Dr. Sharon Sheehan:

I thank the Chairman and members most sincerely for inviting me to give evidence on the future of maternity services in Ireland. I would like to start by introducing myself. I am the Master and CEO of the Coombe Women and Infants University Hospital, the largest provider of women and infant health care in the State. Last year, we delivered almost 9,000 babies. As well as being CEO, I am a consultant obstetrician and gynaecologist and have trained in both Ireland and the UK. I am a member of the executive council of the Institute of Obstetricians and Gynaecologists, a member of the Royal College of Physicians of Ireland and a member of the Royal College of Obstetricians and Gynaecologists in the UK. I am also a member of the national maternity strategy steering group, representing the joint standing committee of the Dublin maternity hospitals.

In looking at our maternity hospitals, we must remember that, thankfully, the vast majority of pregnancies result in a healthy mother and baby. We are on the verge of producing the first ever Irish maternity strategy and we must ensure that each child is given the best start in life while endeavouring to make the experience the best possible one for the mother. Ireland demonstrates one of the highest fertility rates in Europe and despite a recent small decline in the national birth rate, the maternity services are under increasing pressure. The complexity of mothers attending for antenatal care is ever-increasing.

Significant increases in rates of obesity, gestational diabetes, assisted reproduction and coexisting medical problems coupled with advancing maternal age continue to pose enormous challenges for obstetricians, midwives and other allied health professionals. Poor social circumstances and, more recently, homelessness, are adding to the complexity of patient care. Advances in neonatal care, particularly at the threshold of viability and the therapeutic cooling of the full-term infant to prevent cerebral palsy, are great success stories but the intensity and acuity of the workload must be recognised and resourced.

In recent years, maternity services have rarely been out of the media spotlight. Much work needs to be done to restore public confidence in our maternity services. We must acknowledge what is working well and what needs to be improved. When we look at maternity services, we cannot ignore gynaecology. Gynaecology is provided in all of the 19 maternity units throughout the country. Following the very successful introduction of the national cancer control programme, the increase in benign referrals transferred to non-cancer services spiralled out of control in the absence of resources. Waiting lists for gynaecology outpatients are wholly unacceptable, often exceeding 18 months, but we simply do not have the staff to bring down these numbers.

In respect of quality and patient safety, perinatal death rates continue to decline and maternal death rates are among the lowest in the developed world. Despite the low rates, we cannot become complacent. A death is a tragedy and we must learn from it and drive improvement and change. From the most recent confidential enquiry into maternal deaths across Ireland and the UK published in December 2014, we know that the majority of women who died during or after pregnancy died from indirect causes, that is, from an exacerbation of a pre-existing disease. Three-quarters of the women who died had medical or mental health problems before they became pregnant. We must plan for the care of women with known medical complications, particularly before they become pregnant, and also during their pregnancy. Only one third of women died from direct complications of pregnancy such as bleeding.

A spotlight has been shone in the past decade on severe maternal morbidity as an important quality indicator of obstetric care and maternal well-being in high-resourced countries. Learning from morbidities is really important - looking at what went wrong and what went well. One of our colleagues, Dr. Michael Geary, refers to "great saves" rather than "near misses" - recognising when patients have received exceptional care and when this care has averted an adverse outcome. Review and oversight in respect of the provision of high-quality maternity services are really welcome. Each of the three Dublin maternity hospitals produces annual clinical reports which are not only published but externally assessed and peer reviewed each year. In addition, each of the 19 maternity units submits data relating to patient safety and quality of care to a number of national agencies for review, including the State Claims Agency, the National Perinatal Epidemiology Centre and the quality assurance programme of the HSE clinical care programme in obstetrics and gynaecology. These allow assessment of performance over time and but even more importantly, they allow us to benchmark our performance against other similar units nationally.

In designing models of maternity care for the future, the principles of access, equity, appropriateness, effectiveness and value must be considered. All women should expect and receive high-quality, safe care delivered in the most appropriate setting by the most appropriate care provider based on the needs of the woman and her baby. Care must be patient-centred and evidence-based and allow the patient choice. In Ireland, most maternity care is hospital-based. Much of this antenatal and postnatal care could and should be delivered in the community. Community midwifery services in Ireland are patchy and are largely confined to the Dublin maternity hospitals, allowing the woman to access care close to home and, most importantly, permitting continuity of care, usually with a team of midwives.

It is not surprising that demand for these services is increasing. A nationwide solution must be put in place to resolve this issue.

Collaboration and teamwork are essential for the delivery of a safe and high quality maternity service. Too often we get lost in debates on midwifery-led care versus consultant-led care, high risk versus low risk, consultant-led units versus midwifery-led units, or alongside midwifery-led units, or stand-alone midwifery-led units, and home birth versus hospital birth. If we revert to the principle of what a woman and her baby or babies need and providing that care, then the pathway becomes much clearer. Every single woman, irrespective of her risk, deserves midwifery care during pregnancy. Clinical care pathways facilitate the seamless transition of a woman across health care providers and services based on her needs at a particular time.

In looking at models of care it is important to define standards. At present the standards of care throughout the country are inequitable. By way of example, international best practice recommends that every mother has a scan early in pregnancy to confirm her dates and again a little later to assess any foetal problems. These standards are only being delivered in a handful of maternity units throughout the country which is wholly unacceptable.

The promotion of normality must also be balanced with the need for escalation in the event of an obstetric emergency. It is important to define levels of care and determine what level of care should be provided in each hospital. It is completely inappropriate to suggest that all maternity units should be able to offer high-tech intensive care facilities, but we must guarantee and ensure there is streamlined access to critical care at a time when it is most needed. The national neonatal transport system is a great example and has been hugely successful. It aims to provide all neonates who require critical care transport with access to a dedicated, highly professional and equipped team that is available at all times of the day or night. A similar programme for in uterotransfers is urgently required. Both of these transport systems must have dedicated and ring-fenced funding.

In terms of the staffing of maternity services, an integrated approach to workforce planning is required. In addition to midwives and obstetricians, a host of other specialists and specialties interact with the mother or her baby during their time in maternity service care. They include neonatologists, anaesthetists, general practitioners, perinatal mental health physicians, perinatal pathologists and other allied health care professionals. Therefore, investment in staff is paramount. We have a highly skilled and talented workforce in Irish maternity services. Internationally our doctors, nurses and midwives have always held the reputation of being the best educated and trained, so it is not surprising that other countries look to our highly skilled doctors, midwives and nurses to staff their maternity units.

Staffing levels in maternity services in Ireland are a major concern. The lifting of the moratorium in HSE hospitals has resulted in a significant movement of staff away from voluntary hospitals. More recently, financially rewarding and attractive packages offered in the Middle East have attracted our highly trained and skilled staff. Of greatest concern to me are the unfilled places on the bachelor of midwifery university degree programmes and the higher diploma of midwifery programmes.

A recent study, entitled Birthrate Plus, reviewed the appropriate staffing levels in Irish maternity units. I understand that the funding requests for the additional posts deemed necessary to achieve minimum staffing levels have been made to the Department of Public Expenditure and Reform. Such funding must be approved but we need a robust national recruitment strategy to attract midwives to take up these posts.

Our hospitals continue to face ongoing challenges in terms of the European working time directive for non-consultant hospital doctors. There are insufficient numbers of NCHDs working in maternity services to achieve compliance. The 20% reduction in training time that would result from a 48-hour week has not been adequately addressed.

Last June a supplementary report on consultant workforce planning in 2015 was published by the HSE's national clinical programme for obstetrics and gynaecology. It showed that Ireland has the lowest number of obstetricians and gynaecologists per 100,000 women and the lowest per 1,000 live births of all OECD countries. The report states that there is somewhere between 120 and 140 consultant obstetricians delivering services in our maternity units. It recommends that an additional 100 new consultant posts are required to bring us in line with our UK counterparts. Promotion and integration of education, training, research and innovation are essential components of high quality clinical care and should be included in all clinical strategic considerations and planning.

In terms of governance, all women should have a clearly identifiable lead health care professional. We need to realise that patient safety is not only a clinical responsibility but is also a corporate responsibility. Any model of care proposed must be founded on the principles of good corporate and clinical governance and have a strong leadership to drive clinical excellence, quality, safety and clear accountability. I firmly believe that the mastership model operating in the three Dublin maternity hospitals works extremely well and should be maintained and expanded to the hospital groups.

In terms of systems, there is wide acceptance that teamwork and good communication are essential, but there is increasing evidence to suggest that systems can either obstruct or support collaboration. Therefore, organisational design must support effective collaboration.

Kofi Annan has said that knowledge is power and information is liberating. Therefore, investment in information technology is essential. Many of the 19 maternity units have no ICT system whatsoever and data must be collected manually. At present, data are collected through the national perinatal reporting system and the hospital inpatient enquiry scheme, HIPE. More recently, the Irish maternity indicator system has begun to collect data which highlight the lack of consistency across the different systems. I welcome the new maternal and newborn clinical management system which has an expected roll-out date of early 2016 to four of the 19 maternity units.

Ireland has an international reputation for quality research on maternity services. Advances in medical research and technologies must be supported. Maternity care in the future is likely to involve early innovative screening for biomarkers to detect pregnancies that are at risk of potentially life threatening conditions such as pre-eclampsia and other pregnancies most at risk.

In terms of funding, our maternity units have suffered from chronic under-investment. Numerous reports and recommendations for improvements in quality and patient safety have been produced but never funded or implemented. We cannot allow this cycle to be perpetuated. Maternity is a demand-led specialty, there are no waiting lists and we cannot cancel clinics or close wards. In addition, our emergency rooms are neither recognised nor resourced. There is a lack of transparency about the funding mechanism for our hospitals. I welcome the new funding models of activity-based funding and money follows the patient. However, historical under-funding and deficits which have accrued over the years must be addressed if we are to move forward.

In terms of location and our facilities, maternity facilities must be fit for purpose with infrastructure that is appropriate for clinical needs. It is inappropriate to have bereaved mothers sharing a room or a ward with newborn babies. It is inappropriate to have mothers who are miscarrying sitting alongside mothers with buggies while waiting for hospital appointments. That is what is happening to some mother as we sit here at this committee. Funding for the business cases to redevelop our units must be prioritised and made available in advance of any proposed relocations in order that we can deliver a humane service to mothers.

To summarise, the national maternity strategy along with all of the other reports must not be allowed to sit on bookshelves gathering dust. The strategy will only be as good as the plan designed to implement it.

We have a poor track record of implementation of reports and recommendations and I urge the Minister for Health, the Department of Health and the HSE to prioritise, fund and support the full implementation of this strategy. If I could leave the committee with just one message today, it is that investment in our maternity services, namely, investment in models of care, technologies, equipment, facilities and, most important, our staff, must be prioritised.

I thank the committee for giving me the opportunity to present my views today and look forward to answering any questions the committee might have for me.