Professor Richard Greene:

On behalf of Maternal Death Enquiry Ireland I propose to explain the background to this issue and outline the very good health care that is available to women in Ireland. Maternal Death Enquiry was established in the 1950s in the United Kingdom and has since then produced a number of good reports which have improved the care of patients in obstetrics. Ireland became involved on the basis of the scientific approach taken to ascertaining the causes of maternal deaths and because we could learn more by being part of a larger cohort of patients or, unfortunately, deaths of patients. In 2007, we established a working group to initiate a confidential inquiry with the support of the then Department of Health and Children, the HSE, the Institute of Obstetrics and Gynaecology and other interested parties. The inquiry commenced in 2009.

I will now speak briefly on the definitions of maternal death. We refer to direct deaths as those resulting directly from pregnancy. Indirect deaths result from diseases which existed prior to or developed during pregnancy and were aggravated by the physiological effects of pregnancy. Coincidental deaths are those where the pregnancy was only coincidentally related. As it is difficult to identify the nominator when calculating maternal mortality rates, we take the figure used in the United Kingdom, namely, 100,000 maternities or those women who deliver babies alive or older than 24 weeks and stillborn.

The great value from undertaking this inquiry is that the case ascertainment in confidential inquiries internationally has been shown to detect somewhere of the order of 1.5 to two times the number of maternal deaths found in civil registration procedures. There are many reasons for this discrepancy. Confidential inquiries are also valuable because they can assess the causes of death and identify whether lessons should be learned in terms of altering care or improving outcomes for women during pregnancy.

We have carried out comparisons in Ireland with the CSO's figures. Maternal mortality in Ireland is often touted as being low compared to other countries. The triennial report for 2009-11 identified 25 maternal mortalities based on the scientific approach of the maternal death classification system. Of these mortalities, six were classified as direct maternal deaths or associated directly with pregnancy, 13 were indirect maternal deaths and the remaining six were attributed to coincidental causes. During this period there were 225,136 maternities in Ireland, giving an overall rate of 8.6 maternal deaths per 100,000. It is important to note from a care point of view that there was no evidence of clustering in any hospital. The exercise should be treated with caution given that it is the first time to attempt it in Ireland and perhaps some cases were not identified but we have received a phenomenal response from clinicians not only in maternity units, but also general hospitals. Our maternal mortality rates compare favourably to our nearest neighbours if we use the same classification system. During the period in which Ireland experienced 8.6 maternal deaths per 100,000 maternities, the UK experienced a rate of 11.3. If one takes international civil registrations of maternal deaths, Ireland again has a comparatively low rate of maternal deaths.

In regard to causes of maternal deaths, direct deaths are closely associated with pulmonary embolism, or clot to the lung, amniotic fluid embolism and multi-organ failures secondary to a condition called HELLP, which is associated with pregnancy. Indirect causes included cardiovascular disease, influenza including the H1N1 variant, epilepsy, chronic obstructive pulmonary disease and bleeding esophageal varicose veins.

There were also two suicides, one of which occurred during pregnancy and the other during the postpartum period after the woman had delivered her baby. Both cases were well known to the psychiatric services and under care. The notifications for 2012 have also identified three women who committed suicide around the time of pregnancy, one during pregnancy and two post-delivery, all of whom were known to the psychiatric services. This indicates that pregnant women in Ireland are availing of a very high level of health care. While these figures are inevitably a factor of Ireland being a wealthy country with a highly educated population and excellent health care system, it is important that women understand this country has very good results. We need to take away some of the scare concerns the public has.

The value of the confidential inquiry is that we have a really good baseline for one of the markers for maternity care in Ireland and it shows that we are doing exceptionally well. We do not have information on whether termination of pregnancy has reduced or otherwise affected these figures. Inevitably it is part of the total health care package that will continue to assist women in having, I hope, successful pregnancies.