services, including maternity services. HIQA points out the urgent need for “ownership” and the “inability to implement change in a connected way and apply system-wide learning from adverse events across the system.” HSE staff and the public believe the rhetoric about our maternity services being among the best in the world. When you are the best why change? Professor Richard Greene, interviewed on Morning Ireland about the Audit of Perinatal Mortality published last week, said when you compare Ireland’s rate of perinatal mortality (6.1 per 1,000 births) with say, Sweden’s (4.7) and Germany’s (5.5), “we are right up there”. Concluding that Ireland has better or worse maternity services than other high-income EU countries is erroneous because statistically the numbers are too small to be compared. Women’s experiences of ante-natal care and childbirth would be a better indicator.
The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts published earlier this year says that “Ireland has some of the best healthcare professionals in the world. They deserve as much freedom as possible to deliver for the patient.” Can they be trusted with freedom? HIQA found that maternity services in general breached almost a third of the National Standards for Safer Better Healthcare and that national controls are needed including “the development of models of care that reflect modern day, reliable and integrated maternity services both in-hospital and in the out-of-hospital setting”. In the vast majority of pregnancies midwives should lead with obstetricians involved only when women have complex needs.
Minister James Reilly recently announced the development of a National Strategic Plan for Maternity Services. This will not be published any time soon. An advisory group has to be set up first. A national maternity services policy will be developed to guide the development of the Plan. All this will take several years because of the 60-year old power imbalances. Why not cut through the red tape and adapt the new Strategy for Maternity Care in Northern Ireland 2012-2018? This emphasises the normality of pregnancy and midwife-led care in accordance with best practice, exactly what is needed everywhere. Power and complacency will ensure things stay as they are for years to come.