Harney sets up maternal deaths inquiry

MINISTER FOR Health Mary Harney has established a confidential inquiry into maternal mortality which aims to provide safer care for pregnant women, women who have recently given birth and their children.

The inquiry will focus on learning lessons from maternal deaths, according to the HSE.

It said the inquiry would ensure that maternal deaths were reviewed in a “standardised and confidential manner”, with recommendations for change and improvement “applied across all centres providing maternity services”.

Ireland has a “consistently low” mortality rate compared with the rest of Europe, according to the HSE. The statistics are derived from hospital data reported to health ministries, with trends across Europe having been monitored by the World Health Organisation (WHO) since 1980.

A maternal death is defined as the death of a woman while pregnant or within 42 days of a pregnancy ending. This is irrespective of duration and “site”, and has occurred from “any cause related to, or aggravated by, the pregnancy or its management, but not from accidental or incidental causes”.

The confidential inquiry into maternal and child health (CEMACH), as the structure is known, originated in Britain, and Ireland is now participating in its work for the first time. Main drivers of the co-operation are the Institute of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland (RCPI) and the HSE.

The Department of Health and Children and the Clinical Indemnity Scheme are also supporting it, according to the HSE.

Funding will be provided by the HSE, and maternal deaths here will be included in the CEMACH review from this year (2009). Every three years, CEMACH in Britain publishes a report on findings and recommendations, arising from “learning” which it has “identified through standardised and confidential reviews of maternal deaths”.

The report is made public, and has “made a major contribution to improve the safety and quality of care”, the HSE said.

It will now cover all such cases in England, Wales, Scotland and all of Ireland.

The HSE said Ireland’s participation would also ensure implementation of recommendations made by the Commission on Patient Safety and Quality Assurance.

A “standalone” CEMACH office will be set up at the National Perinatal Epidemiology Centre based in Cork University Maternity Hospital. It will be staffed by a CEMACH co-ordinator who will be responsible for arranging assessment of reported cases, ensuring data is confidential and liaising with the CEMACH central office in London.

Dr Michael O’Hare, chairman of the CEMACH working group in Ireland and consultant obstetrician and gynaecologist, said an “important step forward” had been taken to “help ensure that all pregnant and recently-delivered women receive safe, high-quality care delivered in appropriate settings”.

Dr Paul Kavanagh, who holds responsibility for patient safety and healthcare quality in the HSE, noted that maternal death in Ireland was “thankfully a rare occurrence”, but it was important that each incident was reviewed in a standard way to improve services, avoid recurrences and “ensure accountability for delivering improvements”.

He paid tribute last week to the Institute of Obstetricians and Gynaecologists for its “leadership” in providing the services of CEMACH to professionals working in this area in Ireland.