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Healthcare reform: Maternity service provision in Ireland
Health Policy 97 (2010) 145–151
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Healthcare reform: Maternity service provision in Ireland Patricia Kennedy ∗ School of Applied Social Science, University College Dublin, Belfield, Dublin 4, Ireland
a r t i c l e
i n f o
Keywords: Maternity hospitals Midwifery-led units Consumers Health reform
a b s t r a c t The objective of this article is to explore recent and proposed future developments in maternity service provision in Ireland in the context of health policy reform. Ireland is experiencing an unprecedented demand for maternity services with in excess of 75,000 births in 2009, the highest since the 1970s when Ireland experienced a ‘baby boom’. A further 10% rise is projected for 2010. This demographic change has placed increased demands on an already over-stretched maternity service. Despite more than a decade of economic success the health service has remained in constant crisis with many commentators arguing it has worsened rather than improved since the reform process was instigated in 2001 [1]. Reform of maternity services has begun and this article presents two case studies to demonstrate the regional variations in maternity provision in a country which has a national health service and a national Maternity and Infant Care Scheme. It shows what developments have occurred and what direction maternity services are likely to go in the next decade. The two regions under scrutiny are the North East Health Services Executive (NEHSE) and the Greater Dublin Area (GDA). The former illustrates important developments which have occurred in the NEHSE as a result of the Maternity Services Task Force (2002–2010) and argues that there are important learning outcomes not only for the GDA which is the subject of the latter case study but also for the development of maternity services nationally. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The objective of this article is to explore recent and proposed future developments in maternity service provision in Ireland in the context of health policy reform. Ireland is experiencing an unprecedented demand for maternity services with in excess of 75,000 births in 2009, the highest since the 1970s when Ireland experienced a ‘baby boom’. A further 10% rise is projected for 2010. This demographic change has placed increased demands on an already overstretched maternity service. Despite more than a decade of economic success the health service has remained in constant crisis with many commentators arguing it has
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worsened rather than improved since the reform process was instigated in 2001 [1]. Reform of maternity services has begun and this article presents two case studies to demonstrate the regional variations in maternity provision in a country which has a national health service and a national Maternity and Infant Care Scheme. It shows what developments have occurred and what direction maternity services are likely to go in the next decade. The two regions under scrutiny are the North East Health Services Executive (NEHSE) and the Greater Dublin Area (GDA). The former illustrates important developments which have occurred in the NEHSE as a result of the Maternity Services Task Force (2002–2010) and argues that there are important learning outcomes not only for the GDA which is the subject of the latter case study but also for the development of maternity services nationally.
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There is a dearth of analysis of maternity provision in Ireland with some notable exceptions [2]. There is no national audit of maternity hospitals in Ireland. A welcome development has been the establishment of the National Perinatal Epidemiology Centre in 2007 with the overall objective of translating outcome data from Irish maternity hospitals and evidence-based best practice into improved clinical services for Irish patients (www.ucc.ie/en/npec). Because very little has been written on maternity policy and provision in Ireland case studies are useful as they include detailed description. 1.1. Health care reform The 2001 Health Strategy, a blueprint to guide policy makers and service providers in developing a future health system states its vision as: • A health system that supports and empowers you, your family, and community to achieve your full health potential. • A health system that is there when you need it, that is fair and you can trust. • A health system that encourages you to have your say, listens to you, and ensures that your views are taken into account [3]. The principles put forward in this vision are equity and fairness; a people-centred service; quality of care and clear accountability. It undertook to draw up ‘a plan to provide responsive, high-quality maternity care’. Recognising that four out of five women in Ireland use the maternity services, it recognises that models of maternity care are changing, with increasing demands for choice regarding type of care and location, pressures on existing services and undertook to establish a working party ‘to prepare a plan for the future development of maternity services’ with the objective that maternity care in Ireland will be: womancentred; equitable across different parts of the country; accessible to all, safe and accountable [4]. The case studies presented here demonstrate that some progress has been made in line with these objectives. However, it would appear that change has come about as a result of regional responses to local issues as opposed to the national reform agenda. Wren indicates that reform was fuelled by a recognition that the Irish health service was characterised by underfunding and inequity [5]. The Commission on Health Funding had identified problems in the health service in relation to planning, organisation and delivery [6]. Health expenditure was under scrutiny in the Brennan Report [7] and the EU Working-Time Directive led to a shift from consultant-led to consultant provided care [8]. Consadine and Duklelow suggest ‘The reform process remains unsettled’ [9] and outlines how the Health Services Executive (HSE), established to replace the previous eight health boards ‘has been subjected to a barrage of criticism’ in relation to the adequacy of the health budget, the appropriateness of budgetary decisions, accountability, administrative and other failures all ‘highlighted by a number of high pro-
file cases involving misdiagnosis and inappropriate care’ [9]. 2. Maternity and Infant Care Scheme Demographic factors have resulted in an increased demand for maternity services. The 2006 Census demonstrates that the population is at its highest since 1861 and for the first time Ireland has become a country which has experienced in-migration and has rapidly become a multi-cultural society, raising new challenges for maternity services [10]. The birth rate (number of births per 1000 of population) in Ireland is 17.0 [11] there were 75,065 births in 2008, the highest recorded since 1980 [11]. The population is expected to grow from 4,167,000 in 2006 to 5,820,000 in 2036 [12]. Hence, the demand for maternity services will endure. Maternity services are available free of charge to all women in Ireland (who meet residency requirements) under the 1954 Maternity and Infant Care Scheme. However this is only for maternity-related illnesses and only during pregnancy and for 6 weeks following birth. The scheme is based on the assumption that ante-natal care is provided by general practitioners (GPs) and obstetricians and this has led to the under-development of midwifery provided/led services. General Practitioners have agreements with the Health Service Executive (HSE) to provide services. The GP provides an initial examination, if possible before 12 weeks, and a further six examinations during the pregnancy, which are alternated with visits to the hospital maternity unit. The schedule of visits may be changed by GPs and/or the hospital obstetrician, depending on medical need. A woman with a significant illness, e.g. diabetes or hypertension, may have up to five additional visits to the GP. Interestingly, the Maternity and Infant Care Scheme only covers maternity-related illnesses and care for other illnesses which the woman may have during pregnancy are not covered. Post-natally the GP will examine the baby (not the mother) at 2 weeks and both mother and baby at 6 weeks. Mothers are entitled to free in-patient and outpatient public hospital services in respect of pregnancy and birth and are not liable for any of the standard in-patient hospital charges. Despite the availability of free maternity care an important feature of maternity services in Ireland is the co-existence of private maternity care. Barrington refers to the Irish healthcare system as an ‘extraordinary’ symbiosis of public and private medicine [13]. In 2007 51.2% of the population was covered by private health insurance [14]. O’Connor highlights the great divide in maternity service with private obstetrics being a lucrative profession describing how consultant doctors in Ireland are allowed to practice medicine ‘privately’. She continues: ‘The market for private obstetrics is worth at least D 49 million annually; this is divided among the country’s 104 obstetricians. . . Dublin doctors can earn an estimated D 503,000 on average from private maternity fees. Outside Dublin, where births are less centralised, revenues tend to be slightly lower, averaging D 447,000 per head annually. . . These incomes are further boosted by public salaries (ranging from D 125 to D 150,000) and private gynaecological fees’ [15]. An impor-
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tant feature of maternity services in Ireland is the role of private medical insurance in emphasising hospital-based doctor-led services. In the past 50 years, maternity services in Ireland have consistently become more medicalized and hospital-based. This pattern has accelerated since the 1970s with the focus steadily shifting from the needs of the mother to the demands of busy obstetricians working in increasingly technology-dominated maternity units [16]. Maternity has become more medicalised with women in Ireland more likely to undergo caesarean section than previously. The caesarean rate for 2005 was 22.39%. The number of women giving birth at home has declined from about a third in 1950 to less that one percent today. A review published by the Institute of Obstetrics and Gynaecology which focuses on services in the context of health reform suggest it ‘uncovers much which is undesirable’ [17] including poor infrastructure, overcrowding, lack of privacy, long waiting times, operational difficulties and sometimes problems with accessing emergency caesarean sections. ‘The dominance of a medically led, hospital-centred model of care provides effective services for women with non-routine clinical conditions. However, approximately 60% of women experience a normal pregnancy and birth. It does therefore limit the choice for women whose routine clinical needs could be provided for in a wider range of settings’ [18]. There has been a trend in Ireland since the 1970s towards larger maternity units [16]. This has implications for the type of service provided. In recent years several maternity units have amalgamated, for example the Cork University Maternity Hospital (CUMH) established in April 2007 is a purpose-built, modern facility with 144 beds and 12 labour rooms. The third biggest maternity hospital in Ireland, it replaced the former Erinville, St Finbarr’s and the Bon Secours maternity hospitals. The projected 7500 births per year were exceeded in 2008 when there were 8725 births at the CUMH. A similar trend is evident in the North Eastern Region. At the end of February 2001, the North Eastern Health Board (NEHB) was forced to suspend maternity services at Monaghan General Hospital and Louth County Hospital due to the withdrawal of insurance cover by the Irish Public Bodies Mutual Insurance. As a result maternity services are concentrated in two rather than four sites. These developments are further examined in Case Study One: The NEHSE (previously the NEHB) Maternity Services Task Force. Re-location is also planned for the three maternity hospitals in the Greater Dublin Area (GDA), where over 30% of all births take place. These proposed developments are examined in Case Study Two: Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area. 3. Materials and methods This article presents two case studies to explore recent and proposed developments in maternity provision in Ireland in the context of health policy reform and increased demand. They illuminate how in a country with one health service, characterized by obstetric-led care and synonymous with the ‘active management of labour’, there are
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regional variations in the provision of maternity services. The value of case studies is explained by O’Leary: ‘. . . an in-depth examination of one particular individual, institution or occurrence can add much illumination to a body of knowledge . . . a method of studying elements of the social through comprehensive description and analysis of a single situation or case, for example a detailed study of a particular group, episode, event or any other unit of social life organization’ [19]. Case studies according to O’Leary, include ‘. . . in depth exploration; are an examination of subtleties and intricacies; attempt to be holistic; explore processes as well as outcomes; and investigate the context and setting of a situation’ [20]. The two case studies presented highlight some of the complexities of Irish maternity provision. They also suggest that those involved in developing services in the Greater Dublin Area can learn from their counterparts in the NEHSE where a major shift in service provision has occurred since 2001. Many of the changes there mirror the goals of national health policy reform in relation to developing a woman-centred, equitable, accessible, safe and accountable maternity service throughout the entire country. 4. Results 4.1. Case Study 1: North East Health Services Executive (NEHSE): Maternity Services Task Force The North Eastern region of Ireland (North East of Dublin, Counties Meath, Louth, Monaghan and Cavan) is one of the areas of greatest population growth in Western Europe. The total population for the Census of Population for the year 1996 was 306,155 [21] and for the year 2002 was 344,926 [22] and in 2006 the population was 394,098 [23]. It is estimated that the population will increase to 432,241 in 2015 [24]. This is as a result of migration into the area, partly as a result of the growth of the region as a commuter belt and increased immigration into Ireland. Large numbers of asylum seekers are dispersed to the area. Numbers of births increased from 3812 in 1999 to 4778 in 2004 [25] and 6210 in 2008 (www.hse.ie). There have been very significant changes in maternity service provision since 2002. Developments in the North East of Ireland have led to a change in focus and what is essentially the most significant shift in maternity policy in Ireland in over 50 years with the emphasis for the first time on the mother as consumer. Positive developments include the development of consumer groups, the adoption of a philosophy and practice of woman-centred care, characterised by greater choice and continuity of care. In May 2001, the Maternity Services Review Group was established under the Chairmanship of Patrick Kinder, following the rejection of the first review of Maternity Services by the North Eastern Health Board [26]. The Report of the Maternity Services Review Group [27] is a very important document as it provides a blueprint for a woman-centred, quality maternity service, which is safe, accessible and sustainable. The report recommends that maternity services in the North East be organised on a regional level. The revolutionary aspect of the Kinder Report is in relation to the establishment of midwifery-led units in two areas:
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Cavan General Hospital and Our Lady of Lourdes Hospital, Drogheda. This involves the provision of ante-natal, intrapartum and post-natal care to women defined as low risk; the provision of midwifery services in the community; providing a home birth team linked to the midwifery units; an inter-hospital transport service with the capacity to deal with emergencies and the establishment of a regionwide consumer committee for maternity and childcare services. Following the acceptance of the Kinder Report by the NEHB in 2001 a Task Force was established to formulate an implementation strategy for the Kinder Review Group’s recommendations. 4.1.1. MLUs and the MidU study In 2004, a pilot Midwifery-Led Service was introduced in the North Eastern Health Board, available to women assessed to be at low risk of having a complicated pregnancy or labour. It was evaluated by a randomised control trial known as the MidU Study, which stands for ‘Midwifery Unit’ [28] undertaken by the School of Nursing and Midwifery at Trinity College Dublin. Cecily Begley the principal investigator is also a member of the Task Force which illustrates the close link in Ireland between policy makers, practitioners and researchers. The results of the MidU Study along with another study, a cost–benefit analysis were handed over to the Health Services Executive in December 2009 [29]. The HSE has stated that it will study the findings with a view to formulating a national maternity policy. In welcoming the study on January 11 2010 AIMS the Association for the Improvement of Maternity Services stated: AIMS Ireland applauds the work of the research team at TCD’s School of Nursing and Midwifery for carrying out this important study and the MLUs at Drogheda and Cavan for progressing midwifery-led care in Ireland. Furthermore AIMS Ireland believes it is important that the findings of this study are not reserved purely for policy makers and the academic and clinical audiences of colleges and maternity units in Ireland. ‘The structure and culture of our maternity services will only evolve if women, as service users, and GPs, as first-line healthcare professionals, are also educated on the benefits of a social model versus the current paternalistic medical model in normal pregnancy and birth.’ The Midwifery-Led Unit (MLU) was developed to offer women experiencing a healthy pregnancy a quality, woman-centred service. The MLU is organised and managed by midwives; it offers midwifery-led care to women throughout labour, birth and the immediate post-natal period who have no significant medical or obstetric problems. It has a separate identity to that of the established consultant-led delivery unit and has a senior midwife responsible for daily service operation. The MLU aims to provide high quality, evidence-based woman-centred care and there is a strong emphasis on skilled, sensitive and respectful midwifery. Among its services are: a homely, safe environment in which to give birth; additional choice for childbirth and improved continuity of care and carer [28]. In September 2005 an economic evaluation of the MidU Study commenced. It was established to examine the overall impact of the MLUs on the provision of maternity services and to economically evaluate the costs of the dif-
ferent components of the midwife led and obstetrician led care. 4.1.2. Developing a strategy for consumer involvement Jentsch et al. outline how ‘. . . public policy has been steadily evolving to meet the needs of healthcare consumers-needs’ [30]. In his speech to the Dáil (Irish Parliament) on the launch of the Health Reform Programme, Minister for Health Michéal Martin (27 June 2003) referred to ‘. . . the most important voice to be heard in planning the delivery of services is the patients, clients and their families’. This reflected one of the goals of the health strategy: ‘Provision will be made for the participation of the community in decisions about the delivery of health and personal services’ and ‘. . . the central contribution of staff, users, communities and voluntary organisations in shaping this Strategy will be mirrored by a continuing key role for all stakeholders in its implementation oven the next 7 years [31]’. The aim being to make health services more user centred and responsive to users needs. This goal is compromised due to the ongoing crisis in Irish hospital services [32]. To this backdrop the Maternity Services Task Force was beginning to develop a model of consumer involvement for maternity services in the North East of Ireland. In addition to the national difficulties, in the North Eastern Region a Public Enquiry was held to investigate the irregular practices of one obstetrician in Our Lady of Lourdes Hospital over a 25-year period. In September 2003 a consultant obstetrician was struck off the Medical Register following a lengthy hearing before the Fitness to Practice Committee of the Irish Medical Council. In the wake of the publication of The Lourdes Hospital Enquiry [33], a redress scheme was established to compensate women. One hundred and eighty eight postpartum hysterectomies were carried out at the hospital’s maternity unit between 1974 and 1988, 129 of them carried out by the named obstetrician. There is an estimated 250 people involved. Forty-four patients’ records went missing, preventing them from taking court action. It is in this challenging context that attempts have been made to establish consumer involvement in the North Eastern Region. This author was a member of the Kinder Review Group, representing the National Women’s Council of Ireland (NWCI), and continued on in this role as a member of the Task Force. Consumer involvement is one of the key objectives of the Kinder Review: We consider that a region-wide Consumer Committee for Maternity and Childcare Services should be put in place. Representatives of Consumer organisations would have the opportunity to be involved in consultation about present operations and future developments and should be able to assess the quality of the services being provided [34]. Thus, the Review Group understood consumer in a sense similar to other bodies, for example the NHS Involvement Works the second report of the Standing Group on Consumers in NHS Research, which defines consumers as: ‘. . . patients, potential patients, carers, organisations representing consumers’ interests, members of the public who are the targets of health promotion programmes
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and groups asking for research because they believe they have been exposed to potentially harmful circumstances, products or services’ [35]. In the autumn of 2006, 5 years after the publication of the Report of the Kinder Review Group, the first MSLCs were launched in the North East. In Cavan/Monaghan: Birth Matters: Together We Can Make Maternity Services Even Better was established on 20th September 2006. It is a multi-disciplinary forum bringing together consumers and the different professions involved in maternity care. It will work with the Health Services Executive on all aspects of maternity services provided for its residents, including: Contributing to the development of more women centred services, which are respectful, personalised, and rewarding for both consumers and staff; involvement in the planning, further improvement and evaluation of maternity services; quality standards for maternity services and ways of monitoring standards; guidelines for clinical care. While MSLCs are not responsible for producing guidelines, they do, however, play an important part in reviewing and developing guidelines for local services. It is important that these are supported by all professionals and take account of the views of consumers; In relation to publicity and information, consumers can advise on what information women find useful and help to pilot draft information leaflets. A second maternity Services Liaison Committee (MSLC) Birth Matters: Together We Can Make Maternity Services Even Better was launched in Louth/Meath on 25 October 2006 when it held its inaugural meeting at Our Lady of Lourdes Hospital in Drogheda. Its goal is for consumers and staff to work together towards developing more women friendly services that are respectful, personalised and rewarding for both consumers and staff. The role of the consumer representatives in particular, is to promote the needs of local people using the maternity services. The group identified six main areas of focus and members undertook to work on the sub groups as appropriate. These are: Post-natal Care including breast feeding support; Provision of Information for Parents – before during and after pregnancy; Ante-natal Care – attendance at clinics, fertility issues, early pregnancy, etc.; Protocols and Guidelines – evidence based maternity care; Multicultural issues – food, infant mortality, equality of access and Home Births [25]. It will be interesting to see how these two MSLCs develop over the next number of years and in particular to monitor developments when the Maternity Services Task Force, which has had a supportive function will undoubtedly cease to exist. 4.2. Case Study 2: Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area (GDA) In 1997 a Joint Standing Committee was established to work as a collective body for the three maternity units in the Greater Dublin Area, to facilitate collaboration and to improve the level of care provided to mothers and infants. The three units: The National Maternity Hospital (NMH), The Coombe Women’s Hospital and the Rotunda are tertiary referral centres for Ireland. The Greater Dublin
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Area (GDA) was defined as consisting of Dublin City, DunLaoghaire-Rathdown, South Dublin, Fingal, Kildare, Meath and Wicklow. In 2007 the HSE commissioned KPMG to undertake an independent review of maternity and gynaecological services in the Greater Dublin Area. It reported in August 2008. Its terms of references were: • To build on the strengths of the current service configuration model of care. • To define the optimal configuration of maternity, gynaecology and neonatology services for the Greater Dublin Area. • To identify the optimal location of services. • To provide a roadmap for the future, outlining the steps required to get from where the service is now to our vision for the future [36]. The three maternity hospitals providing service in the GDA are within a 5 km radius of the city centre and are long established there. In 2006 there were 63,237 births in Ireland, of these 36.85% occurred in the three maternity hospitals in Dublin: The Coombe (8084), The Rotunda (7235) and the National Maternity Hospital (7986). Considering that these three hospitals cater for over a third of births in Ireland, the nature of their future development is of national importance The KPMG report indicates that the capacity of the three hospitals is no longer adequate. It indicates that hospitals are under staffed, with a requirement to address this involving the recruitment of a further 20 obstetricians, 221 midwives, 20 neonatal nurse and 35 theatre staff. It states: ‘there is an urgent need to increase the level of staffing of consultants and to make changes has had to consultant work practices to provide cover dedicated to care on the labour ward’. This is one area where the GDA can look to the NEHSE for guidance. In changing its maternity service since 2002 the NEHSE had to deal with the challenge of a midwife shortage and in addition a shortage of midwives with experience of midwifery-led care. It also had to deal with changes in consultant work contracts resulting from the EU Working-time Directive. The KPMG report outlines how in the GDA there currently is a reliance on consultants, who are delivering private patients out of hours, to provide care for public patients too [37]. This is an example of the public/private divide in maternity provision in Ireland. The NEHSE had to deal with this issue when it introduced MLUs as they are a part of the Maternity and Infant Care Scheme and so outside of the private/public split. Developments in the NEHSE have shown the efficacy of a service delivered by midwives. This is a model which side-steps the issue of consultant delivered care as care is delivered by midwives. It is an important move towards the development of a more equitable service. Women in Ireland often explain their choice of private care as a demand for private accommodation rather than private obstetric care. This need for private accommodation has been met in the MLUs of the NEHSE. KPMG identified the serious issue that all three hospitals are operating in a ‘sub-optimal infrastructure’ and many of the wards have higher than recommended occupancy levels. This ‘compromises privacy and dignity for patients whilst also increasing the likelihood of the spread of infec-
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tions’ [38]. The number of delivery suites and the number of theatres and their location is sub-optimal. In the context of international literature, KPMG suggest that ‘Dublin is somewhat out of step with current best practice’ [39]. Ireland’s stand alone policy is not good with bi-location and tri-location preferable internationally. Other concerns raised are the emphasis on a hospital-based medical-led model of care, the lack of choice for women, the poor availability of primary and community care services. Among the recommendations outlined in the report are: that there should be three new facilities developed within the GDA, two of which should be co-located with an adult hospital and one tri-located on the site of the new paediatric hospital. Again here the GDA can learn from the NEHSE where the change towards a regional maternity service has necessarily involved re-negotiation of governance and issues around multi-discipliniarity and leadership roles. The KPMG report is concerned with ease of access to services. The recommendation put forward is that services currently delivered at the Rotunda relocate to the Mater Misericordiae site where there is an acute hospital and the new paediatric hospital; the Coombe re-locate to Tallaght, co-locating with the acute hospital there and that the National Maternity Hospital re-locate to the site of St. Vincent’s University Hospital. These developments will require substantial capital investment which is a particular challenge given the current economic crisis. Each obstetric unit should have the capacity to deliver up to 10,000 babies, with up to 8000 in a standard obstetric unit and 200 in an adjacent MLU with the MLU being used for deliveries form the outset. In this context important lessons can be learned from developments in the NEHSE. The MidU study has established: Midwifery-led care, as practised in this study is as safe as consultant-led care, results in less intervention, is viewed by women with greater satisfaction in some aspects of care and is more cost-effective [29]. The KPMG report recommends that MLUs should be located on the hospital site adjacent to obstetric units. ‘This will greatly enhance the choices available to women whilst providing the maternity services a more cost-effective means to provide capacity for increased numbers of births’ [40]. It further states that; ‘providing that the midwives in the MLU are experienced and adhere to guidelines, MLUs can provide a safe alternative location for low risk mothers to deliver their babies in addition to the main obstetric unit’ [41]. Interestingly the KPMG report argues that the smaller capacity of the maternity units in the GDA contributes to the continued use of the active management of labour. ‘The current number of deliveries could not be provided without using active management; however that does not mean that it represents best practice’ [42]. 5. Discussion and conclusions Despite the fact that the birth rate in Ireland is 17.0 and that numbers of births are at the highest number in 30 years, there is a dearth of research on maternity service provision. The absence of any national audit or in fact data
collection until 2007 when the National Perinatal Epidemiology Centre was established made comparison difficult. The Institute of Obstetricians and Gynaecologists in 2006 completed a review of services in the light of health policy reform which painted a picture of inadequate and flawed services. Maternity provision in Ireland continues to be obstetric-led and is synonymous with the ‘active management of labour’, ensuring a highly medicalised model of care. This is due in part to the way in which the Maternity and Infant Care Scheme has been delivered by GPs and hospitals and also the two-tiered system of medical care where private health insurance offers a lucrative income to obstetricians and as a result midwifery-led care has been marginalised. In this context women in Ireland have been denied choice in relation to place of birth and type of care provided. This article has looked more closely at two particular regions in Ireland where large numbers of births occur. In presenting two case studies it explores recent developments in maternity service provision in Ireland in the context of a national health reform programme. Demographic factors have put stress on Maternity Services in the Greater Dublin Area and in the North Eastern Region and this has in turn led to reviews of maternity provision in both areas. The future for the Greater Dublin Area in the present economic climate remains unclear but the current proposals offer a glimpse of a future where women could avail of MLUs and have greater choice and continuity of care in pregnancy. The NEHSE on the other hand has ushered in some important changes including the establishment of two MLUs and increased consumer involvement and for the first time in Ireland an emphasis on the mother and infant as central to maternity care [29]. Again the economic context may dictate the future for services in the NEHSE. The findings of the MidU study that MLUs are more costeffective than consultant-led care needs to be seriously considered. In conclusion, in the context of an economic recession, a health service in disarray, increased demand due to a rise in the annual number of births and new challenges brought about by a more multi-cultural society maternity service provision is in transition. The 2001 Health Strategy, a blueprint to guide policy makers and service providers in developing a future health system states its vision as: • A health system that supports and empowers you, your family, and community to achieve your full health potential. • A health system that is there when you need it, that is fair and you can trust. • A health system that encourages you to have your say, listens to you, and ensures that your views are taken into account [3]. The principles put forward in this vision are equity and fairness; a people-centred service; quality of care and clear accountability. It undertook to draw up ‘a plan to provide responsive, high-quality maternity care’. Recognising that four out of five women in Ireland use the maternity services, it recognises that models of maternity care are changing, with increasing demands for choice regarding type of care and location, pressures on existing services and
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undertook to establish a working party ‘to prepare a plan for the future development of maternity services’ with the objective that maternity care in Ireland will be: womancentred; equitable across different parts of the country; accessible to all, safe and accountable [4]. The case studies presented here demonstrate that some progress has been made in line with these objectives. The former illustrates important developments which have occurred in the NEHSE as a result of the Maternity Services Task Force (2002–2010) and argues that there are important learning outcomes not only for the GDA which is the subject of the latter case study but also for the development of maternity services nationally. References [1] Burke S. Irish apartheid: healthcare inequality in Ireland. Dublin, New Island; 2009; Consadine M, Dukelow F. Irish social policy, a critical introduction. Dublin: Gill and Macmillan; 2009. [2] Devane D, Murphy-Lawless J, Begley C. The invisible woman: maternity care in Ireland. Midwifery 2007;23(March(1)):92–101; Begley CM, Devane D. The Practising Midwife 2003;6(5): 10–2. [3] Department of Health and Children. Quality and fairness – a health system for you – health strategy. Dublin: Department of Health and Children; 2001. p. 10. [4] Department of Health and Children. Quality and fairness – a health system for you – health strategy. Dublin: Department of Health and Children; 2001. p. 84. [5] Wren M. Unhealthy state anatomy of a sick society. Dublin, New Ireland; 2003. [6] Commission on Health Funding. Report of the Commission on Health Funding. Dublin: Stationery Office; 1989. [7] Department of Health and Children. Report of the Commission on Financial Management and Control Systems in the Health Service. Dublin: Stationery Office; 2003. [8] Department of Health and Children. Report of the National Task Force on Medical Staffing. Dublin: Stationery Office; 2003. [9] Consadine M, Dukelow F. Irish social policy, a critical introduction. Dublin: Gill and Macmillan; 2009. p. 265. [10] Kennedy P, Murphy-Lawless J. The maternity care needs of refugee and asylum seeking women in Ireland. Feminist Review 2002;73:39–53, 2003. [11] Central Statistics Office. Vital statistics third quarter 2008 – 17th June. Stationery Office; 2009. [12] Central Statistics Office. CSO population and labour; 2004. [13] Barrington R. Health, medicine and politics in the Republic of Ireland. Dublin; 1987. [14] Health Insurance Authority. Annual report and accounts. Dublin; 2007. [15] O’ Connor M. Conjuring choice while subverting autonomy: medical technocracy and home birth in Ireland. In: Symon A, editor. Risk and choice in maternity care; an international perspective. London: Churchill Livingstone Elsevier; 2006. p. 109–22. [16] Kennedy P. Maternity in Ireland, a woman-centred approach. Dublin: The Liffey Press; 2002.
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[17] Institute of Obstetricians and Gynaecologists. The future of maternity and gynaecology services in Ireland 2006–2016. Report from Institute Sub-Group. Dublin; 2006. p. 8.; Force Projections 2006–2036. Dublin: Stationery Office. [18] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008. p. 8. [19] O’Leary Z. The essential guide to doing research. London: Sage; 2004. p. 15. [20] O’Leary Z. The essential guide to doing research. London: Sage; 2004. p. 116. [21] Central Statistics Office. Census of population 1996. Dublin: Stationery Office; 1996. [22] Central Statistics Office. Census of population 2002. Dublin: Stationery Office; 2002. [23] Central Statistics Office. Census of population 2006. Dublin: Stationery Office; 2006. [24] Central Statistics Office. CSO population and labour force projections 2006–2036. Dublin: Stationery Office; 2004. [25] Kennedy P. A woman-centred maternity service for the North Eastern Health Board. International Journal of Consumer Studies 2008;32:27–33. [26] Condon D. Report of the Review Group on Maternity Services in the North Eastern Health Board. Kells: North Eastern Health Board; 2000. [27] Kinder P. Report of the Maternity Services Review Group to the North Eastern Health Board. Kells: North Eastern Health Board; 2001. [28] Begley C, Devane D. Research progress report: fifteenth research progress status report to the Maternity Services Taskforce and HSEDublin North East 1st September 2006–31st December 2006. School of Nursing and Midwifery, Trinity College Dublin; 2006. [29] School of Nursing and Midwifery TCD. An evaluation of midwiferyled care in the Health Service Executive North Eastern Area. The Report of the MidU Study. Dublin; 2008. [30] Jentsch B, Durham R, Hundley V, Hussein J. Creating consumer satisfaction in maternity care: the neglected needs of migrants, asylum seekers and refugees. IJCS 2007;31:18–34. [31] Department of Health and Children. Quality and fairness: a health system for you (2001). Dublin: Stationery Office; 2001. [32] O’Connor M. Emergency: Irish hospitals in chaos. Dublin: Gill and MacMillan; 2007. [33] Harding Clarke M. The Lourdes Hospital enquiry: an inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital Drogheda. Dublin: Stationery Office; 2006. [34] Kinder P. Report of the Maternity Services Review Group to the North Eastern Health Board. Kells: NEHB; 2001. p. 35. [35] NHS Involvement Works the second report of the Standing Group on Consumers in NHS Research. NHS Executive. Winchester; March 1999. [36] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008. p. 5. [37] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008. p. 7. [38] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008. p. 8. [39] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008. p. 9. [40] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008. p. 21. [41] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008. p. 15. [42] KPMG. Independent review of maternity and gynaecology services in the Greater Dublin Area. Dublin: KPMG; 2008.
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Health Policy journal homepage: www.elsevier.com/locate/healthpol
Healthcare reform: Maternity service provision in Ireland Patricia Kennedy ∗ School of Applied Social Science, University College Dublin, Belfield, Dublin 4, Ireland
a r t i c l e
i n f o
Keywords: Maternity hospitals Midwifery-led units Consumers Health reform
a b s t r a c t The objective of this article is to explore recent and proposed future developments in maternity service provision in Ireland in the context of health policy reform. Ireland is experiencing an unprecedented demand for maternity services with in excess of 75,000 births in 2009, the highest since the 1970s when Ireland experienced a ‘baby boom’. A further 10% rise is projected for 2010. This demographic change has placed increased demands on an already over-stretched maternity service. Despite more than a decade of economic success the health service has remained in constant crisis with many commentators arguing it has worsened rather than improved since the reform process was instigated in 2001 [1]. Reform of maternity services has begun and this article presents two case studies to demonstrate the regional variations in maternity provision in a country which has a national health service and a national Maternity and Infant Care Scheme. It shows what developments have occurred and what direction maternity services are likely to go in the next decade. The two regions under scrutiny are the North East Health Services Executive (NEHSE) and the Greater Dublin Area (GDA). The former illustrates important developments which have occurred in the NEHSE as a result of the Maternity Services Task Force (2002–2010) and argues that there are important learning outcomes not only for the GDA which is the subject of the latter case study but also for the development of maternity services nationally. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The objective of this article is to explore recent and proposed future developments in maternity service provision in Ireland in the context of health policy reform. Ireland is experiencing an unprecedented demand for maternity services with in excess of 75,000 births in 2009, the highest since the 1970s when Ireland experienced a ‘baby boom’. A further 10% rise is projected for 2010. This demographic change has placed increased demands on an already overstretched maternity service. Despite more than a decade of economic success the health service has remained in constant crisis with many commentators arguing it has
∗ Tel.: +353 1 7168275; fax: +353 1 7161197. E-mail address: [email protected]. 0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2010.04.002
worsened rather than improved since the reform process was instigated in 2001 [1]. Reform of maternity services has begun and this article presents two case studies to demonstrate the regional variations in maternity provision in a country which has a national health service and a national Maternity and Infant Care Scheme. It shows what developments have occurred and what direction maternity services are likely to go in the next decade. The two regions under scrutiny are the North East Health Services Executive (NEHSE) and the Greater Dublin Area (GDA). The former illustrates important developments which have occurred in the NEHSE as a result of the Maternity Services Task Force (2002–2010) and argues that there are important learning outcomes not only for the GDA which is the subject of the latter case study but also for the development of maternity services nationally.
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There is a dearth of analysis of maternity provision in Ireland with some notable exceptions [2]. There is no national audit of maternity hospitals in Ireland. A welcome development has been the establishment of the National Perinatal Epidemiology Centre in 2007 with the overall objective of translating outcome data from Irish maternity hospitals and evidence-based best practice into improved clinical services for Irish patients (www.ucc.ie/en/npec). Because very little has been written on maternity policy and provision in Ireland case studies are useful as they include detailed description. 1.1. Health care reform The 2001 Health Strategy, a blueprint to guide policy makers and service providers in developing a future health system states its vision as: • A health system that supports and empowers you, your family, and community to achieve your full health potential. • A health system that is there when you need it, that is fair and you can trust. • A health system that encourages you to have your say, listens to you, and ensures that your views are taken into account [3]. The principles put forward in this vision are equity and fairness; a people-centred service; quality of care and clear accountability. It undertook to draw up ‘a plan to provide responsive, high-quality maternity care’. Recognising that four out of five women in Ireland use the maternity services, it recognises that models of maternity care are changing, with increasing demands for choice regarding type of care and location, pressures on existing services and undertook to establish a working party ‘to prepare a plan for the future development of maternity services’ with the objective that maternity care in Ireland will be: womancentred; equitable across different parts of the country; accessible to all, safe and accountable [4]. The case studies presented here demonstrate that some progress has been made in line with these objectives. However, it would appear that change has come about as a result of regional responses to local issues as opposed to the national reform agenda. Wren indicates that reform was fuelled by a recognition that the Irish health service was characterised by underfunding and inequity [5]. The Commission on Health Funding had identified problems in the health service in relation to planning, organisation and delivery [6]. Health expenditure was under scrutiny in the Brennan Report [7] and the EU Working-Time Directive led to a shift from consultant-led to consultant provided care [8]. Consadine and Duklelow suggest ‘The reform process remains unsettled’ [9] and outlines how the Health Services Executive (HSE), established to replace the previous eight health boards ‘has been subjected to a barrage of criticism’ in relation to the adequacy of the health budget, the appropriateness of budgetary decisions, accountability, administrative and other failures all ‘highlighted by a number of high pro-
file cases involving misdiagnosis and inappropriate care’ [9]. 2. Maternity and Infant Care Scheme Demographic factors have resulted in an increased demand for maternity services. The 2006 Census demonstrates that the population is at its highest since 1861 and for the first time Ireland has become a country which has experienced in-migration and has rapidly become a multi-cultural society, raising new challenges for maternity services [10]. The birth rate (number of births per 1000 of population) in Ireland is 17.0 [11] there were 75,065 births in 2008, the highest recorded since 1980 [11]. The population is expected to grow from 4,167,000 in 2006 to 5,820,000 in 2036 [12]. Hence, the demand for maternity services will endure. Maternity services are available free of charge to all women in Ireland (who meet residency requirements) under the 1954 Maternity and Infant Care Scheme. However this is only for maternity-related illnesses and only during pregnancy and for 6 weeks following birth. The scheme is based on the assumption that ante-natal care is provided by general practitioners (GPs) and obstetricians and this has led to the under-development of midwifery provided/led services. General Practitioners have agreements with the Health Service Executive (HSE) to provide services. The GP provides an initial examination, if possible before 12 weeks, and a further six examinations during the pregnancy, which are alternated with visits to the hospital maternity unit. The schedule of visits may be changed by GPs and/or the hospital obstetrician, depending on medical need. A woman with a significant illness, e.g. diabetes or hypertension, may have up to five additional visits to the GP. Interestingly, the Maternity and Infant Care Scheme only covers maternity-related illnesses and care for other illnesses which the woman may have during pregnancy are not covered. Post-natally the GP will examine the baby (not the mother) at 2 weeks and both mother and baby at 6 weeks. Mothers are entitled to free in-patient and outpatient public hospital services in respect of pregnancy and birth and are not liable for any of the standard in-patient hospital charges. Despite the availability of free maternity care an important feature of maternity services in Ireland is the co-existence of private maternity care. Barrington refers to the Irish healthcare system as an ‘extraordinary’ symbiosis of public and private medicine [13]. In 2007 51.2% of the population was covered by private health insurance [14]. O’Connor highlights the great divide in maternity service with private obstetrics being a lucrative profession describing how consultant doctors in Ireland are allowed to practice medicine ‘privately’. She continues: ‘The market for private obstetrics is worth at least D 49 million annually; this is divided among the country’s 104 obstetricians. . . Dublin doctors can earn an estimated D 503,000 on average from private maternity fees. Outside Dublin, where births are less centralised, revenues tend to be slightly lower, averaging D 447,000 per head annually. . . These incomes are further boosted by public salaries (ranging from D 125 to D 150,000) and private gynaecological fees’ [15]. An impor-
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tant feature of maternity services in Ireland is the role of private medical insurance in emphasising hospital-based doctor-led services. In the past 50 years, maternity services in Ireland have consistently become more medicalized and hospital-based. This pattern has accelerated since the 1970s with the focus steadily shifting from the needs of the mother to the demands of busy obstetricians working in increasingly technology-dominated maternity units [16]. Maternity has become more medicalised with women in Ireland more likely to undergo caesarean section than previously. The caesarean rate for 2005 was 22.39%. The number of women giving birth at home has declined from about a third in 1950 to less that one percent today. A review published by the Institute of Obstetrics and Gynaecology which focuses on services in the context of health reform suggest it ‘uncovers much which is undesirable’ [17] including poor infrastructure, overcrowding, lack of privacy, long waiting times, operational difficulties and sometimes problems with accessing emergency caesarean sections. ‘The dominance of a medically led, hospital-centred model of care provides effective services for women with non-routine clinical conditions. However, approximately 60% of women experience a normal pregnancy and birth. It does therefore limit the choice for women whose routine clinical needs could be provided for in a wider range of settings’ [18]. There has been a trend in Ireland since the 1970s towards larger maternity units [16]. This has implications for the type of service provided. In recent years several maternity units have amalgamated, for example the Cork University Maternity Hospital (CUMH) established in April 2007 is a purpose-built, modern facility with 144 beds and 12 labour rooms. The third biggest maternity hospital in Ireland, it replaced the former Erinville, St Finbarr’s and the Bon Secours maternity hospitals. The projected 7500 births per year were exceeded in 2008 when there were 8725 births at the CUMH. A similar trend is evident in the North Eastern Region. At the end of February 2001, the North Eastern Health Board (NEHB) was forced to suspend maternity services at Monaghan General Hospital and Louth County Hospital due to the withdrawal of insurance cover by the Irish Public Bodies Mutual Insurance. As a result maternity services are concentrated in two rather than four sites. These developments are further examined in Case Study One: The NEHSE (previously the NEHB) Maternity Services Task Force. Re-location is also planned for the three maternity hospitals in the Greater Dublin Area (GDA), where over 30% of all births take place. These proposed developments are examined in Case Study Two: Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area. 3. Materials and methods This article presents two case studies to explore recent and proposed developments in maternity provision in Ireland in the context of health policy reform and increased demand. They illuminate how in a country with one health service, characterized by obstetric-led care and synonymous with the ‘active management of labour’, there are
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regional variations in the provision of maternity services. The value of case studies is explained by O’Leary: ‘. . . an in-depth examination of one particular individual, institution or occurrence can add much illumination to a body of knowledge . . . a method of studying elements of the social through comprehensive description and analysis of a single situation or case, for example a detailed study of a particular group, episode, event or any other unit of social life organization’ [19]. Case studies according to O’Leary, include ‘. . . in depth exploration; are an examination of subtleties and intricacies; attempt to be holistic; explore processes as well as outcomes; and investigate the context and setting of a situation’ [20]. The two case studies presented highlight some of the complexities of Irish maternity provision. They also suggest that those involved in developing services in the Greater Dublin Area can learn from their counterparts in the NEHSE where a major shift in service provision has occurred since 2001. Many of the changes there mirror the goals of national health policy reform in relation to developing a woman-centred, equitable, accessible, safe and accountable maternity service throughout the entire country. 4. Results 4.1. Case Study 1: North East Health Services Executive (NEHSE): Maternity Services Task Force The North Eastern region of Ireland (North East of Dublin, Counties Meath, Louth, Monaghan and Cavan) is one of the areas of greatest population growth in Western Europe. The total population for the Census of Population for the year 1996 was 306,155 [21] and for the year 2002 was 344,926 [22] and in 2006 the population was 394,098 [23]. It is estimated that the population will increase to 432,241 in 2015 [24]. This is as a result of migration into the area, partly as a result of the growth of the region as a commuter belt and increased immigration into Ireland. Large numbers of asylum seekers are dispersed to the area. Numbers of births increased from 3812 in 1999 to 4778 in 2004 [25] and 6210 in 2008 (www.hse.ie). There have been very significant changes in maternity service provision since 2002. Developments in the North East of Ireland have led to a change in focus and what is essentially the most significant shift in maternity policy in Ireland in over 50 years with the emphasis for the first time on the mother as consumer. Positive developments include the development of consumer groups, the adoption of a philosophy and practice of woman-centred care, characterised by greater choice and continuity of care. In May 2001, the Maternity Services Review Group was established under the Chairmanship of Patrick Kinder, following the rejection of the first review of Maternity Services by the North Eastern Health Board [26]. The Report of the Maternity Services Review Group [27] is a very important document as it provides a blueprint for a woman-centred, quality maternity service, which is safe, accessible and sustainable. The report recommends that maternity services in the North East be organised on a regional level. The revolutionary aspect of the Kinder Report is in relation to the establishment of midwifery-led units in two areas:
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Cavan General Hospital and Our Lady of Lourdes Hospital, Drogheda. This involves the provision of ante-natal, intrapartum and post-natal care to women defined as low risk; the provision of midwifery services in the community; providing a home birth team linked to the midwifery units; an inter-hospital transport service with the capacity to deal with emergencies and the establishment of a regionwide consumer committee for maternity and childcare services. Following the acceptance of the Kinder Report by the NEHB in 2001 a Task Force was established to formulate an implementation strategy for the Kinder Review Group’s recommendations. 4.1.1. MLUs and the MidU study In 2004, a pilot Midwifery-Led Service was introduced in the North Eastern Health Board, available to women assessed to be at low risk of having a complicated pregnancy or labour. It was evaluated by a randomised control trial known as the MidU Study, which stands for ‘Midwifery Unit’ [28] undertaken by the School of Nursing and Midwifery at Trinity College Dublin. Cecily Begley the principal investigator is also a member of the Task Force which illustrates the close link in Ireland between policy makers, practitioners and researchers. The results of the MidU Study along with another study, a cost–benefit analysis were handed over to the Health Services Executive in December 2009 [29]. The HSE has stated that it will study the findings with a view to formulating a national maternity policy. In welcoming the study on January 11 2010 AIMS the Association for the Improvement of Maternity Services stated: AIMS Ireland applauds the work of the research team at TCD’s School of Nursing and Midwifery for carrying out this important study and the MLUs at Drogheda and Cavan for progressing midwifery-led care in Ireland. Furthermore AIMS Ireland believes it is important that the findings of this study are not reserved purely for policy makers and the academic and clinical audiences of colleges and maternity units in Ireland. ‘The structure and culture of our maternity services will only evolve if women, as service users, and GPs, as first-line healthcare professionals, are also educated on the benefits of a social model versus the current paternalistic medical model in normal pregnancy and birth.’ The Midwifery-Led Unit (MLU) was developed to offer women experiencing a healthy pregnancy a quality, woman-centred service. The MLU is organised and managed by midwives; it offers midwifery-led care to women throughout labour, birth and the immediate post-natal period who have no significant medical or obstetric problems. It has a separate identity to that of the established consultant-led delivery unit and has a senior midwife responsible for daily service operation. The MLU aims to provide high quality, evidence-based woman-centred care and there is a strong emphasis on skilled, sensitive and respectful midwifery. Among its services are: a homely, safe environment in which to give birth; additional choice for childbirth and improved continuity of care and carer [28]. In September 2005 an economic evaluation of the MidU Study commenced. It was established to examine the overall impact of the MLUs on the provision of maternity services and to economically evaluate the costs of the dif-
ferent components of the midwife led and obstetrician led care. 4.1.2. Developing a strategy for consumer involvement Jentsch et al. outline how ‘. . . public policy has been steadily evolving to meet the needs of healthcare consumers-needs’ [30]. In his speech to the Dáil (Irish Parliament) on the launch of the Health Reform Programme, Minister for Health Michéal Martin (27 June 2003) referred to ‘. . . the most important voice to be heard in planning the delivery of services is the patients, clients and their families’. This reflected one of the goals of the health strategy: ‘Provision will be made for the participation of the community in decisions about the delivery of health and personal services’ and ‘. . . the central contribution of staff, users, communities and voluntary organisations in shaping this Strategy will be mirrored by a continuing key role for all stakeholders in its implementation oven the next 7 years [31]’. The aim being to make health services more user centred and responsive to users needs. This goal is compromised due to the ongoing crisis in Irish hospital services [32]. To this backdrop the Maternity Services Task Force was beginning to develop a model of consumer involvement for maternity services in the North East of Ireland. In addition to the national difficulties, in the North Eastern Region a Public Enquiry was held to investigate the irregular practices of one obstetrician in Our Lady of Lourdes Hospital over a 25-year period. In September 2003 a consultant obstetrician was struck off the Medical Register following a lengthy hearing before the Fitness to Practice Committee of the Irish Medical Council. In the wake of the publication of The Lourdes Hospital Enquiry [33], a redress scheme was established to compensate women. One hundred and eighty eight postpartum hysterectomies were carried out at the hospital’s maternity unit between 1974 and 1988, 129 of them carried out by the named obstetrician. There is an estimated 250 people involved. Forty-four patients’ records went missing, preventing them from taking court action. It is in this challenging context that attempts have been made to establish consumer involvement in the North Eastern Region. This author was a member of the Kinder Review Group, representing the National Women’s Council of Ireland (NWCI), and continued on in this role as a member of the Task Force. Consumer involvement is one of the key objectives of the Kinder Review: We consider that a region-wide Consumer Committee for Maternity and Childcare Services should be put in place. Representatives of Consumer organisations would have the opportunity to be involved in consultation about present operations and future developments and should be able to assess the quality of the services being provided [34]. Thus, the Review Group understood consumer in a sense similar to other bodies, for example the NHS Involvement Works the second report of the Standing Group on Consumers in NHS Research, which defines consumers as: ‘. . . patients, potential patients, carers, organisations representing consumers’ interests, members of the public who are the targets of health promotion programmes
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and groups asking for research because they believe they have been exposed to potentially harmful circumstances, products or services’ [35]. In the autumn of 2006, 5 years after the publication of the Report of the Kinder Review Group, the first MSLCs were launched in the North East. In Cavan/Monaghan: Birth Matters: Together We Can Make Maternity Services Even Better was established on 20th September 2006. It is a multi-disciplinary forum bringing together consumers and the different professions involved in maternity care. It will work with the Health Services Executive on all aspects of maternity services provided for its residents, including: Contributing to the development of more women centred services, which are respectful, personalised, and rewarding for both consumers and staff; involvement in the planning, further improvement and evaluation of maternity services; quality standards for maternity services and ways of monitoring standards; guidelines for clinical care. While MSLCs are not responsible for producing guidelines, they do, however, play an important part in reviewing and developing guidelines for local services. It is important that these are supported by all professionals and take account of the views of consumers; In relation to publicity and information, consumers can advise on what information women find useful and help to pilot draft information leaflets. A second maternity Services Liaison Committee (MSLC) Birth Matters: Together We Can Make Maternity Services Even Better was launched in Louth/Meath on 25 October 2006 when it held its inaugural meeting at Our Lady of Lourdes Hospital in Drogheda. Its goal is for consumers and staff to work together towards developing more women friendly services that are respectful, personalised and rewarding for both consumers and staff. The role of the consumer representatives in particular, is to promote the needs of local people using the maternity services. The group identified six main areas of focus and members undertook to work on the sub groups as appropriate. These are: Post-natal Care including breast feeding support; Provision of Information for Parents – before during and after pregnancy; Ante-natal Care – attendance at clinics, fertility issues, early pregnancy, etc.; Protocols and Guidelines – evidence based maternity care; Multicultural issues – food, infant mortality, equality of access and Home Births [25]. It will be interesting to see how these two MSLCs develop over the next number of years and in particular to monitor developments when the Maternity Services Task Force, which has had a supportive function will undoubtedly cease to exist. 4.2. Case Study 2: Independent Review of Maternity and Gynaecology Services in the Greater Dublin Area (GDA) In 1997 a Joint Standing Committee was established to work as a collective body for the three maternity units in the Greater Dublin Area, to facilitate collaboration and to improve the level of care provided to mothers and infants. The three units: The National Maternity Hospital (NMH), The Coombe Women’s Hospital and the Rotunda are tertiary referral centres for Ireland. The Greater Dublin
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Area (GDA) was defined as consisting of Dublin City, DunLaoghaire-Rathdown, South Dublin, Fingal, Kildare, Meath and Wicklow. In 2007 the HSE commissioned KPMG to undertake an independent review of maternity and gynaecological services in the Greater Dublin Area. It reported in August 2008. Its terms of references were: • To build on the strengths of the current service configuration model of care. • To define the optimal configuration of maternity, gynaecology and neonatology services for the Greater Dublin Area. • To identify the optimal location of services. • To provide a roadmap for the future, outlining the steps required to get from where the service is now to our vision for the future [36]. The three maternity hospitals providing service in the GDA are within a 5 km radius of the city centre and are long established there. In 2006 there were 63,237 births in Ireland, of these 36.85% occurred in the three maternity hospitals in Dublin: The Coombe (8084), The Rotunda (7235) and the National Maternity Hospital (7986). Considering that these three hospitals cater for over a third of births in Ireland, the nature of their future development is of national importance The KPMG report indicates that the capacity of the three hospitals is no longer adequate. It indicates that hospitals are under staffed, with a requirement to address this involving the recruitment of a further 20 obstetricians, 221 midwives, 20 neonatal nurse and 35 theatre staff. It states: ‘there is an urgent need to increase the level of staffing of consultants and to make changes has had to consultant work practices to provide cover dedicated to care on the labour ward’. This is one area where the GDA can look to the NEHSE for guidance. In changing its maternity service since 2002 the NEHSE had to deal with the challenge of a midwife shortage and in addition a shortage of midwives with experience of midwifery-led care. It also had to deal with changes in consultant work contracts resulting from the EU Working-time Directive. The KPMG report outlines how in the GDA there currently is a reliance on consultants, who are delivering private patients out of hours, to provide care for public patients too [37]. This is an example of the public/private divide in maternity provision in Ireland. The NEHSE had to deal with this issue when it introduced MLUs as they are a part of the Maternity and Infant Care Scheme and so outside of the private/public split. Developments in the NEHSE have shown the efficacy of a service delivered by midwives. This is a model which side-steps the issue of consultant delivered care as care is delivered by midwives. It is an important move towards the development of a more equitable service. Women in Ireland often explain their choice of private care as a demand for private accommodation rather than private obstetric care. This need for private accommodation has been met in the MLUs of the NEHSE. KPMG identified the serious issue that all three hospitals are operating in a ‘sub-optimal infrastructure’ and many of the wards have higher than recommended occupancy levels. This ‘compromises privacy and dignity for patients whilst also increasing the likelihood of the spread of infec-
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tions’ [38]. The number of delivery suites and the number of theatres and their location is sub-optimal. In the context of international literature, KPMG suggest that ‘Dublin is somewhat out of step with current best practice’ [39]. Ireland’s stand alone policy is not good with bi-location and tri-location preferable internationally. Other concerns raised are the emphasis on a hospital-based medical-led model of care, the lack of choice for women, the poor availability of primary and community care services. Among the recommendations outlined in the report are: that there should be three new facilities developed within the GDA, two of which should be co-located with an adult hospital and one tri-located on the site of the new paediatric hospital. Again here the GDA can learn from the NEHSE where the change towards a regional maternity service has necessarily involved re-negotiation of governance and issues around multi-discipliniarity and leadership roles. The KPMG report is concerned with ease of access to services. The recommendation put forward is that services currently delivered at the Rotunda relocate to the Mater Misericordiae site where there is an acute hospital and the new paediatric hospital; the Coombe re-locate to Tallaght, co-locating with the acute hospital there and that the National Maternity Hospital re-locate to the site of St. Vincent’s University Hospital. These developments will require substantial capital investment which is a particular challenge given the current economic crisis. Each obstetric unit should have the capacity to deliver up to 10,000 babies, with up to 8000 in a standard obstetric unit and 200 in an adjacent MLU with the MLU being used for deliveries form the outset. In this context important lessons can be learned from developments in the NEHSE. The MidU study has established: Midwifery-led care, as practised in this study is as safe as consultant-led care, results in less intervention, is viewed by women with greater satisfaction in some aspects of care and is more cost-effective [29]. The KPMG report recommends that MLUs should be located on the hospital site adjacent to obstetric units. ‘This will greatly enhance the choices available to women whilst providing the maternity services a more cost-effective means to provide capacity for increased numbers of births’ [40]. It further states that; ‘providing that the midwives in the MLU are experienced and adhere to guidelines, MLUs can provide a safe alternative location for low risk mothers to deliver their babies in addition to the main obstetric unit’ [41]. Interestingly the KPMG report argues that the smaller capacity of the maternity units in the GDA contributes to the continued use of the active management of labour. ‘The current number of deliveries could not be provided without using active management; however that does not mean that it represents best practice’ [42]. 5. Discussion and conclusions Despite the fact that the birth rate in Ireland is 17.0 and that numbers of births are at the highest number in 30 years, there is a dearth of research on maternity service provision. The absence of any national audit or in fact data
collection until 2007 when the National Perinatal Epidemiology Centre was established made comparison difficult. The Institute of Obstetricians and Gynaecologists in 2006 completed a review of services in the light of health policy reform which painted a picture of inadequate and flawed services. Maternity provision in Ireland continues to be obstetric-led and is synonymous with the ‘active management of labour’, ensuring a highly medicalised model of care. This is due in part to the way in which the Maternity and Infant Care Scheme has been delivered by GPs and hospitals and also the two-tiered system of medical care where private health insurance offers a lucrative income to obstetricians and as a result midwifery-led care has been marginalised. In this context women in Ireland have been denied choice in relation to place of birth and type of care provided. This article has looked more closely at two particular regions in Ireland where large numbers of births occur. In presenting two case studies it explores recent developments in maternity service provision in Ireland in the context of a national health reform programme. Demographic factors have put stress on Maternity Services in the Greater Dublin Area and in the North Eastern Region and this has in turn led to reviews of maternity provision in both areas. The future for the Greater Dublin Area in the present economic climate remains unclear but the current proposals offer a glimpse of a future where women could avail of MLUs and have greater choice and continuity of care in pregnancy. The NEHSE on the other hand has ushered in some important changes including the establishment of two MLUs and increased consumer involvement and for the first time in Ireland an emphasis on the mother and infant as central to maternity care [29]. Again the economic context may dictate the future for services in the NEHSE. The findings of the MidU study that MLUs are more costeffective than consultant-led care needs to be seriously considered. In conclusion, in the context of an economic recession, a health service in disarray, increased demand due to a rise in the annual number of births and new challenges brought about by a more multi-cultural society maternity service provision is in transition. The 2001 Health Strategy, a blueprint to guide policy makers and service providers in developing a future health system states its vision as: • A health system that supports and empowers you, your family, and community to achieve your full health potential. • A health system that is there when you need it, that is fair and you can trust. • A health system that encourages you to have your say, listens to you, and ensures that your views are taken into account [3]. The principles put forward in this vision are equity and fairness; a people-centred service; quality of care and clear accountability. It undertook to draw up ‘a plan to provide responsive, high-quality maternity care’. Recognising that four out of five women in Ireland use the maternity services, it recognises that models of maternity care are changing, with increasing demands for choice regarding type of care and location, pressures on existing services and
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undertook to establish a working party ‘to prepare a plan for the future development of maternity services’ with the objective that maternity care in Ireland will be: womancentred; equitable across different parts of the country; accessible to all, safe and accountable [4]. The case studies presented here demonstrate that some progress has been made in line with these objectives. The former illustrates important developments which have occurred in the NEHSE as a result of the Maternity Services Task Force (2002–2010) and argues that there are important learning outcomes not only for the GDA which is the subject of the latter case study but also for the development of maternity services nationally. References [1] Burke S. Irish apartheid: healthcare inequality in Ireland. Dublin, New Island; 2009; Consadine M, Dukelow F. Irish social policy, a critical introduction. Dublin: Gill and Macmillan; 2009. [2] Devane D, Murphy-Lawless J, Begley C. The invisible woman: maternity care in Ireland. Midwifery 2007;23(March(1)):92–101; Begley CM, Devane D. The Practising Midwife 2003;6(5): 10–2. [3] Department of Health and Children. Quality and fairness – a health system for you – health strategy. Dublin: Department of Health and Children; 2001. p. 10. [4] Department of Health and Children. Quality and fairness – a health system for you – health strategy. Dublin: Department of Health and Children; 2001. p. 84. [5] Wren M. Unhealthy state anatomy of a sick society. Dublin, New Ireland; 2003. [6] Commission on Health Funding. Report of the Commission on Health Funding. Dublin: Stationery Office; 1989. [7] Department of Health and Children. Report of the Commission on Financial Management and Control Systems in the Health Service. Dublin: Stationery Office; 2003. [8] Department of Health and Children. Report of the National Task Force on Medical Staffing. Dublin: Stationery Office; 2003. [9] Consadine M, Dukelow F. Irish social policy, a critical introduction. Dublin: Gill and Macmillan; 2009. p. 265. [10] Kennedy P, Murphy-Lawless J. The maternity care needs of refugee and asylum seeking women in Ireland. Feminist Review 2002;73:39–53, 2003. [11] Central Statistics Office. Vital statistics third quarter 2008 – 17th June. Stationery Office; 2009. [12] Central Statistics Office. CSO population and labour; 2004. [13] Barrington R. Health, medicine and politics in the Republic of Ireland. Dublin; 1987. [14] Health Insurance Authority. Annual report and accounts. Dublin; 2007. [15] O’ Connor M. Conjuring choice while subverting autonomy: medical technocracy and home birth in Ireland. In: Symon A, editor. Risk and choice in maternity care; an international perspective. London: Churchill Livingstone Elsevier; 2006. p. 109–22. [16] Kennedy P. Maternity in Ireland, a woman-centred approach. Dublin: The Liffey Press; 2002.
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