‘Hospital trusts’ and centralisation are seen as solutions, but we need more midwives, writes Marie O’Connor
Every perinatal death in smaller hospitals now seems to be under the spotlight, yet little is known, even today, about the deaths in Portlaoise Hospital that led to the recent Hiqa report.
The highly political terms of reference given to the authority by James Reilly drew attention away from these individual cases onto wider hospital issues. In its equally ‘strategic’ report, not alone did Hiqa shirk from examining these now very public tragedies, it neglected to highlight some of the core issues involved.
The authority admits it did not investigate any individual cases of patient care (p113), claiming (elsewhere in the report) that the 2007 Act prevented it from doing so. However, nothing in the Act appears on the face of it to substantiate this assertion. An earlier report, from the chief medical officer, is slightly more informative: an appendix (p85) gives us a glimpse into why these deaths may have occurred: Staffing issues and the use of oxytocin — a drug used routinely to induce or accelerate labour — jump out.
Given the doubling in births at Portlaoise Hospital from 2002 to 2012, one might have expected Hiqa to plot midwifery staffing levels against the numbers of births during this period, but no; understaffing is mentioned, glancingly. Yet the complement of midwives at Portlaoise Hospital stood at 30 in a relevant period instead of the 72 later deemed necessary for patient safety. The CMO’s report fingers the use or misuse of oxytocin, albeit lightly, while Hiqa barely mentions this potentially dangerous drug. The authority’s solution is more and better bureaucracy, as though more form filling will resolve anything.
Smaller hospitals have been systematically starved of resources for years. Starve ’em enough and (adverse events will ensure) they can be closed. Hiqa says the absence of a national maternity strategy made it difficult to deal with the increasing birth rate in Portlaoise. So what was the response to the dire warning issued by technology company Philips in 2009 in relation to some of its foetal monitors? Was the ‘regionalisation’ agenda allowed to take precedence over patient safety?
In disaster lies opportunity, as a previous cancer tsar once said. Milton Friedman saw in the New Orleans floods a chance to privatise education. The city’s public institutions were replaced by ‘charter schools’ that were publicly funded but run by private entities, according to their own rules. Health Minister Leo Varadkar has committed to accelerating the legislation required to convert public hospitals into ‘hospital trusts’. They, too, will be unaccountable private entities. The cancer strategy is now seen as a model for development in maternity care. ‘Reconfiguration’ is likely to lead to unit closures, with bigger hospitals cannibalising smaller ones, as the (unequal) struggle for resources is played out.
The long-standing drive to centralise acute hospital services has now got fresh impetus from perinatal deaths in Portlaoise and elsewhere. Much of the commentary in the media suggests that the closure of smaller maternity units would be a step towards patient safety. Nothing could be further from the truth. Closing smaller units would medicalise an already overcentralised and overmedicalised system further, leaving tens of thousands of women two hours’ drive or more from their nearest hi-tech unit. The use of oxytocin would inevitably rise, as more and more women would be faced with induction and/or acceleration, done to avoid the perils of roadside deliveries and bottlenecks in overcrowded labour wards. Caesarean-section rates, already sky high, would increase still further.
Most women don’t need obstetric services when they are pregnant: They need midwifery-based care as close to home as possible. Midwives are not mini-docs or trainee pilots; they are specialists in normal birth, a subject not on the obstetric curriculum. However, midwives have been in short supply for many years. Under the system of specialist consultant care for all (which one no one in power seems to have any interest in changing), midwives do most of the work of looking after women in labour, while obstetricians earn €500,000 per head per annum (or used to) in private fees, in addition to their (€250,000) State salaries. No wonder the Institute of Obstetricians and Gynaecologists is so opposed to midwife-led care.
Wherever it’s provided, in standalone midwifery units or in the home, the boys say no.
Marie O’Connor is a health correspondent and author of several works on healthcare, including Birth Tides, the first book on women’s experiences of maternity care in Ireland.
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