In March this year, AIMS Ireland was sent a story by a woman who was forced to travel for a D&C - we shared her story here: http://nocountryforpregnantwomen.blogspot.ie/2013/03/womans-story-uchg-denies-d-for.html
This woman decided to come forward and was interviewed in this past Sunday's Irish Times. The link is not available online, however, the woman has forwarded the text.
See below:
The Sunday Times, 14th July,
Justine Mc Carthy
A SPANISH woman who was refused surgical help after a miscarriage says she and her husband are leaving Ireland because they have no faith in its maternity services.
Lupe Royan, a mother of one, was almost 14 weeks pregnant when a scan taken at University Hospital Galway (UHG) on February 22 showed the absence of a foetal heartbeat. She claims that when she asked for the foetal remains to be removed from her womb, her request was refused.
“I told [the doctor] I was devastated by this loss and that I was aware there was a risk of infection,” Royan said. “Because the embryo only measured 7mm, she said she would have to book another scan for me in a week’s time and I would have to come back then. It was very cruel. I was thinking about what happened to Savita.”
Savita Halappanavar from India died at UHG last October following a miscarriage in the 17th week of pregnancy.
An inquiry report commissioned by the HSE was critical of her treatment in the days leading up to her death from sepsis.
Royan was referred to UHG by a Galway GP when she had a bleed at 11 weeks.
Following an inconclusive vaginal examination, an appointment was made for an ultrasound scan two weeks later, but she was not prepared to wait that long.
She paid €100 for a scan on February 16 at the Terryland Medical Centre in Galway, a private clinic that specialises in early-pregnancy ultrasound. The scan showed no foetal heartbeat and the clinic referred Royan back to UHG.
“I went to the hospital the following Monday and gave them the scan images and the report from the clinic,” Royan said.
“The doctor said they would have to do a second scan to make sure there was no mistake with the dates of my pregnancy. I understood that.”
The second scan on February 22 again failed to detect a foetal heartbeat. It showed an embryo of a size normally equivalent to about four weeks of pregnancy.
“There was no life there. This was clear,” Royan said. “The doctor said they would have to wait a week to do another scan to make sure it was a miscarriage. I asked her, ‘How can the embryo grow if it is dead?’”
Royan says two other doctors told her and Gonzalo Matanala, her husband, that medical protocol required that the hospital do its own second scan to confirm the miscarriage. Royan phoned a doctor in Valencia, Spain, whom she had attended during her first pregnancy. The doctor, she says, advised her to return to Spain where she would undergo a scan and a procedure known as “evacuation of retained products of conception”.
Royan, Matanala and their three-year-old son set off for Valencia on February 24 but she suffered a natural miscarriage en route.
“I don’t feel safe here [Ireland]. I would never try to get pregnant again in this country,” said Royan, who is moving with her family to Luxembourg.
“Ireland is very proud to be Catholic but it lacks compassion.”
The HSE does not comment on individual cases but it said: “Galway University Hospital adheres to the national clinical guideline on the management of miscarriage which was formulated by the National Clinical Advisory Group in Obstetrics and Gynaecology.
“This guideline recommends waiting a week or more between doing a first and second scan before intervention.”
In its section on the treatment of miscarriage, the guideline states: “Follow-up scans may be arranged at two-weekly intervals, until a diagnosis of complete miscarriage is made.
“However, if the woman requests a surgical or medical approach to their management at any stage, it should be arranged.”
Fionnuala McAuliffe, a professor of obstetrics and gynaecology, said: “Certain criteria have to be met to diagnose a miscarriage. We would err on the side of caution. I understand how this woman must have felt, but it is important to be sure. A foetal heartbeat only comes at about 6½ weeks and sometimes a woman can be less pregnant than she thinks she is.”
Thank you to Guatelupe for coming forward and sharing her story.
AIMS Ireland support services: support@aimsireland.com
Tuesday, 23 July 2013
Monday, 22 July 2013
Irish Inquests - Jo Murphy-Lawless looks at the inquest into Savita Halappanavar’s death and its aftermath
Irish Inquests - Jo Murphy-Lawless looks at the inquest into Savita Halappanavar’s death and its aftermath
The full inquest on the death of Savita Halappanavar opened on 8 April 2013 and concluded on 17 April, with the jury returning a unanimous verdict of medical misadventure. The jury also endorsed nine recommendations for fundamental change. Two of the recommendations alone reveal the
utter clinical impoverishment of Irish maternity services:
We know that obstetric clinicians, driven by interventionist imperatives, are quick enough to imagine the worst of outcomes for pregnant and labouring women in ordinary circumstances and react accordingly, very often to the detriment of women’s well-being. Why, when this woman’s condition did point to genuine risks, was she not strictly monitored? The inquest revealed that the confusion arising from the 1992 constitutional ruling on the X case, that a woman whose life is at risk can be given a termination, formed only one strand, if a significant one, in the appalling lapses of care Savita endured.
It is even more distressing to read a recommendation that calls for ‘proper and effective communication between staff on-call and a team coming on duty’.(1) Surely this is what comprises basic clinical care that people expect as a matter of course when entering hospital, that clinicians communicate effectively with one another?
The inquest explored a terrible catalogue of errors: the blood sample taken on the Sunday evening which was never followed up or noted again, which would have shown an elevated white blood cell count; an examination by the obstetric consultant on Monday morning, over eight hours after the membranes had ruptured fully, showing ‘no infection’, but a full blood screen and c reactive protein test were not ordered to confirm that; instead, a clinical decision to ‘await events’ was taken; readings showing an elevated pulse which were taken on Tuesday evening by an alert student midwife were not picked up by senior clinical staff; then a large gap of time when vital signs were not taken; Savita’s shaking with cold in the early hours of Wednesday morning was attributed to a cold room, with an extra blanket brought in for her, while paracetamol was given for her raised temperature, her pulse and blood pressure not recorded, and no alarm bells sounded; the note made by a junior doctor about a foul-smelling discharge from a vaginal swab taken some hours later at 6.30am, which was not picked up by the consultant obstetrician at 8.30am; bloods taken at 7am that Wednesday morning did not reach the laboratory until three hours later.(2) In his summing up, the Galway Coroner, Dr Ciarán MacLoughlin, said that by 1pm, when the consultant obstetrician was contacted again, Savita ‘was in peril of her life’.(3)
A microbiologist called in as an expert witness by the Coroner noted that on the Sunday she was admitted, Savita was not given a vaginal examination nor was she checked for leaking amniotic fluid. This consultant also took issue with the type of antibiotics finally prescribed on the Wednesday, the wrong drug for the extent of the sepsis and the E. Coli ESBL, and the lack of ‘prompt attention’ to deliver the fetus.(4)
What was perhaps even more unbearable to hear was how Savita, in tears, was subjected to an ultrasound on several occasions to determine if there was still a fetal heartbeat. This surveillance related to a possible decision about a medical termination by Dr Katherine Astbury, the consultant obstetrician in charge of Savita’s case, in accordance with that consultant’s interpretation of what constituted a risk to the life of the woman.
In February 2013, there was a series of hearings before the Oireachtas Health Committee, a joint parliamentary committee, in which obstetric consultants from the Dublin maternity hospitals stated that six terminations had taken place in the Rotunda Hospital and three in the National Maternity Hospital in 2012. They were taking their lead from guidelines published by the Irish Institute of Obstetricians and Gynaecologists which is all consultants have to rely on, given the current legislative vacuum. They estimated that the numbers of terminations nationally to save women’s lives ‘could be as low as 10 or as high as 30’ in any given year.(5) Is it really conceivable that these same obstetricians wait on all similar occasions to perform a medical termination when there is no fetal heartbeat, until severe chorioamnionitis has set in, until the delay most certainly puts a woman’s life in the balance?
The barrister for the hospital and the Health Services Executive maintained an aggressive presence throughout the inquest. In respect of the nine hours between Tuesday night and Wednesday morning when there was no regular recording of vital signs, this barrister argued that it would be incorrect to say that no vital signs had been taken as Savita’s temperature had been taken on two occasions. If that passes for good-quality clinical care, women in Ireland should feel a sense of dread in having to enter a maternity unit at all.
In the wake of the inquest, those who carry the principal responsibility for the poor quality of our maternity services, namely the community of consultant obstetricians who stand at the apex of this system, continue to dodge that responsibility. They appear to prefer splitting hairs and defending their own positions with their considerable egos. Peter Boylan, former Master of the National Maternity Hospital, who was an expert witness at the inquest at the Coroner’s request, tried to argue that given the current legal vacuum, Savita was not ill enough and therefore not enough at risk of losing her life on Monday or Tuesday to justify a termination, whereas by Wednesday morning she was, but it was too late to carry it out in order to save her. His focus was not the clinical care and he effectively exonerated the consultant obstetrician in charge of Savita’s case about that dimension. Boylan is determined to get legislation in place on the X case so that clinicians will have some legal safety in the decisions they must take on medical terminations. Yet he gave no indication at the Oireachtas hearings in February that women were literally at death’s door before he intervened in the National Maternity Hospital. On the other hand, in a recent letter to the Irish Times, some of his obstetric colleagues including two consultants from Galway, one the professor emeritus of University Hospital Galway, objected to Boylan’s position about termination. They argued variously and confusingly, that maternal mortality is on the rise in developed countries, that this was one of the worst cases of sepsis ever seen, that E. Coli ESBL is extraordinarily virulent, and that hospitals must reflect on the lessons from the inquest.(6)
The battle lines now dividing Irish obstetricians on the need for legislation for the X case do not get us to the heart of the matter. Despite their speeches and positions about how they care for women, what neither side is doing is stepping forward to say that our services are in need of urgent reform from the top down, starting with the consultants themselves. Many of the 125 consultants in Ireland are very wealthy indeed as a result of their generously paid public contracts which historically have left considerable scope for a lucrative private practice. Yet it is as if the standards of care have little or nothing to do with them, even though it is their interests and their decision-making which most determine our services. This is the same professional group which has consistently blocked any wide-ranging initiative to establish midwifery led care.
At the conclusion of the inquest, Praveen Halappanavar, Savita’s husband said: ‘She was just left there to die. We were always kept in the dark…It’s horrendous and barbaric and inhuman the way Savita was treated in that hospital.’(7) We are now in the midst of the inquest for Bimbo Onanuga, an impoverished Nigerian woman who died in the Rotunda in 2010 from a ruptured uterus leading to DIC and cardiac arrest, after she had come into the hospital for treatment for a late intrauterine fetal death. An inquest has been urgently sought about Dhara Kivlehan, an Indian woman married to an Irish man, who developed pre-eclampsia and died from HELLP syndrome after a caesarean in Sligo General Hospital in 2010. What may be the lessons from the deaths of these three young, healthy women? That fragmented care on top of unaccountable obstetric practice kills. Our overriding problem continues to be how to make the Irish obstetric community truly accountable for its work.
Jo Murphy-Lawless
References
1. Irish Times (2013) Recommendations. Irish Times Saturday, 20 April, 2013.
2. Sheehan, M. (2013) Shortcomings in care of Savita have ramifications for all State hospitals: Inquest shows litany of mistakes caused fatal infection to be missed. Irish Independent, 14 April 2013.
3. Holland, Kitty (2013) Death by Medical Misadventure. Irish Times, 20 April 2013.
4. Cullen, Paul (2013) The systems, not individuals, to blame? Irish Times, 19 April 2013.
5. Kennedy, Geraldine (2013) Valuable debate complete with medical facts, figures. Irish Times, 19 February 2013.
6. Monaghan, John et al (2013) Letter, Irish Times, 30 April 2013.
7. Irish Daily Mail (2013) The Inquest’s Key Quotes, Irish Daily Mail, 20 April 2013.
This article first appeared in the AIMS UK Journal (Volume:25 No:2, 2013) and is reproduced here with their kind permission.
Full copies are available from www.aims.org.uk/ or by emailing publications@aims.org.uk
The full inquest on the death of Savita Halappanavar opened on 8 April 2013 and concluded on 17 April, with the jury returning a unanimous verdict of medical misadventure. The jury also endorsed nine recommendations for fundamental change. Two of the recommendations alone reveal the
utter clinical impoverishment of Irish maternity services:
- • that protocols on the management of sepsis along with ‘proper training and guidelines for all medical and nursing personnel’ should be instituted;
• that a protocol for sepsis be written for each individual hospital by its microbiology department and be applied nationally.(1)
We know that obstetric clinicians, driven by interventionist imperatives, are quick enough to imagine the worst of outcomes for pregnant and labouring women in ordinary circumstances and react accordingly, very often to the detriment of women’s well-being. Why, when this woman’s condition did point to genuine risks, was she not strictly monitored? The inquest revealed that the confusion arising from the 1992 constitutional ruling on the X case, that a woman whose life is at risk can be given a termination, formed only one strand, if a significant one, in the appalling lapses of care Savita endured.
It is even more distressing to read a recommendation that calls for ‘proper and effective communication between staff on-call and a team coming on duty’.(1) Surely this is what comprises basic clinical care that people expect as a matter of course when entering hospital, that clinicians communicate effectively with one another?
The inquest explored a terrible catalogue of errors: the blood sample taken on the Sunday evening which was never followed up or noted again, which would have shown an elevated white blood cell count; an examination by the obstetric consultant on Monday morning, over eight hours after the membranes had ruptured fully, showing ‘no infection’, but a full blood screen and c reactive protein test were not ordered to confirm that; instead, a clinical decision to ‘await events’ was taken; readings showing an elevated pulse which were taken on Tuesday evening by an alert student midwife were not picked up by senior clinical staff; then a large gap of time when vital signs were not taken; Savita’s shaking with cold in the early hours of Wednesday morning was attributed to a cold room, with an extra blanket brought in for her, while paracetamol was given for her raised temperature, her pulse and blood pressure not recorded, and no alarm bells sounded; the note made by a junior doctor about a foul-smelling discharge from a vaginal swab taken some hours later at 6.30am, which was not picked up by the consultant obstetrician at 8.30am; bloods taken at 7am that Wednesday morning did not reach the laboratory until three hours later.(2) In his summing up, the Galway Coroner, Dr Ciarán MacLoughlin, said that by 1pm, when the consultant obstetrician was contacted again, Savita ‘was in peril of her life’.(3)
A microbiologist called in as an expert witness by the Coroner noted that on the Sunday she was admitted, Savita was not given a vaginal examination nor was she checked for leaking amniotic fluid. This consultant also took issue with the type of antibiotics finally prescribed on the Wednesday, the wrong drug for the extent of the sepsis and the E. Coli ESBL, and the lack of ‘prompt attention’ to deliver the fetus.(4)
What was perhaps even more unbearable to hear was how Savita, in tears, was subjected to an ultrasound on several occasions to determine if there was still a fetal heartbeat. This surveillance related to a possible decision about a medical termination by Dr Katherine Astbury, the consultant obstetrician in charge of Savita’s case, in accordance with that consultant’s interpretation of what constituted a risk to the life of the woman.
In February 2013, there was a series of hearings before the Oireachtas Health Committee, a joint parliamentary committee, in which obstetric consultants from the Dublin maternity hospitals stated that six terminations had taken place in the Rotunda Hospital and three in the National Maternity Hospital in 2012. They were taking their lead from guidelines published by the Irish Institute of Obstetricians and Gynaecologists which is all consultants have to rely on, given the current legislative vacuum. They estimated that the numbers of terminations nationally to save women’s lives ‘could be as low as 10 or as high as 30’ in any given year.(5) Is it really conceivable that these same obstetricians wait on all similar occasions to perform a medical termination when there is no fetal heartbeat, until severe chorioamnionitis has set in, until the delay most certainly puts a woman’s life in the balance?
The barrister for the hospital and the Health Services Executive maintained an aggressive presence throughout the inquest. In respect of the nine hours between Tuesday night and Wednesday morning when there was no regular recording of vital signs, this barrister argued that it would be incorrect to say that no vital signs had been taken as Savita’s temperature had been taken on two occasions. If that passes for good-quality clinical care, women in Ireland should feel a sense of dread in having to enter a maternity unit at all.
In the wake of the inquest, those who carry the principal responsibility for the poor quality of our maternity services, namely the community of consultant obstetricians who stand at the apex of this system, continue to dodge that responsibility. They appear to prefer splitting hairs and defending their own positions with their considerable egos. Peter Boylan, former Master of the National Maternity Hospital, who was an expert witness at the inquest at the Coroner’s request, tried to argue that given the current legal vacuum, Savita was not ill enough and therefore not enough at risk of losing her life on Monday or Tuesday to justify a termination, whereas by Wednesday morning she was, but it was too late to carry it out in order to save her. His focus was not the clinical care and he effectively exonerated the consultant obstetrician in charge of Savita’s case about that dimension. Boylan is determined to get legislation in place on the X case so that clinicians will have some legal safety in the decisions they must take on medical terminations. Yet he gave no indication at the Oireachtas hearings in February that women were literally at death’s door before he intervened in the National Maternity Hospital. On the other hand, in a recent letter to the Irish Times, some of his obstetric colleagues including two consultants from Galway, one the professor emeritus of University Hospital Galway, objected to Boylan’s position about termination. They argued variously and confusingly, that maternal mortality is on the rise in developed countries, that this was one of the worst cases of sepsis ever seen, that E. Coli ESBL is extraordinarily virulent, and that hospitals must reflect on the lessons from the inquest.(6)
The battle lines now dividing Irish obstetricians on the need for legislation for the X case do not get us to the heart of the matter. Despite their speeches and positions about how they care for women, what neither side is doing is stepping forward to say that our services are in need of urgent reform from the top down, starting with the consultants themselves. Many of the 125 consultants in Ireland are very wealthy indeed as a result of their generously paid public contracts which historically have left considerable scope for a lucrative private practice. Yet it is as if the standards of care have little or nothing to do with them, even though it is their interests and their decision-making which most determine our services. This is the same professional group which has consistently blocked any wide-ranging initiative to establish midwifery led care.
At the conclusion of the inquest, Praveen Halappanavar, Savita’s husband said: ‘She was just left there to die. We were always kept in the dark…It’s horrendous and barbaric and inhuman the way Savita was treated in that hospital.’(7) We are now in the midst of the inquest for Bimbo Onanuga, an impoverished Nigerian woman who died in the Rotunda in 2010 from a ruptured uterus leading to DIC and cardiac arrest, after she had come into the hospital for treatment for a late intrauterine fetal death. An inquest has been urgently sought about Dhara Kivlehan, an Indian woman married to an Irish man, who developed pre-eclampsia and died from HELLP syndrome after a caesarean in Sligo General Hospital in 2010. What may be the lessons from the deaths of these three young, healthy women? That fragmented care on top of unaccountable obstetric practice kills. Our overriding problem continues to be how to make the Irish obstetric community truly accountable for its work.
Jo Murphy-Lawless
References
1. Irish Times (2013) Recommendations. Irish Times Saturday, 20 April, 2013.
2. Sheehan, M. (2013) Shortcomings in care of Savita have ramifications for all State hospitals: Inquest shows litany of mistakes caused fatal infection to be missed. Irish Independent, 14 April 2013.
3. Holland, Kitty (2013) Death by Medical Misadventure. Irish Times, 20 April 2013.
4. Cullen, Paul (2013) The systems, not individuals, to blame? Irish Times, 19 April 2013.
5. Kennedy, Geraldine (2013) Valuable debate complete with medical facts, figures. Irish Times, 19 February 2013.
6. Monaghan, John et al (2013) Letter, Irish Times, 30 April 2013.
7. Irish Daily Mail (2013) The Inquest’s Key Quotes, Irish Daily Mail, 20 April 2013.
This article first appeared in the AIMS UK Journal (Volume:25 No:2, 2013) and is reproduced here with their kind permission.
Full copies are available from www.aims.org.uk/ or by emailing publications@aims.org.uk
Thursday, 4 July 2013
Your Service, Your Say?
I’m sure you are all too familiar with this, favoured phrase of the HSE “Your Service Your Say”. What exactly does it mean? Well firstly it does not mean that “your” service allows you to access any information on how well it delivers “your” service. You might think that is the most basic of rights, in Ireland you would be wrong.
In 2007 AIMS Ireland was formed, by women, who wanted to see the service user have some say in their maternity service. I was one of those women. We quickly realised that in order to effect change we needed some basic information. We also found that we, as service users were not entitled to this information. I can access arrogated national data, but not information on individual hospitals.
In the Spring of 2013, following a tip-off from a member of staff in one of Ireland’s maternity units of rising rates, AIMS Ireland decided to look into rates of certain procedures and request the birth statistics in each maternity unit to publish for women to use when deciding on their birth options.
What kind of information did AIMS Ireland want to find out and why?
AIMSI requested birth statistics for several key interventions which have short and long-term affects on women. We wanted to know how many labours were induced, the current C-section rate per unit, the episiotomy rate, rates for forceps delivery, and how many women were breastfeeding on discharge, and more.
AIMSI requested this information because we knew from the hospitals who do publish annual reports that the rates of various interventions do vary, sometimes quite a lot. Women have a right to this information. They have a right to know in order to make informed decisions about their care. If for example, breastfeeding support is really important to you, you might like to know what percentages of women are breastfeeding on discharge from the hospital you are considering.
This information should be openly transparent and easy to access within the public domain. This is important for several reasons (i) women cannot make an informed decision if they do not have access to all the information (ii) ensuring full transparency of birth statistics per unit and per individual health care provider holds units and health care providers accountable for wide variations of care (iii) If this information was readily available, it would protect women from individuals or units whom do more harm than good – exposing these inconsistencies quickly. For example, following the Cuidiu publication of birth statistics, a review* was promised by the HSE to look at why first time mothers in one maternity unit had a 50% Caesarean section rate – a huge variation from other units. Another unit showed 43% of first time mothers will have an episiotomy.
Are we to believe that first time mothers in these particular areas are more likely to require an episiotomy or Caesarean?
Or does the local practice and policy within a particular unit or with a specific health care professional increase the likelihood of a woman having these procedures.
*While the review was promised, we are still awaiting the findings
*While the review was promised, we are still awaiting the findings
Cuidiu Birth Statistics
Irish organization, Cuidiu, painstakingly wrote to each of the country’s 22 maternity units, (19 public consultant led unit (CLU), 2 midwifery led units (MLU) and 1 private maternity unit) asking for their rates of various procedures. Some hospitals promptly replied with all of the relevant information. A few did not reply at all, and many others gave very incomplete or partial information. As there is no official duty to supply this information, it is solely at their discretion.
Ironically, 20 of these hospitals, along with 20 Self Employed Community Midwives*, collect all the data required and send it annually to the ESRI, who run the National Perinatal Reporting System (NPRS). The ESRI are not allowed to make available information on individual hospitals.
The question has to be asked, why do some hospitals choose to leave some questions unanswered in their response to Cuidiu, when it is clear that they already collect this information for the NPRS?
Ironically, 20 of these hospitals, along with 20 Self Employed Community Midwives*, collect all the data required and send it annually to the ESRI, who run the National Perinatal Reporting System (NPRS). The ESRI are not allowed to make available information on individual hospitals.
The question has to be asked, why do some hospitals choose to leave some questions unanswered in their response to Cuidiu, when it is clear that they already collect this information for the NPRS?
* Self Employed Community Midwives (SECMs) are required to provide birth statistics for every woman booked, events in pregnancy, labour, birth, outcomes, morbidity, etc, including transfers, however, the same is not required for each individual consultant obstetrician.
AIMS Ireland's Requests
AIMS Ireland has recently made a Freedom of Information Request to the HSE to try obtain this information for the public. Our request was denied. We were informed that the HSE did not hold this information centrally, and as such the information does not exist. Individual member hospitals under the control of the HSE do however hold this information. We were informed that the NPRS does hold this data, but they are not allowed to produce data on individual hospitals, in order to protect patient confidentiality.
This is a new one. Transparency = violations of patient confidentiality?
How exactly does informing the public about the number of C-sections or episiotomies performed in each maternity unit affect a patient’s confidentiality?
The plain unvarnished truth is that many hospitals produce annual reports, which contain this data and AIMSI commend the hospitals who publish these figures. And the others, who choose not to publish this data, are protected by the HSE.
- 20 of our maternity units collect a lot of data
- These maternity units send this data to NPRS
- The NPRS is not allowed to tell you about the data that Your maternity unit has sent them
- Your maternity unit is not obliged to let you see this data.
- Your HSE prefers to step aside and abdicate its responsibility in ensuring You have any right to see information about Your maternity unit.
How can You have a Say in Your Service if you have no information with which to inform Your Say?
Wednesday, 3 July 2013
Severe Maternal Morbidity Audit report - Points to consider before we start Congratulating ourselves.
This week, an audit report of severe morbidity in the Irish maternity system, carried out by the National Perinatal Epidemiology Centre in Cork in 2011, was published. This report was eagerly anticipated by AIMS Ireland and we have been quoting the need for such an audit for some time.
The reasons for a need to audit morbidity in maternity care are outlined in the AIMSI 42 weeks campaign aricle, "Healthy Births for Healthy Mothers and Babies"
For a long time, the quality of maternity care has been measured by the rate of deaths to mothers and babies. But, many now argue that this is not a true reflection of care as technology, nutrition, disease control, and hygiene have reduced the rate of deaths drastically. Instead, a way of measuring care is to look at the rates of complications that arise in pregnancy, and during labour, birth, and the postpartum period. These complications are called morbidity and can affect the health of mothers and babies ranging from moderate to severe harm. Some procedures and care increase the chances of these complications and, as a result, morbidity is on the rise in Ireland.
Severe Maternal Morbidity Report
For the purpose of this report, only severe maternal morbidities were collected. To you and me that means the NEAR MISSES.
The 20 maternity units in Ireland (19 public units and 1 private) were asked to provide data on instances of severe maternal morbidity.
What is 'severe morbidity'?
According to the report from UCC its:
" 15 categories of maternal morbidity including: major obstetric haemorrhage (MOH), eclampsia, renal/liverdysfunction, cardiac arrest, pulmonary oedema, acute respiratory dysfunction, coma, cerebrovascular accident, status epilepticus, septicaemic shock, anaesthetic complications, pulmonary embolism, peripartum hysterectomy, admission to intensive care and interventional radiology. Major obstetric haemorrhage was defined as an estimated blood loss of ≥ 2,500ml, and or a transfusion of ≥ 5 units of blood and or documented treatment for coagulopathy."
Key Findings of Severe Maternal Morbidity Report
"Overall, 260 women were reported as experiencing at least one severe maternal morbidity, which translated as a national morbidity rate of 3.8 cases per 1,000 maternities or 1 in 263 maternities."
"The majority of women (57.7%) were diagnosed with one severe morbidity and one third (32.3%) were diagnosed with two severe morbidities. A small proportion was diagnosed with three or four morbidities."
"The perinatal mortality rate among women experiencing severe maternal morbidity was 32.6 deaths per 1,000 births. This was substantially higher than the national rate, which was estimated recently at 6.6 per 1,000 births." "Key findings and rates of women experiencing MOH mirrored findings from successive SCASSM reports. These include: Uterine atony was the most frequently reported cause of MOH, followed by: other specific causes; retained placenta; and placenta praevia. The majority of cases of MOH occurred in the postpartum period, with Caesarean section the most common associated mode of birth. MOH was also the most common morbidity associated with ICU admission."
With Ireland's rising Caesaeran Section rates, the rates of severe maternal morbidity look set to rise also.
And finally:
"The incidence of severe maternal morbidity was disproportionately higher among ethnic minorities."
Does this send a red alert? It should.
AIMS Ireland has been highlighting concerns regarding care received by ethic minorities for some time. Clare Daly has put in numerous Parliamentary Questions from AIMS Ireland on the disproportionate instances of maternal mortality and morbidity among women of ethic minority backgrounds.
According to UK and Irish data, maternal deaths, while a rarity, nonetheless statistically affect non-national emigrant women almost twice as frequently as women born in either the UK or Ireland (CMACE, 2011; MDE, 2012).
Maternal Death Enquiry Ireland (2012) Confidential Maternal Death Enquiry in Ireland, Report for Triennium 2009-2011, Cork: MDE.
http://www.mdeireland.com/
This report adds to concerns that ethnic minority women are not receiving appropriate, safe maternity care.
Limitations of the Audit
Unfortunately, there are limitations to this audit which result in unknown and misleading results.
1) Only 19 of 20 maternity units participated in the audit, the unit which did not participate has not been named. Transparency and availability of information have been issues raised by AIMSI to the Minister for Health (twice), and HIQA. This is a 'National Audit' - every unit must participate and those who do not, should be named so that women know that their maternity unit has (i) not been included in the findings (ii) has chosen not to participate (As an aside, AIMSI have been campaigning for the full disclosure of annual audit reports of birth statistics per unit available to the public online in order to aide informed choice. Information such as episiotomy, caesarean section rate, assisted delivery, induction rates, pph, etc should be available per unit and per individual health care professional so that women can decide which units and professionals they choose to attend for their care.)
2) AIMSI have been informed that only 6 (yes 6) of Ireland's maternity units has an electronic record system, such as the MIS system. Relying on handwritten records increases the risk of unreliability and quality of the data available to audit.
3) Some of the records from units within the audit were only partial. When looking at the audit report, we see in the 'maternal characteristics' that 2 cases did not provide maternal age and 54 cases did not provide data on ethnicity. 71 cases were missing data on smoking habits and 93 cases had no background data on alcohol habits. BMI data was missing for 1/4 of women's cases. When reports from units are based on partial recording, it is difficult to (i) have a clear understanding of the true extent of instances (ii) some of the missing data would be important to draw conclusions to risk factors contributing to rising rates of severe morbidity (iii) the integrity of the information is put into question - if data is missing or only partially recorded, can we trust the data provided is accurate?
4) Most women with severe maternal morbidity had Caesarean sections. However the report says that 1/5 of women with severe maternal morbidity had spontaneous vaginal deliveries (SVD). However, in this report, SVD is defined in terms of mode of delivery, not mode of management in labour. This is incredibly significant. It means that all vaginal births are being classified in the same way, regardless to how the labour has been managed. Evidence has shown us that some interventions used to manage labour significantly increase the risk of maternal morbidity, such as PPH. To categorize all vaginal births together, regardless of intervention, is misleading.
5) This audit, while welcomed, only measures severe maternal morbidity; the near misses, within the definitions of the classifications. A woman with a PPH of 1500ml, which is still a significant bleed, has not been included in this report. Also, everyday maternal physical and psychological instances of maternal morbidity have not been measured. AIMS Ireland has seen an increase in these types of morbidity and they have a huge impact on the physical and emotional short and long-term health of mothers and babies.
Maternal morbidity is an important aspect in measuring the quality of care within our maternity services and the care we provide to women and babies. In many instances, less severe classifications of maternal morbidity are not considered as significant as a medical means of measuring the safety of maternity care, yet, the impact on women can be lifechanging. Injury from episiotomy, for example, can lead to chronic pain, urinary and fecal incontinence, and can greatly impact on women's self esteem, ability to be active/sport, and maintain a healthy sex life. Women can also suffer from psychological morbidity - depression, PTSD, anxiety - following such interventions.
Before we start congratulating ourselves on our low rates of maternal mortality and severe maternal morbidity in Ireland, we must look at the whole picture. Recording deaths and near misses is not enough - the health of mothers and babies, in the short and long-term must be protected.
Read More:
Just one-in-263 pregnancies has severe difficulties http://www.independent.ie/lifestyle/mothers-babies/just-onein263-pregnancies-has-severe-difficulties-29369343.html
Full Report: http://www.ucc.ie/en/media/research/nationalperinatalepidemiologycentre/NPECSevereMaternalMorbidityReport2011.pdf
The reasons for a need to audit morbidity in maternity care are outlined in the AIMSI 42 weeks campaign aricle, "Healthy Births for Healthy Mothers and Babies"
For a long time, the quality of maternity care has been measured by the rate of deaths to mothers and babies. But, many now argue that this is not a true reflection of care as technology, nutrition, disease control, and hygiene have reduced the rate of deaths drastically. Instead, a way of measuring care is to look at the rates of complications that arise in pregnancy, and during labour, birth, and the postpartum period. These complications are called morbidity and can affect the health of mothers and babies ranging from moderate to severe harm. Some procedures and care increase the chances of these complications and, as a result, morbidity is on the rise in Ireland.
“Results have shown that maternal morbidities in Ireland are common and changing. Analysis of national trends in maternal morbidities from 2005-08 show a statistically significant increase in rates of postpartum haemorrhage (PPH), pelvic and perineal trauma, and gestational diabetes.Over an 11 year period (1999-2009), the overall PPH rate increased from 1.5% to 4.1%, with a significant increase in the rate of blood transfusion co-diagnosed with atonic PPH.....Further increasing rates of Caesarean section have led to an increase in the incidence of peripartum hysterectomy for morbidly adherent placenta. Such findings stress the need for continued surveillance of maternal morbidities to guide clinical practice, focusing on aetiological factors, preventative measures and quality of care.” Measuring maternal morbidity, Edel ManningAIMS Ireland are concerned about rising intervention rates, which can vary greatly between hospitals and even between individual health care providers. Interventions are known to increase the chances of harm to the physical and psychological health of mothers and babies. We all want mothers and babies to come through birth feeling healthy and emotionally complete.
Severe Maternal Morbidity Report
For the purpose of this report, only severe maternal morbidities were collected. To you and me that means the NEAR MISSES.
The 20 maternity units in Ireland (19 public units and 1 private) were asked to provide data on instances of severe maternal morbidity.
What is 'severe morbidity'?
According to the report from UCC its:
" 15 categories of maternal morbidity including: major obstetric haemorrhage (MOH), eclampsia, renal/liverdysfunction, cardiac arrest, pulmonary oedema, acute respiratory dysfunction, coma, cerebrovascular accident, status epilepticus, septicaemic shock, anaesthetic complications, pulmonary embolism, peripartum hysterectomy, admission to intensive care and interventional radiology. Major obstetric haemorrhage was defined as an estimated blood loss of ≥ 2,500ml, and or a transfusion of ≥ 5 units of blood and or documented treatment for coagulopathy."
Key Findings of Severe Maternal Morbidity Report
"The majority of women (57.7%) were diagnosed with one severe morbidity and one third (32.3%) were diagnosed with two severe morbidities. A small proportion was diagnosed with three or four morbidities."
"The perinatal mortality rate among women experiencing severe maternal morbidity was 32.6 deaths per 1,000 births. This was substantially higher than the national rate, which was estimated recently at 6.6 per 1,000 births." "Key findings and rates of women experiencing MOH mirrored findings from successive SCASSM reports. These include: Uterine atony was the most frequently reported cause of MOH, followed by: other specific causes; retained placenta; and placenta praevia. The majority of cases of MOH occurred in the postpartum period, with Caesarean section the most common associated mode of birth. MOH was also the most common morbidity associated with ICU admission."
With Ireland's rising Caesaeran Section rates, the rates of severe maternal morbidity look set to rise also.
And finally:
"The incidence of severe maternal morbidity was disproportionately higher among ethnic minorities."
Does this send a red alert? It should.
AIMS Ireland has been highlighting concerns regarding care received by ethic minorities for some time. Clare Daly has put in numerous Parliamentary Questions from AIMS Ireland on the disproportionate instances of maternal mortality and morbidity among women of ethic minority backgrounds.
According to UK and Irish data, maternal deaths, while a rarity, nonetheless statistically affect non-national emigrant women almost twice as frequently as women born in either the UK or Ireland (CMACE, 2011; MDE, 2012).
Maternal Death Enquiry Ireland (2012) Confidential Maternal Death Enquiry in Ireland, Report for Triennium 2009-2011, Cork: MDE.
http://www.mdeireland.com/
This report adds to concerns that ethnic minority women are not receiving appropriate, safe maternity care.
Limitations of the Audit
Unfortunately, there are limitations to this audit which result in unknown and misleading results.
1) Only 19 of 20 maternity units participated in the audit, the unit which did not participate has not been named. Transparency and availability of information have been issues raised by AIMSI to the Minister for Health (twice), and HIQA. This is a 'National Audit' - every unit must participate and those who do not, should be named so that women know that their maternity unit has (i) not been included in the findings (ii) has chosen not to participate (As an aside, AIMSI have been campaigning for the full disclosure of annual audit reports of birth statistics per unit available to the public online in order to aide informed choice. Information such as episiotomy, caesarean section rate, assisted delivery, induction rates, pph, etc should be available per unit and per individual health care professional so that women can decide which units and professionals they choose to attend for their care.)
2) AIMSI have been informed that only 6 (yes 6) of Ireland's maternity units has an electronic record system, such as the MIS system. Relying on handwritten records increases the risk of unreliability and quality of the data available to audit.
3) Some of the records from units within the audit were only partial. When looking at the audit report, we see in the 'maternal characteristics' that 2 cases did not provide maternal age and 54 cases did not provide data on ethnicity. 71 cases were missing data on smoking habits and 93 cases had no background data on alcohol habits. BMI data was missing for 1/4 of women's cases. When reports from units are based on partial recording, it is difficult to (i) have a clear understanding of the true extent of instances (ii) some of the missing data would be important to draw conclusions to risk factors contributing to rising rates of severe morbidity (iii) the integrity of the information is put into question - if data is missing or only partially recorded, can we trust the data provided is accurate?
4) Most women with severe maternal morbidity had Caesarean sections. However the report says that 1/5 of women with severe maternal morbidity had spontaneous vaginal deliveries (SVD). However, in this report, SVD is defined in terms of mode of delivery, not mode of management in labour. This is incredibly significant. It means that all vaginal births are being classified in the same way, regardless to how the labour has been managed. Evidence has shown us that some interventions used to manage labour significantly increase the risk of maternal morbidity, such as PPH. To categorize all vaginal births together, regardless of intervention, is misleading.
5) This audit, while welcomed, only measures severe maternal morbidity; the near misses, within the definitions of the classifications. A woman with a PPH of 1500ml, which is still a significant bleed, has not been included in this report. Also, everyday maternal physical and psychological instances of maternal morbidity have not been measured. AIMS Ireland has seen an increase in these types of morbidity and they have a huge impact on the physical and emotional short and long-term health of mothers and babies.
Maternal morbidity is an important aspect in measuring the quality of care within our maternity services and the care we provide to women and babies. In many instances, less severe classifications of maternal morbidity are not considered as significant as a medical means of measuring the safety of maternity care, yet, the impact on women can be lifechanging. Injury from episiotomy, for example, can lead to chronic pain, urinary and fecal incontinence, and can greatly impact on women's self esteem, ability to be active/sport, and maintain a healthy sex life. Women can also suffer from psychological morbidity - depression, PTSD, anxiety - following such interventions.
Before we start congratulating ourselves on our low rates of maternal mortality and severe maternal morbidity in Ireland, we must look at the whole picture. Recording deaths and near misses is not enough - the health of mothers and babies, in the short and long-term must be protected.
Read More:
Just one-in-263 pregnancies has severe difficulties http://www.independent.ie/lifestyle/mothers-babies/just-onein263-pregnancies-has-severe-difficulties-29369343.html
Full Report: http://www.ucc.ie/en/media/research/nationalperinatalepidemiologycentre/NPECSevereMaternalMorbidityReport2011.pdf
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