"The Importance of a Birth Trauma Inquiry in Ireland"

Following the conclusion of the first-ever parliamentary inquiry into birth trauma in the UK, mothers and groups representing those who have experienced a traumatic birth in Ireland, have called on the government to conduct a similar inquiry, as part of its Women's Health Action Plan.

The Action Plan's stated aim is to integrate women's voices in policy-making through initiatives like a new Radical Listening exercise, a Patient Voice Forum, and conducting new research and outcomes analysis. It is now argued that the only way for women's voices to truly be heard, is through an independent root-and-branch inquiry into maternity care and postpartum care for those who have been traumatised.

The UK Inquiry

The UK inquiry has exposed "shockingly poor quality" of care in a maternity system plagued by overwork and understaffing. The All-Party Parliamentary Group on Birth Trauma received over 1,300 submissions from parents and nearly 100 from maternity professionals, detailing severe incidents such as stillbirths, premature births, cerebral palsy caused by oxygen deprivation, and severe injuries to women. Many of these traumatic events were due to errors before and after labour, often covered up by hospitals.

The inquiry highlighted systemic issues such as failure to listen to women, lack of informed consent, poor communication, insufficient pain relief, and inadequate handling of complaints. Reports detailed women being ignored, mocked, denied pain relief, and subjected to non-consensual interventions. Poor postnatal care and cases of severe birth injuries causing lifelong pain and incontinence were prevalent. Birth notes were often falsified or lost, and many women were diagnosed with post-traumatic stress disorder due to their experiences.  The OASI care bundle, aimed at reducing childbirth injuries, has shown success but has not been widely implemented.

In light of these findings, major investigations into maternity care failings have taken place at several NHS trusts, and nearly half of England’s maternity units have been rated as "inadequate" or "requires improvement" by the Care Quality Commission.

The inquiry has urged the UK government to implement a national maternity improvement strategy, overseen by a new maternity commissioner reporting to the prime minister. Key recommendations include increasing the recruitment and training of midwives, obstetricians, and anaesthetists, providing mandatory trauma-informed care training, and ensuring universal access to specialist maternal mental health services.

The Irish experience

Unsurprisingly, advocacy groups for improved maternity services, and women in Ireland affected by birth trauma are calling for a similar inquiry to be established; one that is independent of the Health Service Executive, so that there can be utmost confidence that it is impartial in its analysis. They have asked that the results of such an inquiry be published in a full, transparent manner, so that not only clinicians but the public can understand the scale of the problem, and what is required to improve maternity care, and care for women who have experienced a traumatic birth.

In 2016, the National Maternity Strategy 2016-2026 and the National Standards for Safer Better Maternity Services were developed.  Its stated aim was the  delivery of improved maternity care. Safer Births Ireland, an advocacy group for those who have been injured, and families of those who have died in childbirth, believe, serious systemic problems persist in Ireland's maternity services. In recent years, several HIQA and HSE reports and reviews into maternity care including bereavement care have highlighted service deficits and failings in Irish maternity services.

Safer Births Ireland's research found there have been 45 neonatal deaths or stillbirths since 2013, but there may well be more that the group are not aware of. Of those 45:

• 19 involved issues with CTG recording and monitoring;
• In 14, there were delayed deliveries;
• In 13, there had been a delayed diagnosis of one or more conditions;
• In 6, the signs of labour were missed, including where mothers' concerns that they were in labour, were dismissed;
• In 2, there was a diagnosis of vasa previa.

Of note, in more than one instance, the death occurred during a delivery with bank holiday weekends due to staff unavailability.

In a 2022 survey of perceived traumatic birth experiences in an Irish maternity sample of approximately 1,100 women, it was found that there was a prevalence of 18% of women experiencing birth as traumatic. The majority of women were found to be resilient to birth trauma, and while few developed PTSD, a larger cohort had "significant functional impairment associated with sub-clinical postpartum PTSD symptoms." Taking the most recently available annual figure for births in Ireland (2023) of 54,411, this could mean that as many as 9,800 women experience a traumatic birth in Ireland every year. The women affected, and their families would continue to be impacted psychologically, socially, financially for months, and possibly years after the trauma. 

The survey authors recommended that maternity care providers should be aware of the risk factors for traumatic birth. They also recommended considering the introduction of a trauma-informed approach amongst midwives and maternity care providers in the postnatal period to detect emerging or established persisting trauma-related symptoms.

In recent weeks, mothers from around Ireland bravely shared their stories  on Newstalk, detailing the physical trauma, emotional distress, and the lack of empathy and information they received from healthcare providers. One nurse recounted her own difficult pregnancy experience, where she felt blamed and dismissed by HSE staff, endured procedures without consent, and faced critical health issues without adequate communication.

Some steps have been taken to improve maternity services and sharing of information among hospitals, such as the creation of the Obstetric Event Support Team (which it must be noted, was strongly resisted by the Dublin maternity Hospitals). The OEST was established in August 2021 as a “support service” following serious adverse events in obstetrics and aims to yield learning for national response, according to the HSE. The OEST sits within the HSE’s National Women and Infants Health Programme (NWIHP). The NWIHP was established in January 2017 to develop and strengthen delivery of maternity, gynaecology, and neonatal services nationally. 

In regard to quality and safety, a key component of the NWIHP’s work is to support best practice and standardisation. The OEST is a strand of work that deals with the most catastrophic incidents in maternity services, which have the highest human and financial costs.

HSE review into perinatal deaths between 2021 and 2023.

The HSE announced last week that it plans to conduct a review into the circumstances of deaths of newborn infants between 2021 and 2023, before extending the investigation into deaths that occurred in earlier periods. The HSE has said that as part of this review, case notes will be assessed by "expert assessors" from obstetrics, midwifery, etc. The terms of reference for this review are yet to be agreed and will be organised by the National Women & Infants Programme. It remains to be seen whether  the National Women and Infants Programme will seek the input of advocacy groups such as Safer Births Ireland, or the Association for Improved Maternity Services when setting the terms of reference.

It is expected that there will be public and patient involvement in the process, which is welcome, but clarity is still required on what form that involvement will take. In the context of the Interdepartmental Working Group on Medical Negligence Costs, the public's involvement was limited an invitation to make online submissions to a Group composed entirely of doctors, HSE and State Claim Agency managers.

Given the inquiry will consider neonatal deaths as recent as 2023, it is possible that the records which fall to be investigated by thereview team, will include those relating to deaths that are the subject of ongoing litigation. This raises a serious concern in that parents understandably may not want 'independent experts' appointed by the HSE, to be reviewing their records, in circumstances where they are taking a case against that very entity.

It is also unclear whether patients will be notified that their records are to be included as part of this review or whether  they have a right of refusal. There will understandably be concern among those whose babies have died, that their records will be examined with a fine-tooth comb, in some cases before the parents themselves have had an opportunity to request and review the records through their solicitor for assessment by an independent expert. 

Why an Irish birth trauma inquiry is important

While it is of undoubted importance that there are clinical lessons learned from serious birth incidents to prevent future deaths or injuries, it is equally important that those who have been injured and traumatised, are acknowledged and included in any plan to implement a more equitable maternity service. The best way to achieve that is through open, honest and respectful discussions with mothers after a traumatic birth, and to learn from their experiences. The persistent failure to address the concerns raised by advocacy groups such as Association for Improved Maternity Services and Safer Births Ireland, and to hear the voices of women who have been traumatised, has eroded their confidence that this will ever happen.

That is precisely why these groups have called on the government to set up the inquiry separate to and outside of the auspices of the HSE, to conduct a full and impartial investigation. It remains to be seen whether or not there is the political will to undertake an analysis and understand in detail, why it is that women in Ireland are continuing to report experiences of not being fully informed, and that their concerns are dismissed after a traumatic birth experience.

It must be remembered that this lack of open, honest communication on the part of the healthcare provider often results in mothers and their partners feeling litigation is the only means available to them to understand what went wrong that led to birth trauma. It stands to reason that a more humane, comprehensive support process for those who have experienced birth trauma, will cause a reduction in litigation, and where proceedings are brought, it would lead to a less adversarial courts process.

An independent inquiry is therefore crucial for hearing women’s stories and driving systemic change, ensuring that mothers are treated with the respect and care they deserve.

Written by: Johan Verbruggen