Chris Fitzpatrick: Why not make a midwife ‘master’ of a Dublin maternity hospital?

When applying for a job in a Dublin maternity hospital, I was once asked by a paediatrician: “Who do you think this hospital is run for?” When I said “Women and babies,” he replied “No! Obstetricians!” Despite it being a tongue-in-cheek remark, I recognised an uncomfortable sliver of truth.

During my career, I worked in all three Dublin maternity hospitals and was master of one. Although each hospital has a distinctive ethos, all are run along similar lines – by a chief executive called the “master”, who reports to the hospital’s board.

According to the founding charters of these hospitals, only an obstetrician can be a master. Although much of what’s written in these historic documents has been updated over the years, the requirement for a master to be an obstetrician seems to be written in indelible ink.

The job of master is unique to the three Dublin maternity hospitals. The first master was Bartholomew Mosse, who founded the Rotunda hospital in 1757.

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Before hospital chief executives or general managers were invented, there were practical advantages in having doctors in charge of hospitals. In the case of maternity hospitals, the master was also the doctor frequently summoned to deal with obstetrical emergencies.

[ Number of women over 40 giving birth rose almost a third in 10 years ]

[ Former master criticises 'expert shopping' in medical negligence cases ]

Nowadays, masters rely on senior management teams to support them in running the business side of the hospital, and on clinical directors and specialty leads to support them on the clinical side.

Given the degree of subspecialisation in modern obstetrics (and gynaecology), it’s no longer possible (or desirable) to have one person dealing with all clinical emergencies.

It is of note that most of the biggest hospitals in the country are run by chief executives or general managers who do not come from a clinical background or who have been former nurses.

So, apart from tradition, there’s no reason why a master must be an obstetrician; equally there’s no reason an obstetrician shouldn’t apply for the job.

‘More women!’

Looking at the names of masters emblazoned in gold on a large mahogany hospital noticeboard (which included my name), a woman once said to me that the word “master” reminded her of the movie Master and Commander in which Russell Crowe plays the part of an autocratic ship’s captain during the Napoleonic Wars. “Get rid of the name! Appoint more women!” the woman added.

In the long, combined history of the three Dublin maternity hospitals, there have been only two female masters.

As a senior house officer in obstetrics in the 1980s, it was expected that I would want to be a master someday. “The master controls everything,” the master of the hospital I was working in told me. I had come to tell him that I was leaving to start a job in a maternity hospital on the other side of the city – and was plucking up the courage to inform him. In football terms, this was like moving from Glasgow Celtic to Glasgow Rangers, because the hospital I was moving to had never had a catholic master. Back then, religion as well as gender counted. The Dublin maternity hospitals have long traditions – and are slow to change.

Confining the job of master to obstetricians may also explain the dominance of hospital-based obstetrical models of care in our maternity services, as almost every consultant appointed in this country spends time during her or his training in one or more of the Dublin maternity hospitals. The dominance of obstetrical care also serves to reinforce the deluxe status of private obstetrical care.

The implications of implementing Sláintecare in the Dublin maternity hospitals have been the subject of recent discussions in the hospitals and the media.

And although the issues raised – how to facilitate a woman’s choice of private obstetrical care in the absence of private maternity hospitals, the loss of private income to obstetricians, and (of greater financial importance) the loss of private income to public hospitals – need to be carefully considered, the current systemic inequity also needs to end.

In this context, it is of note that the three Dublin maternity hospitals uniquely provide a three-tier system of obstetrical maternity care (public, semi-private, and private) in which access to consultants (even if their intervention is not required) is calibrated with the ability or willingness to pay.

Scenes such as a mother with newborn twins struggling for space on a busy public postnatal ward when there is a vacant single room in an adjacent private ward serve to emphasise that distinctions also apply to access to facilities.

Unique opportunity

In a specialty that operates 24/7 and that is seldom out of the headlines in relation to litigation, there is, perhaps, a unique opportunity to consider a more radical change to obstetrical care.

Not all babies are born equally. At present, obstetricians in the three Dublin maternity hospitals (and in other maternity units) often drive past each other in the middle of the night going in and out of hospitals; the reasons for this are to attend public patients when called in by the registrar, or to be present at the deliveries of all private patients.

Surely the time has come for obstetricians to think outside their contract boxes and provide an after-hours in-hospital service for all women. As well as being immediately available to intervene if required, this would provide a higher level of supervision for trainees as well as support for midwives. This model of care should also apply to other maternity units and 24/7 services. Looking for the resources to do this should not stifle the ambition.

Locked in a three-tier system of inequitable obstetric care for decades, the boards of the three Dublin maternity hospitals and their masters have the opportunity now to change their hospitals – as well as maternity care in Ireland.

To dispel perceptions of vested interests, and to open the door of leadership to the widest range of talents, it’s also time to change the nature (and title) of the job of master. If you ask me, I’d like to see a midwife in the new job for a change.

Chris Fitzpatrick is a clinical professor in UCD, a retired consultant obstetrician and gynaecologist, and former master of the Coombe Hospital.