Politicians don’t pay enough attention to birth. That’s the strongly held opinion of Dr Rhona Mahony– and she should know. As Master of Holles Street hospital, she is responsible for a hospital that delivers more babies than anywhere else in this country and, indeed, most of Europe.

“Birth is a women’s issue. It’s hidden out of the way and women deal with it, hence, we have had next to no substantial investment in maternity infrastructure since the 1930s. When we look at the three Dublin hospitals which deliver 40% of the babies in Ireland, all three have very serious infrastructural problems.

“Birthrate Plus has told us we have a deficit of midwives of about 17% in Dublin and we know from workforce planning that we have about half the number of consultant obstetricians in Ireland than we should have. In fact, we have the lowest number of obstetricians per capita in the OECD.

“We have quite high fertility rates, although they have come down a bit from 17 to 14.6 live births per 1,000 population. In Germany it would be around 7% to 8%. So we have high fertility and low investment in our maternity services and that’s been a chronic picture over many years.

“Consultant positions are not available and it’s extremely difficult to expand your consultant numbers. Our midwives leave Ireland because the terms and conditions are better elsewhere. Our midwifery career structure is flat and although many of our midwives are highly professional, this is not recognised appropriately by either promotion in the clinical area or by remuneration.”

Given this level of understaffing, should women be worried about the level of care they will receive? Dr Mahony says no, as the staff are very well trained and outcomes are really very good by international standards. In addition, there’s been a decline in perinatal mortality and in maternal mortality. She says what’s really exciting is babies now survive from gestations as early as 24 weeks where there is about a 50% expectation of survival.

“That is our threshold for viability and it’s been an extraordinary development over the past 20 years. So we have come a long way. However, for the individual woman who is affected and who becomes part of the adverse outcome figures, that’s a very lonely place to be.”

Complex issues need regulation

Regarding research and development, she says that globally about 1% of this funding goes to obstetrics and maternity care.

“How can this be when everyone has to be born and every birth matters? This must change.”

Funding, where available, appears to be going into the future of fertility and this is a very complex area she says.

“Technological capability is far outstripping our social norms and society. We will soon have the capacity to create a very complicated social structure and we need to start thinking seriously about what we are doing.

“Recently at Electric Picnic I gave a funny lecture imagining what birth would be like in a 100 years from now. When I did my research, it was quite terrifying to see the sort of capabilities that are developing around the world. We have little or no regulation of this. For instance, you can put as many embryos back into a woman in Ireland as you like whereas we know that single embryo transfer is by far the safest method to use in IVF. That’s a simple example yet we don’t have regulation for even the simple things.

“These are all things that we are going to have to figure out. You can buy human eggs, you can buy sperm. The whole area of surrogacy is there. What happens to embryos after five years? What happens to embryos if someone dies? What are the rights of the child? There are a lot of complex issues here.”

There are no Gods in medicine

Turning to the media, Dr Mahony says there needs to be more balance in how outcomes in maternity hospitals are reported.

“Every day we wake up and there’s an adverse story in the paper and it has a very demoralising effect on staff who feel very scared that they will become the next media sensation. Fear is a very negative emotion. It actually makes people run away from giving treatment and low morale and fear are not things you want to see in the people providing care for patients. “Of course, bad stories have to be there, we have to shine a light on society, and I have no argument with that. But I worry about the level of intimate detail that we find in our papers and the lack of balance that undermines patient confidence in the system. It also lowers morale and creates fear among staff.

“I think it drives litigation. It also drives expectations that we can’t keep up with. There are no gods in medicine, just humans.”

Regarding the proposed amalgamation of Holles Street and St Vincent’s University Hospital, Dr Mahony said they have been engaged in intense talks and are hopeful of reaching a successful resolution.

“We are a tertiary referral hospital, the largest in Ireland and one of the busiest in Europe. Women in this country deserve a state-of-the-art hospital that is run for women and infants. I don’t think that is asking too much.”

She says that women from all over the country come to Holles St by choice and that the hospital is gaining much experience with complicated pregnancies. Adverse outcomes are less usual and babies weighing more than 500g have a 99.6% rate of survival.

“We need to be ambitious. We have the capability to create a really amazing hospital for women. I can’t think of anything more important in society than ensuring that every baby has the best chance at birth because so much follows from that.”

Breaking bad news

When there is an adverse outcome to a pregnancy, Dr Mahony says it is important to break the news in a sensitive manner. “At that moment, memory is so acute – people recall every single thing. We have to have some structured training and we do have bereavement counselling. We are setting up bereavement teams and we have seen the new national guidelines on bereavement, so there is tremendous awareness around this.

“But you know guidelines can only help you so much, this is a really human thing and to some extent some people are really good at connecting and others find it more difficult. Often we don’t know people for very long and we are having to break devastating news, so we won’t always get it right. All of us have our bruises. I can remember the patients’ names. I think some of the hardest situations have been late still births. Being on call at 2am and you put the probe on and although you are looking, there’s nothing and you know you are going to have to say this. It’s awful. If you could take it away, you would.”

Dealing with complaints

Dr Mahony says she tries to pre-empt complaints by having a survey on the ward for all women postnatally.

“I have learnt that if we don’t deal with things early, they can fester. Women can go through a lot of heartache that’s not necessary, either through a perceived problem or where they need people to recognise they really are struggling and they need to be assisted or they need a simple apology. There’s nothing worse than when something unpleasant has happened and you haven’t felt cared for, and no one acknowledges that.”

When to get pregnant

As to the best time to get pregnant, Dr Mahony says the message has got to be that the safest time to have your baby is in your 20s. She acknowledges that this doesn’t always fit with life and most women like to be in a stable place before starting a family. She said Holles St has lots of women delivering in their 30s and they do brilliantly, but it is a fact that as women get into the 40s the risks increase.

The Eighth Amendment

Dr Mahony hasn’t been shy about saying she favours repealing the Eighth Amendment to the Constitution. She says that currently, medical professionals are having to make decisions in a criminal rather than a clinical context.

“For that reason alone, I would favour repeal of the Eighth Amendment. We are allowed perform a termination in Ireland when there is a real and substantial risk to a woman’s life that can only be removed by termination of pregnancy. But how do we define a substantial risk to life? What role does a woman have in that definition?

“If I say to you, you have a 50% chance of dying, I’m OK with that but you might not be. There are very rare cases where women are at risk of dying and we have very difficult clinical decisions to make. For example, take a pregnancy of 14 weeks with ruptured membranes. We have very little prospect of a good outcome in that pregnancy but a very serious risk that the woman will develop a potential fatal condition. So we are waiting for her to get sick before we intervene. Now that’s medical roulette and we have to hope that when we intervene we are able to save her. But often because they are fit, strong and healthy, women don’t appear to be sick until infection is very advanced, so we are left in what is a narrow therapeutic window and we are having to make these decisions.

“I think the reason the Eighth doesn’t work particularly is the threshold of foetal viability. Once we get to the point where we can deliver baby and give it intensive care, then our decision-making is much easier. It is much easier for us to balance the two lives and we will always try and save both of those lives.

“Once baby is past 24 weeks then our decision is made much easier because we have an expectation the baby can survive. It’s really before foetal viability and that’s where the Eighth Amendment is difficult because it’s not about right, it’s about medical risk.”

Bio

Background: Youngest of three and grew up in Raheny, Dublin.

Family: Married to Daragh Fagan and mother of Lorna, Sarah, Daragh and Hugh. Says she wouldn’t be able to do the job without the support of her husband.

Enjoys: Tennis, running and theatre.

Music: Adele. Always on in the car.

Most recent film: The Sound of Music with my daughter.

Book: I’ve just finished Gerry Durrell My Family and Other Animals. There are three books in The Corfu Trilogy and it’s the nicest series of books I’ve ever read.

Holidays: With the family in Connemara and west Cork.

Bucket list: I would love to go lambing. I was meant to go last Easter but it didn’t work out. I’d also love to do a caesarean section on a cow.