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Maternity strategy promotes multidisciplinary care

The strategy identifies four priorities:

 

  1. A health and wellbeing approach is adopted to ensure that babies get the best start in life. Mothers and families are supported and empowered to improve their own health and wellbeing;
  2. Women have access to safe, high-quality, nationally-consistent, woman-centred maternity care;
  3. Pregnancy and birth is recognised as a normal physiological process and, insofar as it is safe to do so, a woman’s choice is facilitated;
  4. Maternity services are appropriately resourced, underpinned by strong and effective leadership, management and governance arrangements, and delivered by a skilled and competent workforce, in partnership with women.

The strategy has a well-publicised origin. It comes after the HIQA report into the death of Ms Savita Halappanavar recommended that a strategy be developed to implement standard, consistent models for the delivery of a national maternity service.

This report said that the strategy would have to reflect best available evidence to ensure that all pregnant women have appropriate and informed choices, and access to the right level of care and support.

The new maternity strategy was drafted by a 31-member Steering Group.

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The vision for maternity services articulated in this strategy is for an Ireland where: “Women and babies have access to safe, high-quality care in a setting that is most appropriate to their needs; women and families are placed at the centre of all services and are treated with dignity, respect and compassion; and parents are supported before, during and after pregnancy to allow them give their child the best possible start in life.”

As a practical application of this vision, the strategy says that each woman will be offered choices in their maternity care. These choices will be set according to whether they are classified as either normal risk, medium risk or high- risk, and their care will be delivered by a particular team.

The choices of care that are available include:

 

  • Supported care: This care pathway is intended for normal-risk mothers and babies, with midwives leading and delivering care within a multidisciplinary framework. Women in this pathway will give birth in an alongside birth centre; women in this care pathway may also choose a home birth. 
  • Assisted Care: This care pathway is intended for mothers and babies considered to be at medium risk, and for normal-risk women who choose an obstetric service. Care will be led by a named obstetrician and delivered by obstetricians and midwives, as part of a multidisciplinary team.
  • Specialised Care: This care pathway is intended for high-risk mothers and babies and will be led by a named obstetrician, and delivered by obstetricians and midwives, as part of a multidisciplinary team. Women in the Assisted Care or Specialised Care pathways will give birth in a specialised birth centre. 

In the run-up to the strategy’s publication, many of the debates were around whether care should be consultant- or midwife-led. However, the final strategy (which will be delivered through a new National Women and Infants’ Health Programme) says multidisciplinary teams will offer care.

A new community midwifery service will be developed, according to the strategy. Expectant mothers will be offered choices about their care during pregnancy and birth, ranging from home birth to specialised assistance, depending on the level of risk involved in each case.

Currently, maternity care in Ireland is largely consultant-led and hospital-based; the model of care now proposed represents a fundamental overhaul of services. The strategy recommends that maternity services should be woman-centred and provide integrated, team-based care, with women seeing the most appropriate professional, based on their need.  Every woman will have a named lead healthcare professional who will have overall clinical responsibility for her care.

The strategy recognises that all pregnant women need a certain level of support, but that some need more specialised care. It proposes an integrated care model that encompasses all the necessary safety nets, in line with patient safety principles, which delivers care at the lowest level of complexity needed, yet has the capacity and the ability to provide specialised and complex care quickly, as required.

Currently, over 99 per cent of births occur within a hospital setting; pregnancy is the largest single reason for admission to hospital in Ireland. There were 67,347 births in Ireland in 2014.

In addition, the increased funding available to the Department of Health under the Government’s six-year capital investment framework will enable a wider maternity capital programme towards the later years of the plan, involving the relocation of the Rotunda Hospital to the Connolly Hospital campus in Blanchardstown, and Limerick Maternity Hospital to the University Hospital Limerick campus at Dooradoyle.

The plan also includes the redevelopment of the Coombe Women and Infants University Hospital on the St James’s Hospital campus, the site for the proposed national children’s hospital, thus ensuring the development of a tri-located adult/paediatric/maternity facility. A plan is therefore in place to ensure that all maternity hospitals in the country will be co-located with an adult acute hospital in the medium term.

The Maternal and Newborn Clinical Management System Project is working on the design and implementation of an electronic health record for all women and babies in maternity services in Ireland.

Speaking at the launch of the strategy last month, Minister Varadkar said: “I am delighted to launch the country’s first national maternity strategy.  It was my privilege to present it to Government for approval. This Government has made considerable investment in our maternity services in recent years and the strategy provides further evidence of our very firm commitment to the development and improvement of services.  It sets out a vision of maternity services that is about safety, quality and choice, and that places women very firmly at the centre of the service. I will advocate for it and work for its full implementation. In fact, we’ve already started.”

Adverse maternal and perinatal outcomes are associated with younger and older mothers (see panel).  The general trend towards an older population of women giving birth has implications for maternity and neonatal services, including the capability of services to respond to complex pregnancies.

The average age of mothers giving birth in Ireland has gradually increased over the past 10 years. Certain culturally-distinct groups in Ireland, such as Travellers, have a lower average age of giving birth than the general population, with many factors contributing to this difference.

Maternity facts and figures

Last year, the HSE published the Perinatal Statistics Report 2013, providing information on mothers giving birth and babies born during the year.

Some of its interesting findings included:

Babies

  • 69,267 births were reported in 2013, representing a 3.8 per cent decrease between 2012 and 2013.
  • 6% of total births were preterm (less than 37 weeks’ gestation).
  • 6% of live births were low birth weight (less than 2,500 grams).
  • 2% of live births were high birth weight (4,500 grams or more).
  • 56% of babies recorded any breastfeeding in 2013, compared to 53% in 2009 and 46% in 2004.
  • 46% of babies were exclusively breastfed, compared to 42% in 2009 and 45% in 2004.
  • 30% of total live births were delivered by Caesarean section, with 28% of singleton and 68% of multiple live births delivered by this method. In 2004, 25% of total live births were delivered by Caesarean section.
  • 94% of singleton births and 64% of multiple births were discharged from hospital within five days of birth.
  • The perinatal mortality rate was 6.3 per 1,000 live births and stillbirths (6.0 per 1,000 singleton births and 14.9 per 1,000 multiple births). This rate has fallen by 22% since 2004, when it was 8.1 per 1,000 live births and still births.
  • The perinatal mortality rate was highest, at 9.1 per 1,000 live births and stillbirths, for babies born to mothers age 40 to 44 years. The lowest perinatal mortality rate of 5 per 1,000 live births and stillbirths was for babies born to mothers aged 30 to 34 years.

Mothers

  • 67,952 maternities were reported to the National Perinatal Reporting System in 2013, representing a 3.9% decrease between 2012 and 2013.
  • The average age of mothers has increased from 30.8 years in 2004 to 32.1 years in 2013.
  • 32% of mothers were aged 35 years or older, up from 24% in 2004.
  • 20% of first births were to women aged 35 years or older, compared to 13% in 2004.
  • 2% of total mothers giving birth were aged under 20 years, compared to 4% in 2004.
  • 38% gave birth for the first time, with an average age for first-time mothers of 30.3 years.
  • 2% had a multiple pregnancy.
  • 57% of women having a singleton live birth delivered spontaneously, while deliveries using forceps accounted for 4%, vacuum extractions for 11% and 28% by Caesarean section.
  • 25% of women having a multiple live birth delivered spontaneously, while deliveries using forceps accounted for 2%, vacuum extractions for 6% and 67% by Caesarean section.
  • For women having a singleton birth, 54% had a postnatal length of stay of two days or less and 44% had a postnatal length of stay of three-to-five days.
  • For women having a multiple birth, 12% had a postnatal length of stay of two days or less and 74% had a postnatal length of stay of three-to-five days.
  • 23% of births in 2013 were to mothers born outside Ireland, compared to 24% in 2009 and 15% in 2004.

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