Billy Kelleher (Cork North Central, Fianna Fail)
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The second Maternal Death Enquiry, MDE, Ireland report has just been published at UCC. It makes the point that due to the relatively small number of maternal deaths in Ireland, fluctuation in annual mortality rates is inevitable and should be treated with caution so rates for maternal deaths, MMR, occurring in Ireland are presented in the UCC report over three-year periods. For the three years from 2009 to 2011, the maternal mortality rate was 8.6 per 100,000 maternities, while for the three years from 2010 to 2012, the maternal mortality rate was 10.5 per 100,000 maternities.

It is clear that the apparent increase in mortality rates between the years 2010 and 2012 is not statistically significant and is similar to that of the UK. For the years 2009 to 2012, 38 maternal deaths, occurring during or within 42 days of pregnancy end, were reported to MDE Ireland, of which ten were classified as direct deaths - due to obstetric causes; 21 were classified as indirect deaths - due to pre-existing medical or mental disorders which were exacerbated by pregnancy, and the remaining seven were attributed to coincidental causes - not due to direct or indirect causes. Thus, the majority of deaths were from indirect causes, namely, from pre-existing disorders exacerbated by pregnancy.

The report states that for the years 2009-2012 case ascertainment by MDE Ireland - direct, indirect and coincidental - was four times that of the civil death registration system as per information recorded by the CSO. It also states that this is not unique to Ireland as underestimation of maternal deaths using civil death registration systems, even in developed countries, has been acknowledged by the World Health Organisation. The majority, 60%, of direct maternal deaths occurred in an intensive care unit, ICU, with no direct deaths occurring outside the hospital setting. Women born outside of Ireland were over-represented in reported deaths, reflecting UK findings of an increased risk of maternal death among migrant ethnic minorities. There was also a suggestion of an increasing maternal death rate mong older women. Based on these findings, MDE Ireland makes nine recommendations.

I am inquiring this evening as to whether the Department of Health and the HSE propose to act on these nine recommendations which are: that all health care professionals within the Irish maternity services should be aware of recommendations and lessons contained within the recent UK report, 'Saving Lives, Improving Mothers' Care - Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012; that all maternal deaths occurring during or within in one year of giving birth, ectopic pregnancy, miscarriage or termination of pregnancy should be notified to MDE Ireland in order to support the enquiry process; that a question on pregnancy status at time of death, similar to that on the medical death certificate, should be added to the coroner's death certificate; that interpretative services should be used to ensure that the care of any patient is not compromised by lack of communication and misunderstanding; that in the absence of co-location, establishment of a more effective communication system between general hospitals and maternity units in the event of a maternal death is necessary; that women with medical disorders should receive preconception advice and ideally have their medical conditions optimised prior to pregnancy - this will need to be provided by their GPs and specialist physicians in conjunction with the obstetric services; that pregnant patients with pre-existing medical and mental health disorders should undergo risk assessment at booking and should be afforded high priority by colleagues in other medical disciplines when referred for assessment; that maternity medical staff should review and audit current practice concerning the prevention and treatment of thromboembolic disease, giving consideration to the national guideline, and that consideration should be given to provision of a perinatal psychiatry mother and baby unit in Ireland.

Leo Varadkar (Dublin West, Fine Gael)
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I thank the Deputy for raising this issue. It is generally recognised internationally that official statistics can result in an underestimate of maternal deaths. In particular, indirect obstetric deaths resulting from pre-existing disease or diseases which developed during the pregnancy may not be recorded in official statistics. For this reason, Ireland established a confidential maternal death enquiry, MDE, system in 2009. In so doing, it linked itself with the United Kingdom's confidential MDE, which has been acknowledged in recent decades as a gold standard for maternal death enquiry.

The most recent MDE report, published this month, shows 38 maternal deaths during or within 42 days of pregnancy between 2009 and 2012, of which ten were classified as direct maternal deaths, 21 were classified as indirect maternal deaths due to pre-existing medical or mental disorders which were exacerbated by pregnancy, and the remaining seven were attributed to coincidental causes. There was no evidence of clustering in any one maternity hospital.

The report indicates that the maternal mortality rate for the three year period 2009-2011 was 8.6 per 100,000 maternities. This rate increased to 10.5 in the period 2010-2012. However, we must interpret this increase with caution. Ireland is a small country and, thankfully, maternal mortality cases are rare. Taking account of the relatively small number of deaths, fluctuation in our maternal mortality rates is inevitable, even where data are aggregated over several years. The experts who prepared the report note that the increase is not statistically significant. Our maternal mortality rate of 10.5 per 100,000 maternities compares with a rate of 10.01 in the UK. Again, the authors make the point that the difference in rates between the countries does not represent a statistically significant difference.

In conducting its confidential reviews into maternal deaths, MDE Ireland aims to promote safer pregnancy, identify learning points and use its findings to formulate and disseminate recommendations. It is imperative that the lessons learned from this research informs service development. Some of the issues raised by the report will be, therefore, particularly relevant in the context of service planning and delivery. Reports of incidents of maternal deaths in Ireland cause real concern to some women, their families and partners. It is important to reassure women and their families that maternal and perinatal health statistics indicate that Ireland continues to be a safe country in which to give birth and that our maternal mortality rates are on a par with the rest of the developed world. I should also point out that €2 million has been provided in the National Service Plan 2015 to further improve maternity services. Additional obstetricians, midwives and other staff will be appointed. This is against the backdrop of a falling birth rate. I hope this additional funding will drive further service improvement.

My Department, with the HSE, is currently working on the development of a new maternity strategy. The strategy will provide the direction for the optimal development of maternity services, in line with best international practice. It will be informed by a national review and evaluation of maternity services being undertaken by the HSE.

Billy Kelleher (Cork North Central, Fianna Fail)
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I thank the Minister for his reply and concur with him that our maternity services are very safe and on a par with the best internationally. In regard to the recommendation relating to ethnic minorities, I do not wish to be alarmist but in the context of the divergence in the statistics between the Irish and UK gold standard, will the Minister ensure greater monitoring in this area such that if there is a continuing divergence in these statistics remedial action will be taken? One of the recommendations is that there be proper interpretive services available in the medical arena to ensure people are aware of any underlying conditions in patients.

Leo Varadkar (Dublin West, Fine Gael)
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I often heard it said in the past that Ireland was the safest country in the world in which to give birth. However, the statistics never supported this. I am glad we now have the MDE statistics, which are calculated in the same way as in the UK. This shows, as I consistently say, that our maternal and perinatal mortality rates are on a par with the rest of the developed world. I am not so complacent as to think that we are the best in the world. I am pretty sure we are not. That is why we need to develop the maternity strategy and improve our services further. There may have been a complacency in Ireland in the past about the quality of our maternity services but that complacency is gone now. We are now striving to improve our services, which is backed up by the recruitment of more consultants and midwives than ever before at a time rate when our birth rate is falling. We still have a long way to go, in my view, to get to the point where every woman's pregnancy is managed by a senior decision-maker, be that a senior midwife or senior consultant. That is where I would like us to be in the future.

The point made by the Deputy in regard to ethnic minorities is well made. It is well recognised across the world that people from ethnic minority groups suffer inferior health outcomes. This is often down to issues around language and interpretation. It is also often a cultural issue or due to the fact that they tend to present later to doctors during the course of their illness or, in this case, during the course of their pregnancy. It is a matter we will continue to monitor. Again, this is by no means unique to Ireland but is a matter of which I am sure we need to remain conscious.