Miscarriage misdiagnosis – another damn mess
On Monday last, the day the Independent broke the story, the HSE said the wrong diagnosis of a miscarriage in Our Lady of Lourdes Hospital, Drogheda ‘was extremely rare’. As more women emerged with similar experiences, two days later the HSE has announced a review to find out the number of such cases and a change in procedure for dealing with such incidents. Is this a ‘rare’ mistake or symptomatic of wider problems in maternity care? In the cases of Melissa Redmond and Martha O’Neill Brennan in Drogheda and Galway, mistakes were made. In both cases, the women trusted their instincts and stood up to the system and insisted on a second scan. Both of them were right and have since given birth to healthy babies. This highlights the importance of listening to and trusting patients. So how can this happen?
Specifically, the HSE has said that this should not happen. They have ordered that from now on if a woman is diagnosed with a miscarriage that an obstetrician should be involved in the decision to use drugs or surgical interventions and the decision on whether to get a second scan.
While we have a very safe maternity care, with very good survival rates for women and our peri-natal mortality rate is was 7.3 per 1,000 in 2007, an increase on the previous year when it was seven per 1,000 in 2006. According to the ESRI who produced the figures, Ireland has a comparatively high perinatal mortality rate, ranking 13th out of 20 countries included in the Eurostat system.
Yet, we still know little about the experience of women who give birth but we do know some things. We are in the middle of a baby boom – there were more births last year (75,000) than any year since 1980. The average of women giving birth is 30 – 30 years on from last baby boom – so we knew this baby boom was coming but we are unprepared for it. This year, it is expected that there will be about 80,000 births.
And essentially, the poor performance of our maternity services is is about under-resourcing. The physical conditions of our maternity hospitals and wards are generally appalling; they are bursting at the seams, under staffed and under resourced. We pretty much have the same facilities we had 10-15 years ago when there were just over 50,000 births – a 50% growth in births without a 50% increase in investment.
We have fewer consultants per population than any other EU country 2.2 versus 4.5 Holland, which is the second worst. Also in Holland, the vast majority of births are mid wife delivered, the opposite to Ireland. Here, there is an over reliance on junior doctors and a crisis in junior doctor provision.
There are differences between maternity hospitals in Dublin and outside. In Dublin, there are 3 maternity hospitals and one in Limerick. All the other 16 maternity units are in acute hospitals, which is best practice as they are located nearer by other specialities, ICU etc. So the plan is to move all four stand alone maternity hospitals to nearest acute hospitals however this has been put on long finger – in fact the Dublin hospitals will not now relocate til 2020.
Plus there are draw backs for the smaller regional hospitals in that they are competing for funding with rest of acute hospital. Also all the maternity units were designed for many fewer births than they provide eg Limerick designed for 3,500 births, last year it had 5,500 births. In Cork, the brand new maternity unit on grounds of Cork University Hospital was designed for 7000 births when it opened in 2007. Yet last year, they had 9000 births in Cork. For those 9,000 births, it should have 407 midwives, currently there are 342 – 55 short of requirement.
Also some of the pressure on the hospital in Drogheda is a result of HSE policy of centralising services. Ten years ago, Monahan had about a birth a day, Dundalk had about 2 births a day, now there are no maternity services in these hospitals. All these mothers now go to Drogheda but without the necessary development of services in Drogheda.
Technically, every one is entitled to a second pinion and a second scan. But if units are very over stretched or under staffed or both then they are less likely to give one. Also one cannot under estimate the doctor/patient power relations. The women we have heard speak out were articulate, courageous women. Not every woman might be feeling up to that. Speaking to Patsy Doyle who represents midwives in Cork today she said the good thing to some out of this is that it puts women and patients back in to the centre of the health service – where they should be.
One midwife I spoke to on this topic said ‘consultants are king of the Irish maternity service – not the midwives’. But just recently the HSE published an evaluation of ‘mid-wifery led care in the north east’. And it’s a huge success story. Most Irish women don’t have access to such a service, where all your care is carried out by a mid wife and the evaluation is hugely positive. Women have a really good experience plus it is much, much cheaper – the way to go – in many but not all cases.
Barry White, the new National Director of Clinical Care in the HSE is saying that they are standardising care across obstetric care. Surely this was the rationale for the HSE being set up over 5 and a half years ago, however Barry White was appointed just a year ago. And he has to standardise care across many specialities. It’s good its happening and it has happened in some very specific areas eg breast cancer care but it does seem to be taking a VERY long time. Also when you hear Brendan Drumm saying that it’ll take another two years to standardise child welfare and protection procedures…