A slew of high-profile controversies involving the health of pregnant patients has caused concern about standards of maternity care in the State. The mere mention of the names of women who died in recent years serves to draw attention to the scale of the issue: Tania McCabe, Bimbo Onanuga, Dhara Kivlehan, Savita Halappanavar, Jennifer Crean and Sally Rowlette.
Despite these deaths and the well-aired shortcomings of maternity care in Portlaoise, Portiuncula, Our Lady of Lourdes and other hospitals, there is no shortage of official reassurance about standards. Even Taoiseach Enda Kenny was moved, last year, to describe Ireland as “one of the safest places on the planet” to have a baby.
So which is the more accurate picture: that depicted by the harrowing circumstances of the deaths of Halappanavar and others, or the Taoiseach’s cosy reassurances about the quality of care?
One way of assessing standards is to look at our figures for maternal death – defined as the death of a woman while pregnant or within 42 days of the end of the pregnancy – from a pregnancy-related cause.
Traditionally, the figures gathered by the Central Statistics Office (CSO), and based on the information provided on a death certificate, have been very low. Hence the Taoiseach's assertion. The problem was that this method of collecting the data missed out on many maternal deaths. Septicaemia, for example, was a stated cause of death in Halappanavar's case, yet she would not have died if she had not been pregnant.
Since 2009, the Confidential Maternal Death Enquiry Ireland, based in University College Cork, has been gathering data on the issue from a wider group of sources – maternity units, general hospitals, coroners, pathologists, GPs and other healthcare professionals. The research is being carried out in collaboration with a similar inquiry in the UK, the MBRRACE-UK programme, which began in 1952 and is based in the University of Oxford.
Different picture
The picture that emerges from this work is very different from the situation described in the CSO data. The inquiry, which has just published its second report, says it has identified four times as many maternal deaths as the civil death registration system.
There were 38 maternal deaths between 2009 and 2012, the report says. Ten were classified as direct maternal deaths, ie due to obstetric causes. Twenty-one deaths were indirect maternal deaths due to pre-existing conditions that were exacerbated by pregnancy. Another seven deaths of pregnant women were attributed to coincidental causes, but these are not included when calculating the maternal mortality rate. The rate of maternal mortality increased from 8.6 per 100,000 maternities in the period 2009-2011 to 10.5 in 2010-2012.
Obviously, each individual death is a cause for concern, but should we be worried about the high mortality rate uncovered by the inquiry?
Not particularly, says the report. Although the death rate grew 22 per cent, the report says this increase is not statistically significant. Neither is the Irish rate all that different from that of the UK, which is 10.1 per 100,000 maternities; or France, where the rate is 10.3.
“The figures do not represent a significant change,” says Dr Michael O’Hare, consultant obstetrician and chairman of Maternal Death Enquiry Ireland. “Because we’re dealing with small numbers statistically, in fact, they amount to no change.”
On the other hand, the British rate has been falling consistently for decades, whereas the trend appears to be in the other direction here.
In the Netherlands, the maternal death rate is 5.0, less than half that here, though there is a suspicion of under-reporting of indirect maternal deaths.
Media interest
O’Hare says he understands the level of media and public interest in high-profile deaths in recent years but he argues this is not “a good measure of how things really are” in relation to the deaths of either mothers or babies in childbirth.
“When some of these cases get into the public eye, it can result in a rush to judgment, yet there is no evidence Ireland is any worse than anywhere else on these issues.
“We live in a world where expectations are very high. Success is expected in obstetrics and is usually the outcome but, unfortunately, sometimes things do go wrong.”
With the study showing a rise in indirect maternal deaths, he says there needs to be more focus on the reasons for this. Two Irish deaths were due to flu, pointing to the need for all pregnant women to get vaccinated.
The divergence between the figures emerging from the study and the CSO data also needs examination, O’Hare says, though this is not a problem confined to Ireland.
One welcome trend in the UK has seen a halving of deaths caused by sepsis, which was implicated in the death of Halappanavar. This emerged as the main cause of death in the last report, but a concerted effort to improve training and promote awareness seems to have borne fruit.
See ucc.ie/en/mde
