Life is one big baby boom

Maternity hospitals tend to be seen as far more positive places than general hospitals. In most cases the outcome is a happy one. Prof Peter McKenna, Master of the Rotunda Hospital in Dublin, the third largest and oldest maternity hospital in the State, says he realised obstetrics and gynaecology would be his area when he was a fourth-year medical student. He accepts it has none of the "glamour" or the drama of casualty, and says the good things about it is that there is a deep sense of gratification. "Most of the time you are seen as having done a good job. However, people's expectations are very high and nowadays, anything less than a perfect outcome will be questioned."

Last year 6,300 babies were born at the Rotunda, about 60 per cent were normal routine deliveries. Between 23 and 24 per cent would have required Caesarean sections. About 12 to 15 per cent were either forceps or vacuum deliveries. "Although the number of births is gradually rising, the national birth rate is falling in that people are having fewer children, but there are more having them."

Practical and direct, capable without being pushy, McKenna does not believe in mystifying patients and is far less austere than might be assumed from the Victorian-sounding title of Master. Instead he is a sporty, rangy character with small bright eyes, cropped hair, and a natural expression of calm surprise - still looking much like the schoolboy 400-metres hurdler he once was. The spartan ambience of his little office at the Rotunda, complete with its portrait of founder and first Master, Bartholomew Mosse (1712-1759), is softened by some of his own paintings, mainly gifts, on the wall.

Wearing the regulation white coat swinging open and obviously energetic, he seems all set for a double-shift. He could have walked off the set of Mash. Born in Scotland, the only child of psychologist parents, he will be 50 next month but seems far younger, thanks to his easy-going attitude and the fact that he cycles most places, including into work from his home in Foxrock near where he grew up.

He sees his medical career, which has been dominated by working in busy clinical teaching hospitals, as having always been directed at his current job, that of heading a maternity hospital. Between late 1983 and January 1985 he was Assistant Master, and that early experience of observing the job at close quarters has proved very useful to him on becoming Master in 1995. The father of four children, two of whom were born in the Rotunda, McKenna is known for speaking with rather than at his patients. He would seem to be a natural psychiatrist, yet says he never had any particular interest in that field. Counselling is, however, an important element of his work.

At what age did he decide to become a doctor? McKenna looks even more surprised than usual and says: "I didn't really decide." Adventure, it seems, appealed far more to the young McKenna than studying. On the family's return from Canada, where his father had been working, McKenna at five began school at St Michael's Ailesbury Road. Having enjoyed Irish School at Trabolgan, near Whitegate in Co Cork, the summer when he was 10, he decided he would like to spend an entire school year there, learning everything through Irish. So he set off for a year as a boarder. It was brave stuff for a boy of 11 and also indicated his practicality has always been well matched by his imagination. He sees it now as evidence of his foresight.

"I knew it was a great place. It was also very beautiful. The approach was a long, wooded drive with rhododendrons. When I went there it was like going to Ring in Waterford. People have since recognised the attractions of the place and it has become an indoor, all-year holiday resort." McKenna is pleased that he had its splendours figured out a long time ago. After his year in Cork, he returned to St Michael's and completed his primary education. From there he went to Clongowes Wood College in Co Kildare. It remains one of the most important associations in his life. "Not for what I learnt. But for the friends I made there."

Arriving at University College in 1968, he allowed neither athletics nor student politics to distract him. "In those days getting in was easy, but pre-med was difficult. But then, when I got to the clinical side it became enjoyable." It began going very well. This new sense of relaxation enabled him to return to athletics, and he represented UCD in various athletics matches in Ireland and England. Sport remains important to him. Like many old runners, he discovered a few year ago that running began to hurt. Every time he went for a run his knees began to pain. "I took up cycling." It's pretty serious. He has cycled to Dublin and Belfast and back, and his bike is a good one. Next week he is heading off to Lanzarote for a sports training camp.

Teaching does make a difference to students as far as he is concerned, and he refers to the excellent lecturers he had in obstetrics: "One was good, one was very good and one as outstanding." It seems to have shaped his own approach to lecturing, and McKenna says: "I tend to think about a lecture in terms of `what do I want to get across and what do they absolutely need to know about this topic' and then try to present it in a reasonably entertaining way to teach these people, and then I think `what do I want them to remember after the lecture'."

Since 1995, he has been clinical professor at Trinity College, where he previously lectured in obstetrics and gynaecology, while also lecturing at The Royal College of Surgeons. Having come first in obstetrics and gynaecology in his final exams, McKenna also won the John F. Cunningham Gold Medal in Obstetrics at Holles Street, where he would later work as senior house officer in obstetrics before moving on to neonatal paediatrics.

In 1976 he went to England and worked in a number of hospitals, including Birmingham Maternity Hospital and the Women's Hospital Birmingham, before returning to Dublin and a lectureship in Trinity, while also working as registrar in obstetrics and gynaecology. Since early in his career he has been involved in working in gynaecology and the obstetric care of women with medical problems, particularly cardiac disease, an area he has gathered vast experience in through his eight-year association with the Mater Hospital.

A career clinician with a specific interest in the continuing health and safe delivery of the pregnant woman, he has never been involved in research. "I'm not a lab doctor. I have never worked in a laboratory but I am committed to encouraging research projects that are ethical, feasible and practical in an Irish context." The most successful of these projects to date is one researching cardiovascular adaptation in normal and hypertensive pregnancy. McKenna has so far raised more than £180,000 for this work, which includes monitoring cardiac arrhhythmias in normal pregnancy.

Childbirth has always been among the most contentious of medical areas because of the legal aspects. "The ethical areas surrounding gynaecology and obstetrics such as contraception, sterilisation, HAR (human assisted reproduction or IVF) and abortion have always been the ones to capture the public imagination, certainly in this country." In the 255 years of the Rotunda's existence, giving birth has evolved from a highly risky situation in which many mothers and babies died - indeed death at childbirth was a common occurrence for women of all social classes - to what is now a routine and safe event. Alongside this, however, has been a myriad of ethical and legal aspects.

Asked what is the worst possible outcome of pregnancy, McKenna replies "the death of the mother. Maternal death is the ultimate tragedy. This is rare, maybe one a year for us, maybe four or five in the entire country, but it is the biggest catastrophe. It devastates the hospital when an apparently healthy woman dies. Everyone is upset."

Foetal loss is another highly charged area. Perinatal mortality rates are assessed from a weight of 500 grams or more. If the baby weighs less, the death is then classified a miscarriage. "This is a standard cut-off point as used throughout most of the first world, but this does not make it any easier for parents who have lost a baby of under 500 grams. Clearly their grief does not acknowledge the WHO criteria of 500 grams." There is also the reality of stillbirth, of which there might be about 20 or 30 in a year.

Four years ago McKenna introduced the option of amniocentesis, a test by which women facing the possibility of difficulties related to age or history might detect genetic abnormalities. "Previously women had to leave the State. I felt it was incorrect for somebody to have to leave the country for a diagnostic test that we could do and is perfectly legal. The test involves taking some fluid from around the baby via a needle placed in the mother's abdomen. From this the baby's chromosomes are grown."

Results can take up to three weeks "although with modern methods some results indicating chromosome abnormality can be available sooner. If the result is abnormal this information is obviously given to the woman. Not every woman who has a bad result chooses to leave the country to have a termination. Some feel that armed with the abnormality they are better prepared for dealing with it. I'm often asked `should I have this test or not?' My standard reply is `this is one area I feel very inadequate to give strong advice as I don't have to live with the consequences'. One of the consequences is the one-in-100 risk of miscarrying a healthy baby after the procedure. The other is not having the procedure and having an abnormal baby. And I feel that for somebody to influence somebody's decision in that area is too easy when you don't have to live with the consequences."

At the Rotunda's IVF clinic, the option of freezing surplus zygotes has been available for the past few years. "In an in-vitro fertilisation cycle, up to a dozen eggs can be retrieved. If, say, eight of these are successfully fertilised, you can not replace eight fertilised eggs or zygotes back into the woman's womb in case all eight eggs grow inside. The recommended number of eggs to replace is two, or a maximum of three, so unless you have a freezing of zygotes option available, the surplus fertilised eggs or zygotes will be lost."

Returning to the apparently contentious issue of the medical profession's tendency to place priority on the mother's survival, McKenna explains: "In a very rare case such as a woman in early pregnancy who is diagnosed as having an invasive cancer of the cervix, she would be offered the option of having a hysterectomy if that was the appropriate treatment. Even more rarely, you can have a pregnancy that results in such life-threatening hypertension that the only way it can be controlled is to terminate the pregnancy, such as happened here two years ago.

"Nobody that I know feels that this is the incorrect thing to do. What the argument is over is whether this is `treatment' or a termination. The reason why people argue over it is that if you call it `treatment' you can say there is never a case to justify termination in Ireland and get that written into our Constitution. If you call it `termination' you acknowledge there are sometimes cases that defy a blanket ban - that is the nub as to why people argue over this."

Other dilemmas remain. While he says teenage pregnancies are not increasing, not all pregnancies are in ideal situations. About 40 per cent of births in Rotunda are to single mothers, many of whom face practical and social difficulties. Also to be considered are babies born to HIV-positive and drug-addicted mothers. "It's very hard watching a new baby struggling with withdrawal symptoms. You make it better and then release it out to what?"

In an ideal world, how different would life be in the Rotunda? McKenna is not a complainer but he is compassionate and has a vision. "We would have better facilities, more staff and a different medical/legal system to address adverse outcomes." The Rotunda's ethos has always been a liberal, humane one. "I feel very comfortable with it, and that's speaking as a conservative and as a Catholic." What is the biggest challenge facing the Rotunda in the 21st century? The reply is immediate. "The single biggest one is trying to match patient expectations with the innately imperfect system of human reproduction."

With two years of his seven-year term as Master ahead of him, where does he see the future? "I'll return to being a consultant." Will he miss having to deal with the public relations or media-related aspects of the job? "Funnily enough I don't dislike that. The one part of the job I won't miss is dealing with patients' complaints."

On a wider level, McKenna is well aware that after years of being in the consultative minority in a profession exclusively concerned with women, female doctors have finally caught up. The next master of the Rotunda, or indeed of either of Dublin's two other maternity hospitals, could well be a woman. If so, will she be the master or mistress? Not overly concerned with the semantics, McKenna laughs: "If she is good enough to get the job, I'm sure she, whoever she is, will be able to figure out what to call herself."