'I do not want to wait until she's dying before I intervene'
Existing rules do not help in assessing when a risk to health becomes a risk to life, says the Master of the National Maternity Hospital at Holles Street, writes SHEILA WAYMAN
The Master of the National Maternity Hospital is a woman under pressure. When I arrive at the agreed time for an interview, I am told at the front desk of the antiquated building on Holles Street that there are others waiting ahead of me. The “others” sitting in the small entrance hall waiting for Dr Rhona Mahony include a significant one – the Minister for State at the Department of Health, Alex White.
When Dr Mahony arrives about 10 minutes later to greet White, an apologetic secretary says that she is not sure how long I’ll have to wait as the master also has to go down to theatre.
Being the head obstetrician at a hospital with 700 staff and where about 27 babies are born each day is an onerous responsibility. She wears the stress lightly, although with the country convulsed over the death of Savita Halappanavar and the issues arising from that, everybody working at the coalface of the maternity services must be particularly deeply affected.
Mahony is concerned that neither Medical Council guidelines nor legislation address situations where the degree of risk to a woman’s life, if a pregnancy continues, may be difficult to assess.
“If we think is a woman is going to die, we can terminate the pregnancy – and we do – and there are no issues surrounding that,” she explains.
“But there are areas where we are not sure how to quantify the risk to life, and indeed the risk to health, and there is an overlap between the two – when does the risk to health become a risk to life?
“It can be difficult in practice to make a clinical distinction between threat to life and threat to health, therefore there is a degree of legal uncertainty.”
Doctors need to be able to exercise professional judgment without fear of prosecution, she stresses, “and at the heart of all of this is our wish to look after women the best way we can”.
For instance, more women with serious underlying diseases, such as congenital heart disease, or significant chest or liver disease are now, thanks to improved healthcare, living to an age when they may become pregnant. But the extra burden of pregnancy can significantly impair health and pose a significant risk of mortality.
“When she comes in at 12 weeks gestation she may be very well but I am looking at the effect of this pregnancy as it progresses,” says Mahony, who does not believe it is clear exactly when, in such a case, she is permitted to intervene.
“Do I have to wait until she is unwell, critically ill – at what stage can I make provision to offer her good, sensible healthcare? I do not want to wait until she is dying before I intervene, I want to protect her. I take into account her wishes as well.”
To say that women in Ireland never choose to terminate their pregnancy to safeguard their own health is inaccurate, she says. Some, who feel the risk of pregnancy is too great, will travel to a different jurisdiction to terminate it – before the risk to their life is closer to an “almost certainty” that permits termination here.
“These are not common cases but they do exist and I think one needs to make provision for that.”
Asked for her view of abortion on demand, Mahony says that is a decision for the people of Ireland. She regards situations where there is a threat to the mother’s health and life as being an obstetric decision, but that abortion on demand is a “social decision”. She believes there is a readiness in Irish society now for debate on termination in cases where the foetus is not viable.
Witnessing the public fall-out from the Galway case, Mahony also believes that people need to be reassured that any death of a woman in a maternity hospital, a “catastrophic, devastating event”, is always taken extremely seriously and investigated appropriately.
Nine women have died in Holles Street hospital since 2003, which is in line with the national figure of eight maternal deaths for every 100,000 births, and includes non-obstetric causes.
A death must be reported to the coroner who, after a post-mortem, will either decide an inquiry is not necessary or will, in the public interest, hold an inquest, which the family can attend. Medical staff explain what happened and can then be questioned through the coroner by families, who can also be legally represented.
At the same time the hospital will also closely examine all the circumstances surrounding a death, to see what lessons can be learned.
One problem, says Mahony, is that the hospital does not get the post-mortem results until after the inquest is held, because it is important that is done independently. However families sometimes think there is a big cover up, she says, because the hospital is unable to give them findings from the post-mortem.
“That is very difficult for us because you really want to tell the family everything.”
Irish maternity hospitals are also involved in an UK initiative under which a report on maternal deaths is produced and shared every three years. These are anonymous accounts, she explains, to avoid legal problems and to allow “a very honest appraisal of why a woman died”, in the hope of avoiding a similar case in the future.
Nearing the end of the first year in her seven-year term as master, the big challenge, she says, is managing the number of births, “that are way above our capacity, in an environment of diminishing resources”.
A mother of four children, aged from six to 14 , Mahony is grateful for all the support staff have given her in her first year. The job of an obstetrician, she adds, is “always extraordinary but desperately unforgiving”.
Cutting childhood obesity
Simple lifestyle changes, such as exercise during pregnancy and paying close attention to diet, have reduced the insulin requirements of woman attending the diabetic team at the National Maternity Hospital (NMH).
“This is really objective, clinical success – very exciting,” says Dr Rhona Mahony, who addressed a medical seminar on Maternal and Infant Health and the Effect of Changing Lifestyles in Dublin last Saturday .
Maternal obesity is the big challenge for the health services in Ireland when focusing on the first 1,000 days in a child’s life – during pregnancy and up to the second birthday. This period is very important for laying down the future health of that child, Dr Mahony told The Irish Times ahead of her talk.
There is a much greater understanding now of the cycle between maternal weight gain, large babies at birth, the risk of childhood obesity and then heart disease, stroke and all the diseases that go with obesity, she explains. Thirty-eight per cent of women attending the NMH are overweight and one per cent are morbidly obese, with a BMI of over 40 (18-25 is normal weight range),
With the many benefits of breastfeeding including a reduction in the risk of childhood obesity, Mahony says she would love to have more resources to give to the NMH breastfeeding team who, she says, are really passionate about supporting women. Some 69.7 per cent of mothers start breastfeeding at the hospital.
Asked if she was uncomfortable about Saturday’s seminar for health professionals being sponsored by a formula milk company, she said: “I don’t have any political agenda. I am just delighted to take this opportunity to discuss good nutrition in pregnancy and to promote breastfeeding,” adding that she would donate her fee towards breastfeeding support.