Holles Street can't keep up with the baby boom

Imagine it's 5 a.m. and you've been in labour for hours. The contractions are coming every five minutes and lasting for 20 seconds. You are booked at the National Maternity Hospital. You get yourself in, go to the desk, and the receptionist says: "Sorry, we can't take you. We've had 650 patients already this month and that's our limit. You're number 651."

Your mind in a daze, you hear yourself saying: "OK, I'll go to the Rotunda." The receptionist says: "No point. They closed for admissions an hour ago, and the Coombe closed yesterday. Your nearest hospital is Portlaoise, but if you want a neonatal facility, try Drogheda."

In the brave new world of maternity care, this nightmare scenario could never happen, we are assured. No woman in labour will ever be turned away, the master of the National Maternity Hospital maintains. By next spring, however, Dr Declan Keane warns that unless something is done to avert the midwifery crisis, pregnant women who want to book at Dublin's most fashionable maternity hospital could find themselves in trouble.

"We can't cope," he confesses.

The three big Dublin maternity hospitals are facing a "doomsday scenario", according to Dr Keane. "We've just had 750 for the month of July. This hasn't been seen since the late 1970s." A quota of 650 patients per month has been mooted but Dr Keane is adamant no decisions have been reached. If introduced, private, semiprivate and public patients would all be affected. He admits, however, that such a move by the hospital would need the backing of the Eastern Regional Health Authority and the Department of Health and Children.

The three hospitals, he says, "will have to draw a line in the sand. From a risk management point of view, from a health and safety point of view, there is a safe number you can deliver - otherwise you start to cut corners. It could well happen within the next few months that our insurers say this hospital is uninsurable."

The hospital tried to introduce geographic restrictions last year but the initiative wasn't very successful, he says.

The other teaching hospitals, which get patients from outside the eastern region, did not follow suit.

"The patient has always had the right to go anywhere," he says. "But now we will have to stop patients coming in from outside the ERHA region." These patients make up 8 per cent of the hospital's intake. "Most of them have been with us before," he adds.

The reintroduction of a regional residency requirement would mean women from outside the region would no longer have the option of choosing the hospital for their care.

Former patients would continue to be accommodated, however. The hospital would also continue to take patient referrals from other hospitals for specialist obstetric or neonatal care. All three major hospitals are specialist obstetrics and gynaecological centres.

Dr Keane admits that setting quotas might present a legal difficulty but argues: "We can't keep welcoming all comers unless we have the resources."

The master of the Coombe Women's Hospital, Dr Sean Daly, says the number of births "has gone through the roof, and we are down on midwives". So far, patient numbers at his hospital are up 3 per cent on last year: "We had 6,970 patients in 1999."

The rise in the number of births is attributed to a number of factors related to the economic boom: net immigration rather than emigration; increasing urbanisation resulting in an increase in the population of Greater Dublin; and the influx of refugees and asylum-seekers.

Dr Peter McKenna at the Rotunda says that, were it not for refugees and asylum-seekers, the Rotunda's numbers would be the same or even down on what they were 10 years ago. Non-national numbers in his hospital have risen steadily, growing from 350 in 1998 to 550 in 1999 - a 60 per cent increase. In 2000, the Rotunda looked after as many as 800 non-nationals, more than double the 1998 figure.

Centralisation and "too much hospital obstetrics" are also issues, according to Dr Keane. Holles Street, the Rotunda and the Coombe Women's Hospital deliver more than 40 per cent of the State's babies, but should they?

"In the past patients [from other regions] came to us because local hospitals did not have 24-hour epidural service, or because there was no neonatal intensive care unit (NICU). They came from Kilkenny, Mullingar, and Drogheda. But local hospitals have improved. Most now have NICU and epidural facilities," he says.

All three hospitals are in crisis, suffering simultaneously from a "baby boom" and what Dr Keane calls "a midwife haemorrhage". The three hospitals are short 25 to 40 midwives each. The total midwifery complement in each hospital is approximately 200, so the current shortfall is running at about one-sixth of the total.

The number of midwifery students, he observes, has dwindled to "a trickle".

"The numbers are now what they were back in 81 or 82. Back then, only 25 per cent of patients were first-time mothers. Now it's half - 48 per cent. There were no refugees then. No medico-legal climate as there is today," he says.

THE three maternity hospitals have been scouring the world for midwives but the midwife drain continues, he says. Midwives are leaving the service for a variety of reasons. Highly skilled midwives are poorly paid for their life-and-death responsibilities. Some are dissatisfied with the system of obstetrics-based care which, they say, leaves little room for midwifery. Some are choosing to work outside Dublin.

At both the Rotunda and Holles Street, the cuts have been concentrated in the postnatal area. For patients, this means an inevitable deficit in postnatal care. Dr McKenna points out that staff no longer have as much time to help new mothers with breastfeeding.

To attract nurses back to the specialist area of midwifery, they should be paid the same as public health nurses, Dr Keane believes. "Midwives are not recognised for the complexity of their work," he observes.

He realises that this proposal is unlikely to be welcomed by the Minister for Health and Children. Pay relativities in the public service are a sensitive area. "There is no shortage of gardai," he observes. "The Minister has the ability to ring-fence."

Midwives in New Zealand are paid at the same rate as family doctors. In Germany, they are paid more. So the question of benchmarking for Irish midwives could well be an interesting exercise.

Extra pay, Dr Keane maintains, has to be given to Dublin midwives because the cost of living is greater in the capital. "In London, for example, there are three levels of weighting."

Outside Dublin, the cost of living is lower, the numbers coming through the delivery unit bottleneck are smaller, and midwives have fewer acute cases to look after.

The crisis was discussed at a meeting between the three Dublin teaching maternity hospitals and Eastern Regional Health Authority earlier this week. Proposals put forward at the meeting included "ideas on numbers" and on "midwife retention". The hospitals' matrons will be meeting the authority over the next four to six weeks to find solutions.

They need to move quickly. "Pregnant women have to deliver," says Dr Keane. "It's not like having an operation for a gall bladder. They can't wait."