The Rotunda hospital was ahead of its time when founded in the 18th century, and in its 250th year the world's oldest dedicated maternity hospital is still following the visionary approach of its founder, writes Kate Holmquist
The journey down the birth canal is the most dangerous journey any of us will ever undertake, says Dr Michael Geary, master of the Rotunda Hospital. It's an alarming thought that even when all other risk factors for sudden death are taken into account - from bungie-jumping to car accidents - being born still tops the list of events most likely to kill you.
We take it for granted today that birth should be a joyous experience, and with three-quarters of first-time mothers having epidurals, saysree as well. Death in childbirth has become so rare that it's difficult to imagine what it was like for poor women in the 18th century.
"Their lodgings were generally in cold garrets open to every wind, or in damp cellars subject to floods from excessive rains, destitute of attendance, medicines, and often proper food," reported TPC Kirkpatrick in his history of the Rotunda, written in 1913.
In 1743, childbirth was horrendous. The dirty and overcrowded tenements of Dublin were fraught with the death agonies of young birthing mothers, as young people flooded into Dublin from rural Ireland to escape poverty and the impacts of the Penal laws.
Bartholomew Mosse was just 31 years old when he was so affected by this suffering that he began a crusade to rescue Dublin's wretchedly poor women from "lying-in" in squalor. Within two years, in 1745, he had purchased a theatre of ill repute off South Great George's Street, closed down after Peg Woffington had put in one too many bawdy performances. Mosse worked night and day to turn it into Dublin's first maternity ward and by 1757 had raised enough money to build and open one of Dublin's finest examples of 18th-century architecture - the Rotunda in Parnell Square. Two years later, at the age of 47, he was dead from an infection, his immune system wrecked by overwork.
Mosse was an extraordinary man. The fifth son of a Protestant clergyman from Portlaoise, he was sent to Dublin at the age of 17 to learn medicine under the instruction of a barber-surgeon and then went on to Europe. As Prof Alan Browne, a former master of the Rotunda, has written, it may be that Mosse was inspired by what he witnessed in Paris's Hotel Dieu, which practised midwifery, to become a specialist in childbirth.
In the Dublin of the time, the notion of a doctor taking an interest in childbirth was unheard of. Midwifery, which was passed down from mother to daughter, was considered superstitious and unreliable. But Mosse, protected to some extent by his social status, didn't care what anyone thought of him, and set about fund-raising with an approach uncannily prescient of what goes on today - lotteries, performing arts events and a posh public park in the grounds that offered leisure activities, music and dining for the admission price of one shilling.
Nearly three centuries later, the Rotunda is celebrating its 250th anniversary and remains the oldest dedicated maternity hospital in the world. Prof Browne, who was master between 1960-66, says that when he was born the Rotunda was the last place his mother would have gone to give birth due to its associations with poor women. Yet, in 2007 the Rotunda has become such a centre of excellence that it is "branding" itself - as secretary manager Fintan Fagan puts it - as the maternity hospital "of choice" for 21st-century women.
The Rotunda was the first Irish maternity hospital to set up an infertility treatment programme; the first to freeze sperm and eggs; the first to introduce a dedicated teen pregnancy clinic; the first to offer amniocentesis; the first to offer mothers a 24-hour epidural service; the first to develop a sexual assault unit; the first to have a mental-health programme for mothers with postnatal depression; the first to be accredited by the Health Information and Quality Authority (HIQA); the first to perform life-saving EXIT surgery on infants; and the first to perform surgery on foetuses in the womb.
This groundbreaking surgery is happening at a time when a baby-boom among Irish, non-Irish EU and non-EU mothers has driven the number of births at the hospital up by 16.5 per cent since last year. Controversially, the Rotunda has consequently been the first to put pregnant women up in a hotel, rather than having them suffer the consequences of overcrowding.
Bartholomew Mosse's radical vision has remained alive for 250 years and - believes Prof Browne - this is mainly due to a system of running hospitals devised by Mosse. He believes that mastership, by which a doctor takes on the administration of the hospital for a seven-year period, was Mosse's "greatest single achievement", and it remains unique to Irish maternity hospitals.
The HSE has recognised the need for a similar master's role in all hospitals - that of the "clinical director". However, says Dr Geary, "the clinical director system here is on a goodwill basis with no funding. The HSE needs to deliver on this on a consistent basis because getting doctors and nurses to the management table is a great thing - they understand the practical problems and know how to get things done."
As Dr Geary talks beneath a portrait of Mosse in wig and gown, one gets the sense that he is as impatient as Mosse must have been in the 18th century to provide the best possible care for mothers and babies. His own big project is research into "at risk" babies born to "low-risk" mothers. Currently, "high-risk" mothers can be identified, but it's the seemingly normal mothers who develop serious complications during delivery who are actually at the highest risk of what is known as "near misses", though Dr Geary prefers to think of these incidents as "great saves".
"The outcome for high-risk mothers is better than for low-risk mothers," says Dr Geary. High-risk mothers receive routine scans; low-risk mothers don't. The Rotunda is embarking on a study that will scan low-risk mothers to find out if problems with the placenta, which are currently poorly understood, could be silently putting foetuses at risk of problems that don't appear until the moment of birth. This will be the first such study in the world and, whatever the result, will put the Rotunda on the international map.
Like Mosse 250 years ago, Dr Geary - now in his sixth year of mastership - is quietly passionate about never allowing the hospital to rest on its laurels and to seek out the means of even better care for mothers and babies. Infants born at 24 weeks, and who weigh at least 500g, can survive today, whereas it isn't so long ago that babies born prior to 28 weeks were wrapped in blankets, put in a cot and allowed to die.
The Rotunda has, since the 1970s, had an ethos of saving extremely premature infants, whereas in Holland even today, infants of less than 26 weeks' gestation do not receive resuscitation.
The challenge for the Rotunda has been to provide cutting-edge medical care, while also giving the human touch. Patient surveys show that 93 per cent of women would recommend the Rotunda to their own families, a statistic that Dr Geary and the hospital as a whole take pride in.
"Openness and frankness is vital," says Dr Geary. "No one leaves the hospital with unanswered questions. If they have a forceps delivery due to acute foetal distress or if they have a C-section, we always go back and explain exactly what happened and why it happened and we document it. If people go home satisfied by an explanation of what happened and why, there is no festering of doubts."
Not only is this important in preventing litigation, but it also helps women to feel that whatever the circumstances, the birth of their child was conducted in the best possible manner with the best possible result.
The ethos of the hospital is "liberal", but neither Protestant nor Catholic, say Dr Geary and Prof Brown. A voluntary board of governors oversees the running of the hospital, although each master is allowed to guide developments according to his own vision. As a result, things get done. There's a lesson in this for the rest of the health service, believe Dr Geary and Prof Brown - which is extraordinary considering that the approach was developed 250 years ago by a firebrand who gave his life to his cause.
"Every baby you deliver is rewarding. The day the magic goes out of it is the time to retire," says Dr Geary.
The Rotunda comes of age
1757
Although Bartholomew Mosse founded the Dublin Lying-In Hospital, the first maternity hospital of its kind in the world in 1745, the new Lying-In Hospital, designed by Richard Cassells, architect of Leinster House, opened 250 years ago
1826
Hospital Master Robert Collins enforces hygiene standards to control an epidemic of puerperal fever, with great success
1869
Chloroform first used for relief of pain in labour
1958
Physiotherapists are introduced to provide antenatal training and postnatal exercises
1977
Ultrasound diagnosis is introduced
1978
Paediatrician Tom Matthews appointed as hospital develops its ability to save extremely small pre-term babies
1989
Human Assisted Reproduction Ireland unit opens
2001
Cassidy quintuplets born at 25 weeks and four days and all survive due to the skill of the Neonatal Intensive Care Unit
2002
Miscarriage Clinic and 3D ultrasound introduced
2003
Influx of pregnant women from Sub-Saharan African and Eastern Europe brings 60 cases of HIV-positive mothers to the hospital, the biggest proportion outside the US (30 cases in 2007)
2004
Colposcopy unit opens, allowing more effective diagnosis and prevention of cervical cancer
2007
Ireland's first successful EXIT procedure - a form of caesarean section in which surgery is performed on the fetus while still connected to the umbilical cord. Doctors successfully perform Ireland's first surgery within the womb to save a twin pregnancy threatened by TTTS (Twin-to-twin-transfusion syndrome)
