Mick Wallace (Wexford, Independent)
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To ask the Minister for Health his views on the Confidential Maternal Death Enquiry in Ireland Report for the Triennium 2009-2011 which shows that the maternal mortality rate here is actually double the official figure from the Central Statistics Office; his plans to implement the recommendations of the Maternal Death Enquiry Ireland; and if he will make a statement on the matter. [57136/12]

James Reilly (Dublin North, Fine Gael)
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Statistics on the causes of death are based on civil registration and compiled internationally by the World Health Organisation, WHO. In the WHO's most recent world health statistics annual report 2012, Ireland had the 13th lowest rate of maternal mortality out of 178 countries reporting data. Maternal mortality is a rare occurrence in Ireland. It must be understood that since there are usually fewer than five such deaths per annum, rates can appear to fluctuate significantly from year to year.

This is particularly so in percentage terms. For example, an increase in deaths from two to four in a given year would lead to an apparent 100% increase in the maternal mortality rate. As such, reports based on data from different years can appear to be contradictory.

It is generally recognised internationally that official vital statistics can result in an underestimate of maternal deaths. In particular, indirect obstetric deaths resulting from previous existing disease or diseases that developed during the pregnancy may be missed in the official statistics. For this reason, Ireland established a confidential maternal death enquiry, MDE, system in 2009. In doing so, it linked itself with the United Kingdom's confidential MDE, which has been acknowledged as the gold standard for maternal death inquiries in recent decades.

It is important to emphasis that if data from a confidential MDE are used, the results can only be compared with the results from other similar inquiries. The recently published report of Ireland's confidential MDE for the 2009-11 period cannot be compared with the civil registration-based rates of other EU countries that do not have MDE systems. Comparisons with the UK's MDE for the 2006-08 period showed that Ireland's rate was approximately 30% lower than the UK's. However, caution must be exercised in interpreting this data because, even when aggregating three years of data, for example, 2009 to 2011, the number of deaths remains small and the rates will be subject to significant fluctuation.

Additional information not given on the floor of the House

Variances noted between various reports are a combination of differences in ascertainment - how maternal deaths are identified or found - and definitions. For instance, the international comparisons in table 2 of the MDU report reflect such differences in definitions, calculations, etc. The CSO figures in that table are for 2009 only, are based on live and stillbirths and are based on the date of notification of the death to the CSO. The MDE Ireland figures in that table are for the 2009-10 period, are based on hospitals identifying all women who died of direct and indirect causes and are based on the date the woman was delivered. It is important to state that no matter what definitions are used or how case ascertainment is conducted, Ireland continues to be a safe country for a woman to give birth in and our safety record compares favourably with other developed countries.

The purpose of any confidential inquiry worldwide is to learn lessons about how we provide improved care in the maternity services, which impacts on maternal outcomes. The recent MDE report for Ireland makes a number of valuable recommendations in respect of clinical care and the improved ascertainment of cases. The recommendations will be taken up by the HSE-institute joint working group on maternal mortality. In the short term, the national clinical care programme for obstetrics, which was put in place subsequent to the instigation of the work on this report, will collaborate with health professionals to ensure that all learning from inquiries into tragic events related to pregnancy will be incorporated into service delivery to continue to ensure that care for mother and babies is as safe as possible. As outlined in the MDU report, since its inception, MDE Ireland has promoted dissemination of recommendations from inquiry reports in order to inform health professionals and to improve maternity services.

I would like to emphasise the importance and benefits of confidential MDE reports in advancing quality and safety within the maternity services and such work will be taken into account in the implementation plan for the new patient safety agency.

Mick Wallace (Wexford, Independent)
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I accept that as the numbers are low, just a few can change the percentages dramatically. It is phenomenal that the numbers are so low. I was at each of my four children's births and find it difficult to believe that there are not more problems. The confidential MDE cites a figure that is twice that of the CSO's. For 2009 and 2010, there were 149,000 maternities and 12 maternal deaths in Ireland, a maternal death rate of eight per 100,000 for those combined years. Data on the number of maternities for 2011 were unavailable at the time of writing.

The first of the report's six recommendations calls for a question on pregnancy status at the time of death to be added to the coroner's death certificate. The second recommendation is that interpretative services should be developed to ensure that the care of any patient is not compromised by a lack of communication and any misunderstanding.

The Minister will be familiar with the case of an African woman, Ms Bimbo Onanuga, who died in March 2010. According to her partner, hospital staff would not listen when he repeatedly warned that her condition was deteriorating. It has been reported that 75% of maternities in Ireland in 2010 involved women of Irish nationality, yet 40% of all maternal deaths identified between 2009 and 2011 by MDE Ireland were among women who were not born in this country. That is a bit frightening.

James Reilly (Dublin North, Fine Gael)
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Clearly those statistics on how many births were to women of non-Irish descent must be examined further. If there was a disparity, it would be concerning.

I must agree with the Deputy, in that communication is essential. It is the cornerstone of clinical practice. If one cannot hear what the patient is trying to tell one, the chances of making a proper diagnosis and delivering a proper treatment and best practice are minimal. This is always an area of concern and we must be vigilant. In fairness to the Irish College of General Practitioners, it was the first college to introduce a communication module to its training. Communication should be taught during the training of all health professionals, including doctors, nurses, physiotherapists, etc.

Language barriers and cultural differences make a significant difference. Even those who speak English as their normal language use expressions that have entirely different meanings for other cultures. I could supply a few examples that would amuse the House, but doing so in a public place might not be proper. Not to make light of the issue, expressions have different meanings for different people even if the same words are used. I accept the Deputy's concerns on the issue of communication.

Mick Wallace (Wexford, Independent)
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I understand that if there is a maternal death in England, an inquiry is automatically held, which is not the case in Ireland. There will be an inquiry into Ms Onanuga's inquiry two years after her death. Would the Minister consider putting in place a structure under which inquiries into maternal deaths would be automatic?

James Reilly (Dublin North, Fine Gael)
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Without being categorical, my understanding is that there is an inquiry whenever there is a maternal death. Earlier this year, there were two such inquiries two days in a row at the same maternity hospital, something that had not happened for decades previously. Two different teams and theatres were involved and both investigations found that the deaths owed to different natural causes and were unrelated to specific practices in either case. Occasionally, there are bizarre coincidences in terms of when these tragic events occur.

To my knowledge, there is an inquiry whenever there is a maternal death. The MDE system has requested that the coroner's courts always report to it if any of their inquests involve a woman who has been pregnant.