Dr Rhona Mahony took over as the first female master of a Dublin maternity hospital in January of last year, attaining the mastership of the National Maternity Hospital in Dublin.

The future of the 119-year-old hospital was put on a more solid footing recently when its long-sought-after move to the St Vincent’s site in south Dublin was sanctioned by Health Minister James Reilly. While it could be at least five years before this project becomes a reality, Dr Mahony believes this is a crucial development for the State’s health service and for women generally. In an interview with Irishhealthpro.com, she said her main hope now during the remaining five years or so of her mastership is that the new home for Holles Street will come to fruition at St Vincent’s.

“We expect it to be at least a five-year project. The aim is to be not too much beyond the five-year mark. Essentially, we are building a new hospital within the existing hospital grounds at St Vincent’s.”

€150 million has been earmarked for the project, but this is highly unlikely to cover the full costs of what will be a substantial building project.

“It is an indicative figure. I think the first thing is to work out what is required,” Dr Mahony said.

“This is a project of really critical State importance and we would completely acknowledge the very difficult environment that the government is working in and also the additional difficulty posed by the IMF in terms of balancing the books, and this is not easy.”

Nonetheless, Dr Mahony says, the fact that it is written into the health service capital plan is significant. “It means this is a very serious project and so it should be.

“This will be a really significant development, not just for Holles Street but for women nationally, and I am very committed to that.”

Pressures on Holles Street

The announcement of the planned move to a new home comes at a time when the Holles Street site is finding it increasingly difficult to cope with infrastructural and funding pressures.

“We have had a large increase in our activity levels over the past six years. We have a moratorium on staff recruitment. We have had diminishing resources in terms of our budget, we have to some extent increasing patient expectations. Also we have increased expectations from our regulatory bodies such as HIQA, the HSE, etc. so when you put that all together that is quite a challenge.

“Looking back at recent years and where we are now, I think we have performed really well, considering all of these challenges, and the reason for this has been in our having a highly skilled and committed workforce.”

Rhona Mahony believes this survival against the odds has been a “good news” story. “While the effects of the recession have been really painful across all sectors of society, not just health, there are positives here too, and the fact that staff have stepped up to the plate so successfully gives me great hope and inspiration.”

Practical examples of the pressures Holles Street has been under include the placing of extra beds in wards.

“That has been difficult for patients in terms of privacy, and very difficult for staff who are managing in excess of the normal complement. What has also happened has been a push towards the public side of care and a big decline in private practice. Again this is a reflection of the current economy but that has put further pressure onto the public side, which was already under pressure. Our clinic numbers are very large indeed and doctors and midwives are working very hard to get through the volume that makes up our clinics day on day.”

Dr Mahony points out that Holles Street does not have the “luxury” of running up waiting lists or placing patients on trolleys.

“We have an ‘open door’ system. We work at peak all the time and we also have ‘super-peaks’ which are unpredictable. On April 5 this year, for example, we had almost 50 deliveries in the hospital, whereas normally we would have 25-30 per day. We don’t have the option of a waiting list or having a ‘trolley’ system.”

The number of births per year at Holles Street is currently around 9,000. “Our perinatal mortality rate is low – we are just under four per 1,000 for 2012 corrected for congenital anomalies, which is a phenomenal result.”

Is the level of litigation against maternity services affecting the provision of care?

“I think the current system [of seeking redress in cases of alleged negligence/adverse events] is not working very well. The courts are overwhelmed and the medical services are struggling to keep up with the volume of work. The current legal system is one of tort, that relies on finding fault in order to compensate. So, if you like, the ‘pillars’ of medical negligence are blame, litigation and punishment. Most doctors and midwives set out to do a good job, to care for their patients to the best of their ability. Not all adverse outcomes are the result of a person being negligent or careless, so it is very difficult for staff to be faced with the accusations and the personal questions raised about them when they go through a litigation case.

“It is extremely difficult for staff when they find themselves in a courtroom setting. We are not trained for that. Doctors and midwives by their nature are inherently self-critical, that is the way we are trained and so it can be very damaging for staff to go through this. 

“We actually now have a medical disorder called ‘medical malpractice syndrome’ suffered by clinical staff. The symptoms include anxiety, loss of appetite, depression, etc.” 

Dr Mahony says there is certainly quite a high rate of depression among doctors and midwives who go through the legal system.

“What we see in some cases, what I have seen directly and this hospital has experienced, is people changing their practice following a major case. They may either stop practising or avoid high-risk situations, or take early retirement. 

“That, of course, is not to say that where harm is done people should not be compensated. There are very clear-cut cases where an error has been made and it is imperative that patients are cared for and looked after – there is no issue with that. But in many cases the causation is complex, and so many days and weeks and years are spent arguing the toss in these cases.”

But the bottom line is, Dr Mahony points out, that if a patient is to be compensated then fault must be found under the current system.

“A doctor or midwife must be blamed and that is very difficult in this climate where everyone is working so hard and doing their best. This is also difficult for the patient, of course, who has to go through the system.”

“As regards solutions to this, there is no perfect system. You look at no-fault compensation, mediation etc, in other countries and it is not always as simple as it sounds. But I think we need to look in Ireland about how we can do it better.”

Major recent developments in maternity care

Rhona Mahony believes among the major developments in maternity care in recent years have been advances in terms of survival of pre-term infants.

“The good thing about our care for pre-term birth is we are managing very well to deal with babies born early once they are born. We understand the importance of in utero transfer, allowing the baby be born where the tertiary neonatal unit exists.

“We can give antenatal steroids to promote lung development; which makes a big difference in terms of respiratory distress and inter-ventricular haemorrhage, which are two big complications for pre-term births.

“We have now introduced magnesium therapy for babies as a neuroprotective element, which reduces the outcome of cerebral palsy in very pre-term babies. At term, the big development has been using therapeutic cooling for babies with neonatal hypoxic ischaemic encephalopathy (lack of oxygen during delivery) and that is reducing the incidence of adverse neurological outcome.”

However, there is still one issue that puzzles obstetric experts.

“We still haven’t got to the ‘holy grail’ of why women give birth early. Pre-term birth accounts for 75% of perinatal mortality and over 50% of the long-term adverse outcomes like cerebral palsy. We still don’t know why women go into labour when they do – it’s as basic as that.”

Governance structures

Holles Street’s governance structures are facing change with the rearranging of hospitals into groups and a drive to modernise voluntary hospital governance.

“We are still not quite sure how that will pan out. We are now part of the Ireland East hospital group. We are looking at how we can care for our patients in a network of hospitals and make things better in terms of services, but the detail is a little bit unclear at the moment.”

Does she agree with the Holles Street Governors Chairman, the Catholic Archbishop of Dublin, that the Holles Street governance structure is anachronistic, certainly in terms of having the Archbishop as chair of the board?

“I don’t think he meant this particularly as a critical comment. I think he was being relatively positive in terms of just allowing the hospital to create a modern environment. We have a very robust governance structure at board level and internally. And we have been updating and upgrading our governance structures.”

In the modern sense, Rhona Mahony says, the National Maternity Hospital is not a Catholic hospital.

“The Archbishop is very much a titular head. I have never met him. He has not in any way sought to interfere with hospital policy. We have a range of religions and ethnicities attending our hospital. And our staff are the same, so we do not see ourselves as a Catholic institution.”

The abortion debate

Dr Mahony played a prominent role in the debate leading up to the Protection of Life During Pregnancy Act.

She says the guidelines to be drawn up in line with the legislation will be very helpful in terms of the day-to-day operation of the legislation and will be very necessary.

“I think that is the step we are waiting for now and they will give clarity as to how this will play out. But again, very little changes practically with the legislation, despite the intense debate. This legislation does not change practice particularly, it very much copperfastens what existed already in terms of the Supreme Court’s interpretation of the Constitution. And it really just addresses the criminality that existed under the 1861 Offences Against the Person Act.”

As to whether further liberalisation of the law on abortion is likely in the longer term, Rhona Mahony says that would be much more a question for society than obstetricians.

“Obviously, the recently passed legislation was very medical. We were dealing with risk to life and therefore we had a role in that conversation, But in terms of liberalising and providing choice, that is a matter for society.”

Maternal mortality

Maternal mortality rates have been highlighted lately in the wake of the tragic death of Savita Halappanavar. Dr Mahony stresses Ireland’s rate is low by international standards.

“Our rate is somewhere around 8 per 100,000, in America it is about 24, in the UK it is about 12.5. I think we perform really well in terms of maternal mortality. What should be borne in mind is that we have much fewer resources than many other countries yet we are performing extremely well. We should never be complacent; the whole issue of maternal mortality is very much a global conversation and there is no sensible obstetrician practising in the world who isn’t very concerned about it. Most maternal deaths are related to issues like haemorrhage, high blood pressure, sepsis, clots in the leg or the lung.

“I think the new early warning system recently introduced for maternity care here will be very helpful.” 

Should it have been put in place some time ago? 

“There’s nothing new about an early warning system; we have always looked at blood pressure, pulse, routine respiratory rate, temperature, etc. These observations have been recorded for many years. 

“I think with the new system we will standardise care throughout the State and that is a very good thing. I think where we have adverse outcomes, the main consideration must be to learn and to put systems in place to prevent such a thing happening again. This is not always possible; obstetrics is very unpredictable, very challenging, but we must never waste any learning opportunity we get.

“We can spend a lot of time blaming people and looking for heads to roll but the most important thing is that we learn. I think a lot of lessons have been learned from the Savita Halappanavar case and will be carried forward, and that is as it should be.”    

Birth options

“We work hard to provide a range of birth options for mothers. We are the only maternity hospital in Dublin running a home birth service. Then we have the Domino service. We have midwifery-led clinics, we have doctor-led clinics, we have high-risk clinics. We have private options for patients if that it what they choose. We really do try to give women a range of choices they are comfortable with so that they can choose a package of care that suits their needs.”

As for her views on home birth, Dr Mahony says Holles Street has had a very good experience with its home birth scheme. “But it is very carefully regulated so we have very strict criteria as to eligibility for home birth and a very clear understanding that if a situation arises where we feel there is risk then there is a seamless transfer to hospital care.

“For first-time mothers, there is a very high transfer rate to hospital with home birth, up to 50%, and that merits consideration, but for women who may be having a second or third baby who are very uncomplicated it can work well. But obstetrics is unpredictable and things can sometimes go wrong very suddenly.”

As regards the view in some quarters that the HSE places too many restrictions on women seeking to have home births, Dr Mahony says this all comes down to a safety issue, which has got to be paramount.