By Niall Hunter

Three maternal deaths were recorded at Dublin's Rotunda Hospital last year, it has been revealed - a total of 13 mothers have now died who were under the care of the hospital over the past five years.

The Rotunda's latest clinical report, for 2013, shows an upsurge in maternal deaths at the hospital since 2009, when two mothers died. This was followed by three deaths in 2010, three again in 2011, two in 2012 and three in 2013.

Only two maternal deaths were recorded at the Rotunda over the previous five years, between 2004 and 2008.

According to the most recent maternal death figures for the other two Dublin maternity hospitals, the Coombe recorded five mothers' deaths in the four years 2009 to 2012, while Holles Street recorded four deaths during the same period. The Rotunda recorded 10 maternal deaths during the same period, in adddition to the three last year.

Between 2004 and 2013 the number of babies born at the Rotunda has increased from 6,731 to 8,841, while the number of mothers delivered in 2013 was 8,648. The current number of deliveries at the Coombe is just over 8,400 while it is around 8,700 at Holles Street.

Two of the three deaths* of mothers recorded at the Rotunda last year were due to pulmonary embolism. A coroner's report on the third death was being awaited when the Rotunda report was being published - this woman died in a general hospital having collapsed and having complained of severe headache following a ‘silent miscarriage'.

The Rotunda's rate of maternal mortality is now 16.2 per 100,000 births, while the national rate in Ireland is approximately eight per 1,000.

According to the most recent national figures from the HSE, 10 women died while under the care of maternity units in 2012.

In an interview late last year with irishhealth.com, Rotunda Master Dr Sam Coulter-Smith said despite the relatively high number of maternal deaths at the hospital in recent years, this did not necessarily indicate a trend.

"Maternal mortalities are rare; they are almost always one-off events. You rarely get the same set of circumstances occurring twice. It is often difficult to establish trends. You need to look at much larger numbers to see what those trends are."

Writing in the latest Rotunda clinical report, Dr Coulter-Smith said the Rotunda now looks after 2,500 more women than it did 10 years ago and on one day last year there were 47 deliveries in the hospital.

This, he said, was ‘a completely unacceptable level of activity', given the resources available to the hospital.

Dr Coulter-Smith said the Rotunda was seeing an increasing number of complex maternity cares, with 10 patients transferred to the Mater intensive and high dependency care units in 2013.

He said as the Rotunda was not co-located with a major acute hospital it had no immediate access to intensive care facilities. Given the highlighted issues around deficiencies within the country's maternity services, this was completely unacceptable in a country that purports to have a modern health service, Dr Coulter Smith said.

He added that despite representations made to the HSE and Department of Health, little had been done in terms of making progress on improving infrastructure, services or staffing levels in the maternity sector.

The corrected perinatal mortality rate last year, when congenital abnormalities are excluded, was four per 1,000, which was very much in line with the hospital's results of recent years, according to the report.

* The maternal deaths last year are detailed in the 2013 clinical report as follows:

1. Mother age 37 with four previous pregnancies. Past history of depression and intellectual disability. Unsuccessful ECV (procedure used to turn a fetus from breech position) at 37 weeks, booked for elective caesarean - uneventful delivery and postnatal care. Given drugs to prevent thrombosis. Seen by mental health, GP and community liaison teams. Forty-seven days after birth the mother was taken by ambulance to a general hospital with difficulty breathing; she suffered a cardiac arrest on the way to the hospital and was pronounced dead at the ED. A coroner's post-mortem recorded the death as being due to pulmonary embolism caused by deep vein thrombosis of the leg and pelvic veins.

2. Mother aged 34 with three previous pregnancies plus miscarriage. Two previous caesarean sections. Early scan revealed oligohydramnios, a condition where there is a low level of amniotic fluid; there was also a low-lying globular placenta. The baby, weighing just under two pounds, was delivered by emergency caesarean at 26 weeks. Placenta acreta found, whereby the placenta attaches to the uterine wall; patient transferred to high dependency unit; blood loss of 1,200 mls. Maternal collapse one day post-delivery; transferred to Mater Hospital intensive care unit, where she deteriorated steadily and died four days post-delivery. Coroner's post mortem recorded the death as due to massive pulmonary embolism.

3. Mother aged 39, with four previous caesareans and four previous terminations of pregnancy; past history of neonatal death from trisomy 18 - a chromosomal defect. The woman was also HIV positive. When she presented at nine weeks gestation the scan showed no fetal heartbeat - a ‘silent miscarriage' was diagnosed, whereby the fetus dies but the body does not recognise this and fails to expel the pregnancy tissue. An ERPC (evacuation of retained products of conception) was carried out. Five days later the patient presented to ED with significant and worsening headache. The woman was then referred to the Mater Hospital for assessment; some days later she was admitted to and died at Connolly Hospital having collapsed. The report says the coroner's post mortemreport is awaited on the cause of death.