Crisis as cuts loom
in maternity services

Maternity care is in crisis in Ireland, as it is elsewhere. Yet the services for birth rarely, if ever, feature on our health agenda. Stress in the labour ward has never been higher, with more babies being born and more midwives leaving the service. Against the background of an increasingly pressurised health service, plans to cut maternity services have come as a shock.

Cutting accessible beds
The Medical Manpower Forum propose to reduce the number of maternity units by up to half, cutting the number of accessible beds by at least one-third in two years. Plans to “relocate” the main Dublin maternity hospitals onto acute hospital sites outside the city centre and to close up to nine other maternity units were leaked on 21 February. Other units, as yet unnamed, may also close. All of the hospitals threatened with closure outside Dublin are small. Closing them will increase the size of the remaining units.

Bronagh Livingstone’s death

The tragic death of a baby born in an ambulance at the side of the road after her mother, in a state of advanced labour, was turned away from Monaghan General Hospital, despite suffering from a life-threatening complication in pregnancy, illustrates starkly the danger of centralising the services for birth. The death of premature baby Bronagh Livingstone last December caused national outrage. Now it seems to have been forgotten. Consultants had previously closed the hospital’s maternity unit.

Three women per bed per 24 hours

Ireland already has a highly centralised system of maternity care. In 1976, Comhairle na nOspideal, a medical consultant body, recommended centralising maternity care in large units. Centralisation was based on minimum production levels of 2, 000 births yearly and a bed occupancy of three women per labour ward bed per 24 hours. The new medical policy was backed by the State. From then on, all women, healthy or otherwise, were required to place themselves in bigger hospitals under consultant management. Small maternity units and nursing homes, run by midwives and general practitioners, closed. From 1973-2000, 83 per cent of the country’s maternity units shut.

Thousands of women’s lives at risk

Women’s groups argue that the cuts now proposed by the Medical Manpower Forum, if implemented, will mean that thousands of mothers will have to travel longer distances during pregnancy, and in labour, to access increasingly remote hospital services. These proposals, they say, are grossly unfair to those women, and their families, who live outside urban areas.

These proposals will put thousands of women’s lives at risk, according to Dr John Gallagher, Chair of the Institute of Obstetricians and Gynecologists unless they are replaced by midwifery services. It is now over two years since the Institute of Obstetricians and Gynecologist withdrew from Monaghan and Dundalk Hospitals in the face of massive local opposition. No maternity facilities have been put in place of the suspended obstetric services.

Babies’ lives in jeopardy

Babies’ lives will also be placed in jeopardy, as the numbers of women giving birth en route to hospital will inevitably rise. The scenario of giving birth at the side of the road, in a car, taxi, or ambulance, without professional help, is not just a nightmare, it is also a risk. Unplanned out-of-hospital births carry very high mortality rates of 68 per 1,000, eight times higher than planned hospital birth and sixteen times higher than planned home birth. A national survey on out-of hospital births shows that for every woman who plans a home birth, there is a mother who does not make it to a maternity unit on time.

• National Birth Alliance calls for no more closures of maternity units

Irish perinatal death
rates the highest in Europe

Irish perinatal death rates are already the highest in the European Union. According to a report by the Economic and Social Research Institute, the Irish perinatal death rate was 8.2 per 1,000 in 1999, compared with 5.2 for Luxembourg and 5.6 for Sweden. While maternal deaths are rare, they accounted for 8 per cent of medical negligence claims taken in the Republic from 1978-1998, according to the Medical Defense Union Ireland.

Centralising births in bigger units will increase medical intervention in birth. The proposed cuts will mean that more women will have their labours induced, as doctors bring women into hospital for induction to avoid a roadside birth. More induction's mean more Caesarians, vacuum suction and forceps births.

Irish Caesarian
rates almost one in four

But Ireland already has very high rates of medical intervention in birth. The national Caesarian rate in 1999 was 21 per cent. Caesarian rates are now estimated to be almost one in four, over twice the World Health Organisation’s safety limit. More half of all first babies in the Republic today are born by Caesarian, vacuum or forceps.

• National Birth Alliance calls for a reduction in current Caesarean rates (14-30 per cent) to bring them into line with (WHO) safety limits (10-14 per cent)

Hormones used to speed
up labour in crowded units

More women will have their labours actively managed, as staff manage bigger numbers in crowded labour wards, accelerating throughput by speeding up labour. Speeding up labour in this way is standard practice in Irish maternity hospitals. At the National Maternity Hospital, for example, 50 per cent of all first-time mothers have their labour accelerated through “active management”. Active management uses drugs and instruments to speed up labour. The drug used is Syntocinon, a synthetic form of a naturally occurring hormone, oxytocin.

According to Medical Defense Union Ireland, oxytocin features frequently in medical negligence claims. The use of oxytocin has been identified as a salient factor in infant brain damage and fetal death during labour. Maternal deaths and brain damage have also been reported in connection with its use.

Active management
linked to cerebral palsy

A recent cerebral palsy case starkly highlighted the dangers of “active management” in the labour ward. Haya Shiri Kraft, allegedly injured during her birth at the National Maternity Hospital in 1995, was awarded EUR4.5m. in the High Court in compensation for severe brain damage.

Haya’s parents’ case against the hospital centred on medical procedures used routinely in Irish hospitals to induce and accelerate labour. Mrs Kraft first had an amniotomy, a procedure that involves rupturing the waters surrounding the baby in the womb with a hook. In another standard procedure, Mrs Kraft was then put on a drip containing Syntocinon. The baby was born with no heartbeat and suffered cerebral palsy as a result, say her parents. The hospital did not admit liability.

• National Birth Alliance calls for informed consent to medical interventions in labour to be made a legal requirement

Lack of control a major
complaint among mothers

The Charter of Rights for Hospital patients assumes that no medical procedure is carries out without the patient’s written consent. But there is evidence to the contrary. A national survey on home birth commissioned by the Department of Health shows that for over half of the women interviewed had had a bad hospital birth. Fear of hospital emerged as one of the main factors in their decision to have a baby at home. Women complained of feeling powerless, of having no control over their hospital treatment, of not being allowed to give birth in a position of their choice, of not being free to decline unwanted procedures.

Consent not
needed for oxytocin

A feature published on 13 August 2001 showed that medical interventions in labour were being carried out against women’s wishes. Women complain of being coerced or duped into procedures that seemed to be driven by hospital policy rather than medical necessity. The Masters of the three main Dublin hospitals confirmed to The Irish Times that specific consent is not sought for interventions in labour such as amniotomy or oxytocin. Guidelines for midwives on consent do not exist.

• Calls for informed consent to medical interventions in labour to be made a legal requirement

New mothers asked
to leave hospital early

Women, faced with the hazards of active management in increasingly centralised units, will have less choice than ever in their maternity care if the planned cuts go ahead. New mothers will be asked to leave hospital earlier, if numbers increase. Early discharge is already common. In the main Dublin hospitals, first-time mothers are asked to leave after 48 hours, while women who have already given birth are being discharged 24 hours.

• National Birth Alliance calls for all new mothers to be given full access to community midwifery services in line with other European Union Member States

Breastfeeding rates
in Ireland the lowest in Europe

Ireland’s postnatal care is already poor by European standards. There is almost no community midwifery care and breastfeeding support is generally left to voluntary groups. While these groups provide invaluable help to new mothers, they cannot make up for the lack of midwives’ clinics in the community. Irish breast-feeding rates, in consequence, are extremely low. The Republic’s breastfeeding rates are the lowest in Europe, almost 30 per cent lower than Britain’s, the second lowest in the European Union.

Quality of care will suffer

If the planned cuts are implemented, one to one care in labour, already a luxury in the bigger hospitals, will become a distant memory, say midwives. More women will be looked after in labour wards by the same number of midwives, or fewer, as staff are driven out of a service that is becoming increasingly impossible to work in. Quality of care in those units that survive the cuts will suffer.

• National Birth Alliance calls for choice of midwife as well as choice of doctor and continuity

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