The Shape of Maternity: Recommendations for Reform in Maternity Care #repealthe8th

It is now 21 years since the 8th Amendment. However there are other dates to remember when considering the experience of pregnant women in Ireland. It is also eleven years since Michael Neary was struck off the medical register. Eight years since Judge Harding-Clarke’s report into obstetric practices at Our Lady of Lourdes Hospital Drogheda. It is sixteen years since the first complaints against Dr. Neary and his colleagues were registered with the North Eastern Health Board by midwives at the Lourdes Maternity Unit. It is sixteen years since Returning Birth to Women was published. It is twenty years since the publication of the report by the Maternity and Infant Care Scheme Review Group. It is sixteen years since the Maternity Services Review Group – the Condon Group – was convened. It is twelve years since the Maternity Services Task Group was set up. It is sixty years since the Maternity and Infant Care Scheme was launched. It is eighteen years since the last Magdalene Laundry closed. It is thirty years since Ann Lovett’s body was found by a grotto. It is approximately twenty years since the last symphysiotomy was performed. It is a year since the Walsh Report into the practice of symphysiotomy at the maternity units in the Greater Dublin Area was published. It is four years since the death of Bimbo Onanuga (whose partner was informed her cries of pain were “exaggerated”) of a ruptured uterus. It is two years since the death of Savita Halappanavar of sepsis. It is one year since the deaths of Sally Rowlette and Dhara Kivlehan (whose husband was told it was hard to tell if she had jaundice because she was Indian) at Sligo General Hospital. It is six months since Ms Y first discovered she was pregnant and two months since she underwent pre-term induction. It is one year since the Protection of Life During Pregnancy Act passed into law. It is twenty years since the X case, sixteen years since Miss D discovered her baby had fatal foetal abnormalities and six months since the UNHCR described Ireland’s historic treatment of pregnant women as “degrading and inhumane”. Continue reading “The Shape of Maternity: Recommendations for Reform in Maternity Care #repealthe8th”

The Shape of Maternity: Recommendations for Reform in Maternity Care #repealthe8th

“There’s a lot to think about”: A note on quality assurance in Irish reproductive health care.

We are pleased to welcome this guest post from Dr. Deirdre Duffy, Lecturer in Social Science at Edge Hill University.

Given the tendency of debates regarding abortion, reproductive rights and the management of obstetric care in Ireland to veer between impersonal moral hypothesising and personal case study analysis, I wish to start this note with an anecdote. When I announced my first pregnancy to my mother, among her many observations was that – based on her experience having and raising seven children – when it comes to pregnancy (before, during and after), there’s a lot to think about. Glib as this may seem to some, this observation has stuck in my mind  throughout the present debate on the management of and provision of care during pregnancy, as an invisible, but crucial, part of the discussion.

Quality assurance frameworks and antenatal care in Ireland

The issue of consistent quality assurance is of central import to health care provision and management. In light of continual references to ‘clinical best practice’ and the obvious confusion regarding what this involves on the part of front-line staff, it is important to question not just what ‘best practice’ is in the legal sense but how it is maintained in practice. There is an immediate need to analyse the practice of obstetric care in a more applied sense.

A key problem within the delivery of care in obstetrics in Ireland is the co-existence of discourses of ‘best practice’ which envisage maternity and antenatal care as both a simple and complex system. Antenatal healthcare is positioned as both:

  • a linear, treatment-oriented system (a simple system) with a discrete, single goal in mind (the birth of the unborn and survival of the mother) and
  • a complex system with multiple concerns, operations and without a definite end (reflected by the existence of post-natal care for example).

To see the co-existence of these models one need only look at the publications of the Healthcare Information and Quality Authority (HIQA). Following the death of Savita Halappanavar, HIQA conducted a critical evaluation of the case, with the stated aim of identifying both the causal factors behind Ms. Halappanavar’s death and make recommendations to improve services. Although the report claimed to take into account the complexity of antenatal care, it constructed a ‘story’ of antenatal care which is decidedly linear. Ms. Halappanavar entered into a system with a specific goal (to preserve her life and that of her baby) and this goal was not reached. In framing the main concern of the review as understanding why Ms. Halappanavar died, HIQA implicitly suggested that this was a straightforward case of mistreatment and there was a single outcome which was not achieved. The causal pathways it critiques and recommendations it makes are all intended to ensure that, in future, women entering into antenatal care reach the desired destination.

On the other hand, HIQA’s own guidance on designing research for monitoring and evaluating quality in healthcare emphasises the need to treat the health system as a multilayered agency. It advocates the use of multiple key performance indicators (KPIs) in assessments, reflecting the different levels at which healthcare operates – the individual, the hospital, the community etc – and the innumerable outcomes that can emerge from healthcare interventions (both physiological and emotional). In this way, HIQA presents the care system as inherently complex and advisers evaluators and policy-makers to conduct quality assessments and evaluations which reflect this complexity. Rather than look solely for the achievement of set outcomes, they should explore the dynamics of health service performance on multiple levels and identify the effects of performance at each level.

Set alongside each other, these reports suggest a degree of methodological confusion. In a review of antenatal care is the focus of the evaluation the achievement of a single outcome or to provide evidence on the dynamics of care at multiple levels? Is the primary concern “the Three E’s” – efficiency, effectiveness and economy – in the achievement of goals or is it the maintenance of high quality care at every level? To treat these aims as synonymous is a grave error from the position of both the practitioner and the quality assessor. An efficient antenatal care system may not best meet the needs of its patients. Effectiveness does not equate to care. Moreover when designing inquiry reports, what are evaluators meant to critically assess – whether set outcomes were achieved, how healthcare professionals acted or whether the needs of the patient were met at each level of care?

What this means for women and their families

All of the above seems quite technical. However within the technospeak there are, I feel, the two core issues for ensuring that antenatal care in Ireland is of high quality and demonstrates ‘best practice’:

(i) what does high quality care for pregnant women look like and

(ii) what are we looking for we are assessing the quality of care?

To date, the evidence on high quality care is sparse. Unlike the UK which has explicit quality assurance frameworks dedicated to outline high quality antenatal care, Ireland has no national model, independent of practitioner organisations. What we do have are the reports of inquiries where mistakes have been made (the Halappavanar report is one and the promised report on Miss Y another). These are a poor substitute; their focus is identifying mistakes, not on indicating what practice should look like.

The second issue is equally worrisome. Within the confines of the present debate the label ‘high quality care’ is seemingly attributed to interventions where the lives of the unborn and the mother are preserved. Antenatal care in Ireland, regardless of my mother’s pithy observation, does not have a lot of things going on. It is a simple system with a specific end point and set outcome to be reached through a linear treatment process. As a result, where, as in the Halappavanar case, the assessment of quality is designed in terms of exploring the individual’s pathway through the antenatal care system, then the implication will always be that there is a theoretical ‘correct pathway’ which ends in the achievement of specific outcomes.

Put simply, if Ms. Halappavanar had survived and been discharged, could her experiences been deemed indicative of successful care regardless of the psychological impact on and potential trauma caused to her and her husband? Or, applied to another example, as both Miss Y and her child are still alive, does that mean that her antenatal care can be labelled ‘of high quality’ despite the fact it has resulted in severe psychological trauma for her and potential physical difficulties for her baby?

Even without recognising the need for greater clarity in quality assurance frameworks, this implication suggests a certain callousness. The professes itself to be focused on care, but is overwhelmingly oriented towards the birth of the child at all costs. This suggests that the Irish commitment to care only stretches as far as the preservation of life. What happens after the baby is born (or not) and the experiences of women who come into contact with obstetric and maternity care are removed from consideration. If the woman and child are alive at the end, the system was successful. If being alive at the end of pregnancy is the best outcome we can expect then there is clearly something wrong. We deserve much better.

“There’s a lot to think about”: A note on quality assurance in Irish reproductive health care.

New Resource on UK and Comparative Constitutional Law

Rory O’Connell of Queen’s University Belfast Law School has set up a website which will be of interest to people teaching UK or comparative constitutional law. The website includes a chronology of events and sources relevant to constitutional law. The resource focuses on evens in UK constitutional history though also includes references to Irish, European, International and comparative developments.

The chronology is intended to help students in a number of ways. Continue reading “New Resource on UK and Comparative Constitutional Law”

New Resource on UK and Comparative Constitutional Law

Teen parents and Exclusion: Time for a Departmental Response

The publication of a highly critical report regarding the refusal by a Munster post-primary principal (identified only as School A) to admit a young mother by the Ombudsman for Children and Young People conveys both acutely negative and positive messages. Continue reading “Teen parents and Exclusion: Time for a Departmental Response”

Teen parents and Exclusion: Time for a Departmental Response

Moving past the UK riots: More youth clubs not police, please

The rioting in Tottenham, Brixton, Hackney and now parts of Liverpool, Bristol and Nottingham are the product of a complex mix of long- and short- term factors. One that few have mentioned is the shutting down of the places that have hitherto tried to help young people – the group that has taken the lead role in the violence following the shooting of Mark Duggan – deal with their day-to-day problems. In Haringey – the original locus for the disturbances over last weekend – for example eight of its thirteen youth clubs closed down between December 2010 and June 2011. Continue reading “Moving past the UK riots: More youth clubs not police, please”

Moving past the UK riots: More youth clubs not police, please

Internet 'freedom' and eG8

To be GOVERNED is to kept in sight, inspected, spied upon, directed, law-driven, numbered, enrolled, indoctrinated, preached at, controlled, estimates, valued, censured, commanded…at every transaction [to be] noted, registered, enrolled, taxed, stamped, measured, numbered, assessed, licensed, authorized, admonished, forbidden, reformed, corrected, punished.

It is…to be placed under contribution, trained, ransomed, exploited, monopolized, extorted, squeezed, mystified, robbed; then at the slightest resistanced…to be repressed, fined, despised, harassed, tracked, abused, clubbed, disarmed, choked, imprisoned, judged, condemned, shot, deported, sacrificed, sold, betrayed; and to crown all, mocked, ridiculed, outraged, dishonoured (Proudhon [1851], 1923: 294)

The above quote, part of Pierre-Joseph Proudhon’s 19th century revolutionary demands, leaves little to the imagination. Proudhon’s anti-establishment writings launch a remorseless assault on government – or, more accurately, governance – as anti-freedom and an Continue reading “Internet 'freedom' and eG8”

Internet 'freedom' and eG8

Respecting social housing

Following Tuesday’s Prime Time report on the deplorable condition of Ireland’s social housing stock, the Minister for Housing and Planning, Willie Penrose tried to defend the fact that NAMA’s ‘social dividend’ had still not emerged by commenting that “regeneration is more than bricks and mortar”. From Minister Penrose’s perspective, this counts as a satisfactory response. The failure of successive Governments to protect social housing tenants from the suffering acute effects of poor living conditions adequately is because housing policy is complicated. So complicated in fact that it’s about more than just housing.

Aside from the ridiculousness of such a pithy response, it is also paradoxical given Minister Penrose’s proposals for resolving the social problems associated with housing. Continue reading “Respecting social housing”

Respecting social housing

Innocent Illuminati: Moriarty and the Civil Service

Like most children of the 1980s, the Moriarty Tribunal (or the Tribunal of Inquiry into certain payments to Politicians and Related Matters) has been a bit-player throughout my politically formative years. Barely pubescent, my personal definition of ‘tribunal’ when Moriarty was convened in 1997 was a mish-mash of speeches by Disraeli and judgements by Pontius Pilate. I did not own a mobile phone, had only a vague knowledge of Esat, had never heard of Denis O’Brien and (rather embarrassingly) had paid no real attention to Minister Lowry other than to mentally place him in the “culchie” box (a world apart from the infinitely more cultured, cosmopolitan North-East). Continue reading “Innocent Illuminati: Moriarty and the Civil Service”

Innocent Illuminati: Moriarty and the Civil Service

Election 2011: Why we need to talk about public sector reform

The next election is expected to change Ireland’s political landscape. The leading parties’ proposals include plans to dissolve the Seanad, decrease the number of TDs, to extend the number of working days of the Dáil and massive public service reform. But despite the political grandstanding over institutional reform – apparently it’s a necessity and will save the world – to date there has been very little said about what this means exactly. Apparently there are serious discussions to be had but public sector reform is not one. Continue reading “Election 2011: Why we need to talk about public sector reform”

Election 2011: Why we need to talk about public sector reform

Budget 2011: Young people and youth services

Children and young people have been one of the biggest losers in Minister Lenihan’s ‘austerity budgets’ and Budget 2011 is no different. With predicted “savings” of €307m from the Education and Skills budget, €765m from the Health and Children budget and reductions in Jobseeker’s Allowance, Supplementary Welfare Allowance (for the 22-24 age bracket) and Rent Supplement payments, yesterday’s budget has augmented the problems children and young people already struggle with. The diminished financial support available to young people leaving second-level education will serve to restrict the opportunities available to many, forcing them (and their parents) to make very difficult decisions regarding their future prospects. Continue reading “Budget 2011: Young people and youth services”

Budget 2011: Young people and youth services