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 Header Item Maternal Mortality (Continued)
 Header Item Medical Card Eligibility

Wednesday, 19 December 2012

Dáil Éireann Debate
Vol. 787 No. 4

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(Speaker Continuing)

[Deputy James Reilly: Information on James Reilly Zoom on James Reilly] 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 emphasise 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 MDE 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 mothers and babies is as safe as possible. As outlined in the MDE 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.

Deputy Mick Wallace: Information on Mick Wallace Zoom on Mick Wallace 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.

Deputy James Reilly: Information on Dr. James Reilly Zoom on Dr. James Reilly 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.

Deputy Mick Wallace: Information on Mick Wallace Zoom on Mick Wallace 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 death two years after her death. Would the Minister consider putting in place a structure under which inquiries into maternal deaths would be automatic?

Deputy James Reilly: Information on Dr. James Reilly Zoom on Dr. James Reilly 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.

Medical Card Eligibility

 4. Deputy Billy Kelleher Information on Billy Kelleher Zoom on Billy Kelleher asked the Minister for Health Information on Dr. James Reilly Zoom on Dr. James Reilly if he will help cancer patients in severe distress to acquire medical cards; and if he will make a statement on the matter. [57232/12]

Minister of State at the Department of Health (Deputy Alex White): Information on Alex White Zoom on Alex White Under the provisions of the Health Act 1970, eligibility for health services in Ireland is based primarily on residency and means. There are two categories of eligibility for all persons ordinarily resident in Ireland, those being, full eligibility, which relates to the medical card, and limited eligibility, which applies to everyone else. Full eligibility is determined mainly by reference to income limits and is granted to persons who, in the opinion of the HSE, are unable to provide general practitioner, GP, medical and surgical services to themselves and their dependants without undue hardship.

There is no automatic entitlement to a medical card for persons who have cancer. There is a provision for discretion to grant a card in cases of "undue hardship" where the income guidelines are exceeded. Recently, the HSE set up a clinical panel to assist in the processing of applications for discretionary medical cards where there are difficult personal circumstances.

There is an emergency process for a person who is terminally ill or in urgent need of medical attention and cannot afford to pay for it that provides a card within 24 hours while the normal application process is being completed. Details of this procedure have been made available to all GPs and social workers. Such applications can be initiated through the local health offices, whose managers have access to a dedicated fax and e-mail contact line to the primary care reimbursement service, PCRS. Once the medical condition is verified by a GP or a consultant and the required personal details are provided, an emergency card is issued to that person for a six-month period. No means test applies to an application in the case of a terminally ill patient.

Deputy Billy Kelleher: Information on Billy Kelleher Zoom on Billy Kelleher I thank the Minister of State. Last year, I raised this issue in respect of an individual who was terminally ill and who subsequently passed away. To be fair, the system responded but the reality differs from what the Minister of State claims is occurring on the ground.

The clinical panel that assesses medical card applicants must be strict, given the rate of refusal for cancer sufferers in particular. I have been around Leinster House for 20 years and have always believed that, if one has cancer, one applies in the normal way and the service uses its discretion to grant a medical card based on medical need. That is no longer the case. For example, a woman who has had a mastectomy cannot access a medical card.

It is bizarre, to say the least, that what the Minister of State and the HSE claim is at variance with what is occurring on the ground. According to the Irish Cancer Society, many cancer patients are applying to it for support in accessing treatment. Hospitals are hunting them down for €75 every time they present for chemotherapy. There is something barbaric about this and I ask the Minister of State to consider the issue in the context of next year's service plan.


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