Monday, 3 March 2014

Ireland's Maternity Staffing Levels are an Epic Safety Failure

 Ireland's Maternity Staffing Levels are an Epic Safety Failure

On Friday we saw yet another damning report into unsafe clinical practices and an underlying culture within the HSE which has contributed to deaths in Irish maternity hospitals. This was not the first report of its kind. In fact, it has only been a matter of months since the last. What was interesting in the report was that while there was recognition to the grave failures to provide safe clinical care, an underlying culture which lacked accountability and humanity, and serious concerns over communication and transparency.... the report failed to cite staff levels as a contributing factor.

This was a big surprise.

While AIMSI are delighted to see that communication failures and transparency are cited within the report from Portlaoise, it seems to be an over-sight that the reoccurring complications of an over-stretched and under-staffed system have not been taken into account.


Here's a few reasons why. 


Safer Childbirth Standards - RCOG and RCM - 2007

"Inadequate midwifery staff will lead to many women being left alone for long periods of time when they feel very vulnerable. Incidents like bleeding, drop in blood pressure or abnormality in the fetal heart rate may not be picked up in time to avoid morbidity."

Safer Childbirth standards (RCOG et al 2007
(Written evidence, RCOG)

"The minimum midwife-to-woman ratio is 1:28 for safe level of service to ensure the capacity to achieve one-to-one care in labour (BR+ evaluation  data).89,90 The midwifery total care ratios for services with more complex case mix must be determined locally after case mix (social and clinical determinants) and external workload assessment is done, this may mean a lower midwife to woman ratio up to 1:25. The recommended total care ratios indicate the maximum number of women that a midwife can provide antenatal, intrapartum, and postnatal care for within the service. "

Safer Childbirth standards (RCOG et al 2007)
Irish midwife to woman ratios vary but we have heard consistent calls from Masters of the Rotunda, former Master of the Coombe, and others citing midwife to woman ratios in Ireland to be at desperately unsafe levels in Irish units. Numbers cited have varied from 1:47 in the Rotunda to 1:55 and 1:75 in Portlaoise.

In addition, the HSE has not chosen to establish any more midwifery-led units, in addition to the two pilot units in Drogheda and Cavan despite an extensive HSE-financed Randomised Controlled Trial of those units indicating (Mid-U study):

-better birth outcomes

-fewer interventions

-more cost effective births

For normal low-risk women

(SNM, TCD, MidU Report, 2009)

We know from the extensive 2011 National Perinatal Epidemiology Unit Birthplace Cohort Study in the UK that for low risk women, best, safest and most cost-effective results are obtained from midwifery-led units (Brocklehurst et al., 2011).

March 9, 2007 Tania McCabe and her son Zach died at Our Lady of Lourdes Hospital in Drogheda.

The Midwife to woman ratio at the time of her death was over 1:48

HSE Report: Tania McCabe:
"Maternity Services at Our Lady of Lourdes Hospital have been under increasing pressure, with a significant increase in activity. This has resulted in the Maternity, Paediatric and Anaesthetic services being significantly under-resourced to cope with the current demands. This had an impact on Tania’s care, with staff working long hours while carrying an excessive workload. Despite the good intentions of staff who were working in very difficult conditions, their practice and ultimately the care that they provided to Tania were compromised by their workload and the environment in which they were working."
High Priority Recommendation: Continual Assessment of staffing levels
"The Review Team recommends that the HSE in conjunction with the Clinical Networks’ advice would seek to urgently upgrade the medical and midwifery staffing commensurate with the recommendations from Safer Childbirth (2007)."
In 2008 Rosaleen Harlin wrote: "Significant investment in recruitment has resulted in all but 6 of these posts being filled. This brings the midwife to patient ratio to 1:48.There are currently 6 midwives vacancies in the Maternity Department in Our Lady of Lourdes Hospital, Drogheda and efforts are currently being employed to address this"


2008 KPMG Review of Dublin Maternity Services

 In 2008, the HSE-commissioned report, Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area, by KPMG, with each hospital THEN delivering over 8,000 births per annum, stated:

"Based on the current model of care, compared to standards set by BirthRate Plus, BAPM and the RCOG in the UK, the hospitals are understaffed, with an additional:

20 obstetricians,
221 midwives,
20 neonatal nurses
and 35 theatre staff required across the three hospitals"

The public service embargo along with the numbers of midwives who have retired from the system from 2010 onward, under the voluntary early retirement schemes, mean that on many shifts in our maternity hospitals, midwives are carrying double the caseloads they should be carrying. Staff sickness levels are high and staff are leaving.

 While it is true that the birth rate has dropped nationally by almost 3% between 2011 and 2012, that does not bring our maternity units anywhere near the numbers of births in 2007/8 when the KPMG report already stated that we suffered significant understaffing by best international standards.


Portlaoise Midwives

In 2006, 32 midwives from Portlaoise wrote to the Minister for Health concerned with staffing levels directly citing fears that levels will result in the death of a mother or baby. The midwife to woman ratio in Portlaoise has been reported on twice with conflicting levels. One report of 1:55 and another of 1:75.

Neither are safe nor appropriate staff levels.


"Not enough people to look after you"An exploration of women's experiences of childbirth in the Republic of Ireland - 2010

Objective: women's experiences of childbirth have far reaching implications for their health and that of their babies. This paper describes an exploration of women's experiences of childbirth in the Republic of Ireland

Focus group interviews with women from units which were randomly selected.

Findings: three main themes were identified, ‘getting started’, ‘getting there’ and ‘consequences’. Women experienced labour in a variety of contexts and with differing aspirations. Midwives played a pivotal role in enabling or disempowering positive experiences. Control was an important element of childbirth experiences. Women often felt alone and unsupported. The busyness of the hospital units precluded women centred care both in early labour and in the period following the birth. Some women would not have another baby due to their childbirth experiences.

Key conclusions: the context within which women give birth in the Republic of Ireland is important to their birth experiences. Although positive experiences were reported many women felt anxious and isolated. Busy environments added to women's fears and participants appeared to accept the lack of support as inevitable. Midwives play a pivotal role in helping women achieve a positive birth experience.

 Midwives SHOUT BACK

At the start of February women and midwives started a SHOUTBACK campaign. To tell their examples of why care is unsafe in Ireland from a professional view and examples from women of unsafe care they have experienced. These are a few SHOUT BACK contributions from midwives and their experiences working in an over-crowded and understaffed maternity system with a fundamentally flawed system. These contributions are from units all over Ireland. Urban and Rural. All saying the same.

SHOUT BACK - YOUR SAY: Be 'With Woman'...a Midwife, its what I trained to do, this profession was a passion for many of us, and I see on a daily basis that constraints the system, the hierarchically environment, the lack of on the ground support has made us dispassionate and akin to robots. Everyday I hear stories of fellow midwives leaving the system, dispirited and unsupported they have reached ...burnout stage, no longer having the energy to fight the system, they go along with the diatribe, suppressing their natural instinct, afraid that if seen to be different as they will be blackballed, there is no joy going to work and feeling alienated, or the odd one out. Yet I know they do try everyday to try and make birth better for the women in their care, no matter how bad the day, that passion and the love of midwifery is still there, engrained in their core, we need as women and Midwives to work together, lets not accept this anymore, lets make changes, NOW, SHOUT BACK!
SHOUT BACK - YOUR SAY: As a midwife I can safely say the only reason more people aren't dying is because birth is normal for the most part. There are near misses every day, dreadful post natal care, cattle market prenatal care. Lack of evidence based care is rampant. Midwives are cracking under this broken system. I, myself have taken many sick days because I just can't cope. As a I frequently had 12 women and babies to care for. This level of stress can not continue. Midwives are flocking to other countries. Better countries to work and give birth in

SHOUT BACK - YOUR SAY: I am currently working as a midwife in the Irish maternity system. It seems redundant to say that I work in a very busy and understaffed hospital, however I feel that perhaps the government and a certain minister may need a little bit of reminding. When I began my training as a midwife I knew it would be hard work; I was never afraid of that. However, in the last few years I... feel that my role has shifted from advocate, educator and supporter of women and their families as they traverse the amazing road of parenthood to somewhat of a firefighter. It is a constant struggle just to provide the bare minimum of safe care (and even then it is not always possible).

It is unsatisfactory to say that Ireland is one of the safest places to have your baby. Of course safety is paramount but merely sending a family home alive and "safe" physically is not the only benchmark to which the maternity system should be held accountable.I work with some phenomenal people who try their best every single day to provide as much care to women and their families as they can but it's just not enough. The pressure on our maternity system caused by lack of staff and adequate resources to cater to the number of high and low risk women is having a detrimental effect on the experiences of the clients and the health and wellbeing of the staff.

 I love my job, but it breaks my heart to come home after a long and exhausting shift to feel that I just didn't get a chance to truly support anyone, to employ the skills I have worked hard to obtain. It's a terrible thing to know what you could do if you had just a bit more support, just a bit more time.... you could make all the difference in the world to someone. And as selfish as it sounds, it could make all the difference to me, to all of us working here. No midwife that I know pursued this career to feel like an unwilling abuser, we do it because we know how important this moment is in peoples lives, and we want to help!

Job satisfaction is a wonderful thing and drives us to continue to support and care with everything we have. We glean what we can from a spare ten minutes to give an extra helping hand to someone who is breastfeeding, rocking with and rubbing the back of a woman in labour or having a few precious moments to genuinely listen to a woman about her concerns or worries and give reassurances or education. So often however, Its just not feasible and those moments are considered a luxury for us and the women. I am truly sorry to all the women I have cared for who may have left feeling upset, scared or traumatised and no one had a moment to sit and talk to them. It weighs on me all the time.

So many of us are close to breaking point, so close to leaving the job we love because it's turning out to be unsustainable to continue with those levels of pressure and stress on a daily basis without turning into an apathetic or unhappy person. I sincerely doubt that any woman would want to be cared for by someone who is unhappy and exhausted physically and emotionally.

I wish I had the courage to post this with my name on it, but I am afraid. I am afraid that the foxhole mentality of the maternity system will come crashing down on me; that I will be accused of putting words in other peoples mouths even though I hear these sentiments every day. Or worse, that I will be seen as someone who just can't handle it. I can handle it. I just don't think it's enough to be able to merely 'handle' ones job, especially when that job is so importance and carries such gravitas and may have implications for the rest of a womans life.

I suppose it boils down to the fact that although I'm doing the best I can with what I have, I want the opportunity to be the best that I possibly could be for the families I care for. If we could have that opportunity it would certainly make this an excellent place to have a baby.... not merely an acceptable place.

Its not enough to make recommendations.

Report after report. Recommendation after recommendation. And no action.
  Recommendations and guidelines in the current system go unanswered with no obligation to implement them locally. AIMSI are aware of maternity units which are still failing to implement recommendations (Amnisure) from the Tania McCabe report.

Why have these units not been held accountable?
Why does Ireland have an extensive library of National Clinical Guidelines which have not been implemented into local policy or practice?

The HSE needs to be fully audited and held accountability for its own compliance in creating a culture in which these scandals have been allowed to flourish.

There is a serious need for investment in evidence based care in Ireland. Obstetric led hospital based care must be fully equipped - not only with up to date equipment but also the appropriate safe staffing levels to prevent adverse outcomes for women who chose this care setting. In addition, investment in care options must be available in all units - including midwife led units, birth centres, and homebirth services.

Continuous safety failures clearly illustrate that the current care model needs an urgent overhaul and that health care providers are working in environments without clinical support - just getting by. Women and babies deserve one-to-one care based on the highest possible quality and evidence.

Related Reading:

Baby deaths 'not linked' to hospital's staff levels:

Safer Childbirth 2007:

‘Far off’ level of care needed

Portlaoise midwives wrote to Cowen and Harney over ‘fears that a mother or baby would die’

‘Not enough people to look after you’: An exploration of women's experiences of childbirth in the Republic of Ireland

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