The sequence of reports into maternal and baby deaths in the State, coming on top of a Health Service Executive update on the Savita Halappanavar tragedy, could be seen as a sign of deteriorating standards in maternal care.
With two of the deaths having their genesis in the same hospital, the Sligo Regional Hospital, expectant mothers and their partners could be forgiven for feeling additional anxiety around the outcome of pregnancy.
Statistically, maternal deaths here and in the UK are rare, as shown in a report this week from the joint confidential inquiry into maternal deaths. It showed maternal deaths have dropped from 11 to 10 per 100,000 women giving birth.
Covering 2009 to 2012 the report, led by the National Perinatal Epidemiology Unit at the University of Oxford, acknowledges the tragedy of each mother’s death by carrying out an in-depth investigation into each one.
Of the mothers that died, one third did so from causes directly related to the pregnancy.
These include sepsis, which killed Savita Halappanavar, and Hellp syndrome which led to the deaths of Dhara Kivlehan and Sally Rowlette at Sligo Regional Hospital.
‘Near misses’
And for the first time, the UK and
Ireland
report looks at the care of pregnant women who became severely ill but survived.
There are many lessons to be learned from these “near misses” as well as from those who died.
Significantly, more than two-thirds of women who died did not receive the recommended level of antenatal care.
It is often the failure to do the basics correctly that then creates an ultimately unstoppable train to a tragic outcome: in the case of Ms Halappanavar, not painstakingly recording pulse, blood pressure, temperature and respiratory rate meant that early signs of genital tract infection were missed; for Ms Rowlette it was a delay in administering treatment to tackle her rapidly escalating blood pressure and the absence of an intensive care consultant to direct her care when she was transferred to ICU post delivery.
The inquest into the death of baby Jamie Flynn found that signs that his mother's uterus was being overstimulated by a drug routinely given to speed up delivery were not acted upon.
A number of large studies carried out worldwide have concluded that some 10 per cent of hospital admissions are associated with an adverse outcome.
Most are not life-threatening, but the figure reflects the complexity of secondary medical care.
The research points to a “Swiss cheese model” when things go badly wrong – a series of individually minor omissions or errors line up together, the nipping in the bud of any one of which could have prevented death or serious injury.
Human error
But even the most highly trained health care professional will make human errors, so that demonising an individual who happens to be at the end of a long chain of events will not help: improving the system of care is what will ultimately reduce the rate of healthcare adverse outcomes. Which is why the continued monitoring of recommendations made by various inquiries into the death from sepsis of Savita Halappanavar is crucial.
In its progress report last week, the HSE was able to point to improvements.
However, it also revealed some necessary changes were still not in place. If these are not pursued to a satisfactory conclusion then her death and that of other mothers will have been in vain.
Having a baby in Ireland remains safe by international comparison. But the drive to make it even safer must be relentlessly pursued.
