I move:
That Dáil Éireann calls on the Government to provide maternity facilities at Bantry Hospital, County Cork.
Since this Government came to power a number of maternity units have been selected for closure, including Monaghan, Dundalk and Roscommon. A crisis situation exists in Bantry where the maternity unit was closed last February and the Minister has refused to sanction its reopening. Bantry is one of the two hospitals in the country where an archaic system existed where the county physician was the obstetrician and the county surgeon was the gynaecologist and carried out the operative procedures. This was the system in all county hospitals until about 20 years ago. Bantry and Dundalk were the only hospitals where the old system continued.
Last February the county physician in Bantry went on sick leave. While it was possible to find a locum to carry on for him in relation to general medicine it is understandable that it was quite impossible to find a locum prepared to carry on general medical duties and obstetrics and gynaecology as well. I understand there was no difficulty in getting two consultants to replace him at different times for general medicine but it was not possible to get a locum to look after the obstetrics. The unit was closed last February. The health board requested the Minister to sanction the reopening of the maternity unit and the development of an obstetric unit at Bantry hospital but the Minister has refused to do this. It is difficult to understand this decision.
Bantry general hospital has a catchment area with a population of 55,208. The west Cork health district has 48,973 and Kerry has 6,235 people in the Bantry hospital catchment area. It is interesting to note that the figure of over 55,000 is up 15,000 since the time the Fitzgerald report was published in the late sixties. There are at least three peninsulas in west Cork each about 50 miles from Bantry and there is also an area of Kerry going west as far as Sneem. The number of births in the area in 1982 was 823 and they were divided as follows: in Bantry hospital there were 191 births, Skibbereen 99, Erinville in Cork 269, Saint Finbar's 115, Bon Secours 130 and Victoria 19, a total of 823.
The geographical distribution of where the women came from is Bantry 171, Castletownbere 34, Clonakilty 180, Dunmanway-Drimoleague 142, Skibbereen 185, Schull-Goleen 28, Kenmare-Sneem area 72 and others 12.
Comhairle na nOspidéal published their recommendation in a document in 1976. The objectives for good obstetric care, as outlined by An Chomhairle, are monitoring and maintaining the health of the mother during pregnancy through regular and ante-natal care ensuring safe delivery under skilled supervision, ensuring that through skilful attention the infant is given the best chance of optimum health and normal development. An Chomhairle also pointed out that many considerations point towards the concentration of inpatient obstetrical services at consultant level in viable centres catering for a minimum of 1,500 to 2,000 deliveries per annum. I understand that in Sweden, where some research was done, they discovered that the infant death rate dropped in units where the birth rate was more than 1,500 per annum.
It is interesting that here the infant death rate declined over the past decade. An Chomhairle pointed out in their document that this is in considerable measure because of improvements in obstetrical management. This decline occurred with the majority of the maternity units having less than 1,500 births per annum. In reply to a question last week the Minister said that there are 51 units in the country with less than 1,500 deliveries per annum and there are 17 with more than 1,500. If one takes the major boroughs of Dublin, Cork, Galway, Limerick and Waterford out of it there are only six areas left in the whole country with more than 1,500 deliveries per annum: Sligo, Letterkenny, Wexford, Castlebar, Drogheda and Ballinasloe.
In Cavan hospital the infant death rate is very low compared with the rest of the country. This is one of the hospitals with less than 1,500 deliveries per annum. It is very interesting that Professor Henry from the Rotunda Hospital in the Irish Medical Times of 21 October said that there was a very high perinatal mortality rate in the Rotunda last year. He said that he was satisfied that part of the blame for this must rest with inadequate labour ward accommodation. Obviously it has not been proved that the large centres have any more to offer than the smaller centres. Fianna Fáil reject the concept that it is necessary to have 1,500 deliveries per annum to have a viable unit. We showed that when an appointment was made for an obstetrician to Roscommon with considerably less than 1,500 deliveries. We believe it is necessary to have adequate maternity facilities throughout the country even if the deliveries in such units are considerably less than 1,500. It is important to recognise that there is a move away from major hospitals and super-specialities. Rex Lowry stated in the College of Surgeons Journal that only 10 per cent to 15 per cent of all the people who go into hospital need super-special attention. Up to 95 per cent of the deliveries are normal so we are talking about the 5 per cent of deliveries that there are problems with. We have to balance the risk to the mother and infant where the birth takes place in a smaller maternity unit compared with a major maternity hospital a distance of anything from 60 to 100 miles away. This applies in Monaghan, Dundalk, Roscommon as well as in Bantry. Some parts of the Bantry catchment area are 110 miles from the nearest maternity hospital which is in Cork city. It is very difficult to understand how a Minister could be satisfied to tell any woman that it was acceptable for her to travel 110 miles to have her baby delivered. We are talking of a distance that is equal to the distance between Belfast and Dublin or between Nenagh and Dublin. I fail to understand how anyone in his senses could suggest to a woman in Belfast or in Nenagh, for instance, that she should be satisfied with the maternity service in Dublin. That does not take into account the fact that if one were travelling from Belfast to Dublin or from Nenagh to Dublin, one would be on a national primary route whereas in west Cork one would be travelling on roads which, it is fair to say, are among the poorest in Europe.
It must be accepted that the medical risk both to the mother and to the infant in travelling such distances to a major maternity unit is greater than travelling the much shorter distance to a hospital where there is an obstetrician in attendance although there may be fewer than 1,500 deliveries there each year. There is also the risk of road accidents in travelling the long distances especially when the driver may be the husband of the woman concerned and, consequently, is under stress. All these factors must be taken into account when we are deciding on the best maternity service that we can provide. We must ask ourselves, too, what the medical implications would be if a number of women decided to remain in their own homes during the deliveries of their babies when they may live up to 100 miles from the nearest maternity hospital. Emergencies can occur very rapidly in obstetrics. For example, there can be severe bleeding. If specialist attention is necessary to deal with such an emergency the patient may have to be transferred to hospital which in the case of the Bantry catchement area would be more than 100 miles away or it may be possible to have the emergency service brought to the woman. If we are talking of the emergency service in the nature of the flying squad coming from the maternity hospital in Cork to one of the peninsula areas in west Cork we are talking of a delay of two to three hours and that could prove fatal.
The closing of the unit in Bantry could not be justified in circumstances in which fatalities might occur as a result. In the event of a patient having to be transferred to Cork, I understand that there is available from Cork a helicopter service but it is not necessary for me to remind the House that such a service is very limited. Assuming that a helicopter were available in Cork to go to West Cork there is the factor that these machines do not fly at night. Any doctor who practices obstetrics will confirm that the vast majority of babies are delivered at night. Consequently, the vast majority of emergencies are likely to arise at night.
I would accept that it is not possible to have in Bantry a maternity unit where there are two or three obstetricians and two children's doctors but the results in the smaller units compare favourably with those in the larger maternity hospitals. I have given the example of Cavan where the perinatal mortality rate is among the lowest in the country. I have pointed out what Dr. Henry had to say about the hospital in which he works, that is, the Rotunda. Of the 823 deliveries in the Bantry catchment area to which I have referred, 191 were in Bantry.
In a letter sent on the direction of the Minister for Health to the Southern Health Board in July this year it was stated that the development of a consultant obstetric unit at Bantry would not have attracted more than 300 deliveries per year. However, the Ceann Comhairle as well as the rest of us from his constituency will recall that the same was said in respect of Cavan in 1973 but after the appointment there of an obstetrician the number of deliveries at the unit increased from 500 to more than 1,100, despite there being a decrease in the birth rate in the country as a whole. That, then, is an indication that if an obstetrician is appointed in an area and there is created a good consultant service, the numbers of women availing of that service will increase. There is no reason why there could not be a viable unit at Bantry with, perhaps in a short space of time, the necessity to appoint a second obstetrician. This would be the ideal rather than having one man working in isolation.
In the middle of the last century a leading obstetrician in the UK, Robert Lee, wished to close all maternity hospitals. In the centenary issue of the Practitioner Journal, 1966, he is quoted as saying that it becomes a subject deserving of most serious consideration on the grounds of humanity whether lying-in hospitals should not be abolished altogether as injurious rather than beneficial to society. I am sure everybody here will agree that it was very fortunate that the administrators of the time did not take him too seriously; otherwise, not many of us might be here today.
It is interesting to note that in Ireland in the eight years between 1968 and 1976, two opposite opinions were put forward by very eminent bodies. I refer to the recommendation of An Comhairle that in order to make a maternity unit viable, there would need to be 1,500 deliveries at the unit per annum. The FitzGerald Committee in their report expressed themselves as being satisfied with retaining maternity units not only in county hospitals but in district hospitals. They suggested that the name of district hospitals should be changed to district nursing homes but they reported about keeping the maternity facilities at such places. These two eminent advisery bodies have expressed conflicting views in the past ten years in relation to maternity services. The lesson is that we should move slowly in any programme of rationalisation in the context of discontinuing the smaller units. Dr. Courtney in his combined report for the years 1975 to 1982 had the following to say about the importance of an obstetric unit in a rural community:
Many parameters have been put forward to assess the value of various services to the community. In obstetrics assessment has been based on the number of deliveries in a specific institution or hospital, though this criterion has not been uniform. This is a crude method of assessment. It is clear that the proximity of a consultant to a given area provides significant advantages.
It means that a wide range of doctors have immediate advice available to them, which will help to improve maternal care and neonatal health. Running clinics from a distance has been both useful and necessary in the past but it is more effective clinically to bring obstetrics to the rural areas, quite apart from the cost of travel, the inconvenience and the effect on community life. A rural hospital without obstetrics ceases to be a focal point in the community and the argument that a small unit cannot function effectively is disproven.
Not alone are there good medical reasons for developing an obstretical unit in Bantry, there are other good reasons for having such a service. It is necessary to appreciate all the human, emotional factors involved in childbirth. In a smaller unit nearer to home all these aspects of having a baby can be more comfortably accommodated than in a big hospital. When one considers the human, social and economic factors involved in perhaps travelling to Cork City from Bantry one can see another reason for the re-opening of the maternity unit in Bantry General Hospital.
It must be remembered also that some women may have to remain in hospital for a number of weeks prior to having their babies delivered. It is essential to their well-being that they have frequent visits from their husbands and young children, if they have any. Obviously, while we must be concerned primarly with the high level of medical care, having regard to the geography of the area about which we are speaking, I do not think anybody would doubt that, when one considers the risk of the long distance to be travelled and not having a maternity service available — when one considers that against having a baby in a smaller unit, with an obstetrician appointed — medically one can be satisfied that the smaller unit, in an area such as south-west Cork has the advantage. When one accepts that medically there is an advantage then one examines other aspects of the case.
From the social viewpoint certainly one must consider and examine the problem of a woman who is, say, six months pregnant, having to go to Cork hospital and remain there for the remaining three months. One must consider the effect of that on herself, having regard to the emotional state of women during pregnancy, and, secondly, the effect on her husband and other young children, if any. One must consider also the difficulties involved for relatives travelling that distance. If such a woman were in Bantry — even from a distance of 40 or 50 miles out — her husband could visit her twice or three times a week but it would be impossible to make visits of that frequency if she were in Cork city hospital. It is unreasonable for anybody to believe that the needs of such women and their families can be catered for within the distance we have been speaking about, with a hospital situated over 100 miles, in many instances, from their homes.
The Minister and the Government are responsible for the decision not to develop an obstetric gynaecological unit in Bantry hospital. Although this Government have not been in power a year yet it is extraordinary that their main targets for closure have been maternity hospitals. There is the instance in my county of Monaghan where the Minister wrote to the health board, telling them that he would not sanction the signing of the contract for Cavan hospital——
