Prof Chris Fitzpatrick: We’d do better... with the resources

The results for mothers and babies in Ireland compare well with equivalent high-income countries – but behind the figures are outcomes that should never have happened and others that turned out better than expected.

However, our results could be better. There is no reason – to borrow a phrase from Taoiseach Enda Kenny – that we could not be the best country (of any size) for any mother to give birth in.

Instead, we have long been skating on dangerously thin ice – not enough midwives, the lowest ratio of obstetricians of any OECD country, despite having the highest birth rate. And we are seriously short of neonatologists, anaesthetists and other key staff.

Unexpected deaths in mothers and babies have triggered media interest in maternity services and yet we do not have enough perinatal pathologists to appropriately investigate such cases.

Meanwhile, prenatal ultrasound assessment by qualified sonographers and foetal medicine specialists is not generally available outside larger units.

Recent legislation on the protection of a mother’s life in pregnancy acknowledged the serious problem of suicide, yet we have a dearth of perinatal psychiatrists and other specialists.

After a decade of largely ignored reports, we now do have a new national strategy and new Hiqa guidelines. What we do not have are the staff and the resources.

It is increasingly difficult to attract people to a career in the maternity service. Many now in it are voting with their feet and leaving. Many abroad are not coming back.

Midwifery and consultant posts remain unfilled. Smaller units depend on locums to offer ad hoc clinical cover with little continuity of care. And yet expectations have never been higher.

Educate

So what is it like to be working at the coal-face? First and foremost it’s a privilege to share the joy of bringing new life into the world, but also to care for parents and families who suffer the intense pain of bereavement when that, tragically, occurs.

Although our primary duty is to patients, consultants must educate younger colleagues, undertake audit and research, handle increasing volumes of paperwork, as well as keeping up to date with advances.

The basic working week for most is 45-55 hours, but no one counts. And then there are on-call hours. Obstetricians in the Coombe work on average two to three 24-hour on-call days per month and five 48-hour on-call weekends per year. Many are also on call for other hospitals, staying up for most of the night and work a full day after.

And it is not all about obstetrics. Consultant anaesthetists and neonatologists work incredibly hard – on 1:5 rotas.

The European Working Time Directive simply does not apply to consultants. Short of being hospitalised , sick leave does not exist, so they need to be fit and have stamina.

Since cancer hospitals are increasingly unable to provide benign gynaecology services, more women now come to the emergency rooms and clinics in maternity hospitals with acute and long-standing gynaecological problems. Unlike general hospitals, maternity hospitals are not funded for ED services, yet they provide them – and without using trolleys.

People have varying opinions about private practice and a two-tier health system, but the reality is that maternity hospitals could not survive without it. Private practice takes pressure off public clinics and brings in badly needed revenue.

Patient expectations are at an all-time high. Equally, there is a perception that if there is an adverse outcome then there must be someone to blame. However, obstetrics has become more complicated. First-time mothers are older than ever. Nearly a third of pregnant Irish women are overweight or obese, bringing poorer outcomes. Meanwhile, there are more mothers with medical disorders, mental health problems, or with multiple pregnancies.

Communication

More and more babies are being delivered earlier and earlier during pregnancy. And they are doing better and better, thanks mainly to the tremendous work of neonatal nurses and doctors.

Nearly one-third of new mothers today were not born in Ireland. Communication can be difficult. Looking for an interpreter, or trying to explain something complicated in the middle of an emergency, stresses mothers and doctors.

When things go wrong, everyone focuses on clinical decisions and performance. Inadequate resources, even when they are identified, are less newsworthy. Many clinicians feel they are only one step away from the High Court where decisions, often taken in the middle of the night in a crisis, are dissected and parsed in slow motion by senior counsels and highly paid professional experts enjoying the benefit of a night's sleep.

To see colleagues who have struggled hard unfairly pilloried without the right of redress – because of confidentiality rules – demoralises everyone. No wonder recruitment and retention is such a problem.

Many of us would not want to do anything else. However, given how things stand, most of us would not encourage our own children to follow our path.

Each year, €60m is paid to settle maternity compensation claims. The math is simple. Up-front investment in services will reduce risk, improve outcomes and save money. It makes economic sense. More importantly, it is the moral thing to do.

Meanwhile, more must be done for mothers of babies with congenital fatal abnormalities who choose not to continue with their pregnancies. We must also try to explore the middle ground between the haranguing extremes of pro-life and pro-choice.

So what needs to be done? The necessary funds must be provided. Budgets must be ring-fenced and controlled by clinicians who understand the priorities. More staff must be recruited and equipment shortages sorted and facilities improved, in both hospital and community settings.

The co-location of the National Maternity Hospital, the Rotunda, the Coombe and Limerick must be accelerated and serious consideration given to closing some smaller units that may be unsustainable in terms of clinical safety.

Former Master of the Coombe, Professor Chris Fitzpatrick is a consultant obstetrician and gynaecologist