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Birthing better Irish maternity services

Lastt year saw the publication of Ireland’s first ever National Maternity Strategy, a 10-year roadmap for the future of maternity services in Ireland.

The comprehensive document contains 77 action points for implementation, with the HSE National Women and Infants’ Health Programme (NWIHP) responsible for realising these objectives.

Dr Peter McKenna, former Master of the Rotunda Hospital, Dublin, was appointed Clinical Director of the NWIHP in March.

The three-year, full-time role brings with it many challenges for the consultant obstetrician and gynaecologist, with significant changes required to transform Ireland’s maternity services under the Strategy.

Indeed, it is not a challenge to be taken lightly given the HSE’s ongoing budgetary constraints and the criticism already about the delays in commencing the implementation of the Strategy.

Despite this, Dr McKenna, who has been a clinician for more than 40 years, is passionate and committed to making Ireland’s “good” maternity services “world class”.

“It’s difficult to express how much I am looking forward to doing this,” he told the Medical Independent (MI).

“To me this is really exciting and it’s a chance to put midwifery and obstetrics centre-stage and to improve the experience and the outcome for pregnant women and their babies.

“Ireland has got a good system at the moment and this is an attempt to make it truly world class. I actually can’t think of anything else I would like to be doing more than this.”

The NWIHP currently has in place a programme manager, clinical director and midwifery lead. A business manager and data managers will join the team in the future.

According to Dr McKenna, his job description is very wide, but the two main areas are implementation of the Strategy and the achievement of that working with Hospital Groups.

Funding

During the summer, the NWIHP submitted the implementation plan for the Strategy to the Department of Health, where it remained under observation at time of going to press.

The plan, which has yet to be published, seeks about €19 million in funding for 2018, Dr McKenna advised. “We’re hoping it will be adopted and published fairly soon, because we’re slightly in limbo until it’s ratified by the Department,” Dr McKenna said.

“If we are to implement everything we have put in for next year…even if that money was available, it’s entirely possible that it couldn’t be spent, in that we couldn’t recruit all the staff that would be behind the money… In terms of practicalities, it’s possible that we could achieve a substantial amount, even if less [money] were allocated.”

Dr McKenna acknowledged that hundreds of new staff in a number of areas, such as community support and mental health, are required to bring about the changes contained in the Strategy.

Staff funding will be phased-in annually during the Strategy time frame and new funding will be sought annually to implement service improvements.

Commenting on the initial funding requirement for next year, Dr McKenna said the expectation is that it will be largely front-loaded.

Priorities

In August, a new study revealed that one-third of pregnant women in Ireland are still not offered a routine foetal anomaly ultrasound.

According to Dr McKenna, the inequality of foetal anomaly scanning was identified as an important issue prior to the commencement of the NWIHP.

“One of earlier things we had to do was see what resources were necessary to try to bring the same level of scanning to every hospital,” Dr McKenna explained.

Details on the resources required to improve scanning are contained in the unpublished implementation plan.

Another priority, work on which is already underway, is the improvement of mental health facilities for pregnant women. Ireland has long been criticised for its lack of perinatal psychiatrists, with just three such part-time posts, all based in Dublin. A study by the Trinity College Department of Psychiatry, published last October, found that one-in-six pregnant women — 16 per cent — were at probable risk of depression during pregnancy, one of the highest rates in the OCED.

Some of the bigger maternity units have their own psychiatric services, with consultants and specialist midwives dealing with mental health but this needs to be expanded in these hospitals and rolled-out to smaller hospitals, Dr McKenna acknowledged.

Another significant priority contained in the Strategy’s implementation plan is the development of community midwifery services. One of the Strategy’s core visions for future maternity services is that: “Care will be provided in the community as far as possible, through combined care between the GP and the maternity service and through an outreach community midwifery service, where hospital midwives will work alongside, and in association with, public health nurses and general practice services.”

Plans are in place to introduce community midwives to realise this goal, Dr McKenna confirmed.

Oversight

For the first time ever in Ireland, the NWIHP will provide national oversight of services in maternity units, identifying areas with poor outcomes and offering support to those units.

But this does not mean that smaller maternity units will be under more scrutiny, Dr McKenna noted.

“Part of the objective would be to identify areas where poor outcomes are statistically more common and try to support those units. So, in other words, that we have a fairly uniform, safe system across the country,” he explained.

“If you look at the stories that have been in the public domain, very often they have not been about individual cases, although some have, but they have been about clusters of cases. Do the clusters represent just a statistical blip or do they represent a systemic failure in that department and if so, why is that the case? In some ways, this is the first time there has been some prospective oversight brought to bear on the outcomes from individual units.

“There will be a focus on less safe units; whether they are big or small, it doesn’t matter. It would be wrong to approach this with the point of view that because you’re interested in outcomes, you’re interested in making life difficult for smaller units. That simply wouldn’t be the approach at all. We are interested in making every unit safe.”

Adverse outcomes

While the oversight provided will help to support staff and units, it will not eliminate adverse outcomes entirely, Dr McKenna cautioned.

There will always be some adverse outcomes in obstetrics because it is an imperfect system, he said.

“Part of what we will have to do is put these into the context of, are they coming from one particular part of the country? Is there an unexpected area that is contributing out of proportion? Is there a unit that needs to be supported? In other words, it would be setting yourself up to fail if you said that all adverse outcomes would be eliminated. That simply isn’t possible.” 

“There is a will from everybody to be working in a world-class system. Nobody wants to be part of a system that is not delivering a world-class service. The potential to do that is there.”

Many media news stories have highlighted adverse outcomes for pregnant women and babies in Ireland due to system failures.

The Strategy itself notes that, “several reports and reviews have highlighted significant service deficits and failings which have undermined confidence in our maternity services and staff morale”.

Indeed, obstetrics is a risky business and accounts for more than half of pay-outs made by the State Claims Agency, it is understood, with indemnity insurance costs commensurate to the risks involved. Furthermore, approximately one in 200 babies dies in the latter stages of pregnancy.

“One of the aims of the programme is to establish midwifery and obstetrics as being the important part of the health service it should be. We’re unapologetically looking at the risk that the specialty generates… From our point of view we are a very important and high risk specialty and we need to be resourced to deal appropriately with these risks,” Dr McKenna said.

“There is a lot of good will and people are keen to move to change. But as you know everything does need, number one, official encouragement and, number two, resources.”

Future

So, in three years time what would Dr McKenna like to have achieved when looking back on his time in the role?

“My main interest would be that we can say that there is no [maternity] unit in the country that is not functioning to the best of its ability and that that ability is comparable to what you’ll get anywhere in the world in terms of outcomes; that would be my priority.”

Furthermore, the Strategy notes that there is a lack of choice in birthing options for pregnant women in Ireland. Dr McKenna would like to see an improvement in the level of choice offered to expectant mothers in how they give birth improved when his term reaches a close in 2020.

If all goes well, there should be a new maternity hospital in Dublin at that stage to help lead the way in improving options and facilities for pregnant women. In August An Bord Pleanála granted planning permission for the construction of the proposed replacement National Maternity Hospital, on a site on the campus of St Vincent’s University Hospital, Dublin, after the resolution of a row over ownership and control of the new hospital.

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