During her first pregnancy Maria would spend a long time waiting for her appointments at the Rotunda, one of Europe’s busiest maternity hospitals. Even when she was further along in her pregnancy, she wouldn’t always get a seat while waiting. It had never occurred to her to go private.
“I’m not sick. I don’t need to see a doctor. I’ll just go public, right?” says Maria, who does not want to share her surname.
During her first pregnancy, she was diagnosed with placenta previa – a condition where the placenta can block the cervix – at about 17 weeks. Maria was concerned when it had not moved by 34 weeks. She had researched about the risks from the condition in the third trimester, but says her worries were dismissed.
It was normal for her to see different staff at every antenatal appointment and another clinician was shocked to discover at 36 weeks that she had not been referred to a consultant over the condition.
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“If I had gone into labour, I would have haemorrhaged,” she says.
Maria’s baby boy was born at 37 weeks, and spent 10 days in the neonatal intensive care unit (NICU). It was an extremely stressful experience for Maria.
“Having to leave my six-day-old son in hospital while I drove home, still for all intents and purposes appearing pregnant with a floppy empty belly, was the hardest thing I have ever done,” she says.
Three years later, when pregnant again, she shared some of her anxieties with her GP who suggested she go private, if she had the health insurance and the finances.
Maria spent a lot of time researching private care, “including whether my family could afford this”.
“I don’t [spend] four grand at the drop of a hat; I’m not quite in that socioeconomic space,” she says, referring to the estimated cost of private maternity care.
She had to consider her family’s mortgage payments, car payments and the €1,500 a month they spent on childcare fees for their eldest.
“Just because I had the money in my savings doesn’t mean that it’s something I was able to part with willingly,” she says.
“I just felt like when I was public, nobody had my back, and I had no one central point of contact. I didn’t have one consultant looking after me that I could ask all these questions to – whereas when I was private and my daughter was in the NICU, my consultant popped in every morning and asked me how things are going, how I was feeling, how is my daughter.”
Her second baby, a girl, also had to be treated in the NICU but for different reasons. This time, Maria’s consultant and her midwives advocated for her to be able to hold and feed her baby, something she did not get to do for her firstborn.
“It was the best money I spent,” Maria says.
The differences between public and private maternity care have been brought into sharp focus in the recent dispute between the Rotunda and the Minister for Health, Jennifer Carroll MacNeill.
Within the next decade, private care in maternity hospitals will start to be wound down and the only option for pregnant women such as Maria will be public care. This policy decision was taken three years ago, but most people only became aware of the change over the past two weeks due to the public dispute.
It’s difficult to predict when private care in maternity hospitals will end, as it will depend on the retirement rate of obstetricians who are currently on public-private contracts. Contracts for new consultants have been all public-only since 2023, meaning they cannot offer private maternity care.
Some within the maternity service expect private care to have between 12 and 15 years left, but many anticipate that semi-private care will end sooner.
As private care is wound down, the fewer women who are able to avail of it may face much higher fees as demand starts to outstrip supply.
Maria represents many women who feel that a better model of maternity care is now being taken away from them, even with the recognition that more consistent pregnancy care should not only be available to those with means.
Two of the State’s biggest maternity hospitals – the Rotunda and the National Maternity Hospital – are now calling on the Government to exclude maternity care from its plan to remove all private care from public hospitals.
Private care is more than a private room, which may not even be available for fee-paying patients, depending on the capacity of the hospital. The main benefit is that a woman sees the same clinician throughout her pregnancy, and feels that there is a named person who is responsible for her care.
Anecdotally, private patients also have more appointments and more scans than public patients. One person at the Rotunda explained it as: “Public care isn’t less safe from a health perspective, but public care is ‘worse’ from a consumer perspective.”
Consultants lobbying for private care will often present it as a benign extra: great for the people who can afford it, neutral for everyone else. Six senior and more junior clinicians working across maternity hospitals, who spoke on condition of anonymity, had differing views.
Some argue that, given the unpredictable nature of obstetrics and the fact that private patients pay thousands of euro to expect a consultant to be there for the birth of their baby, there are times when a consultant prioritises a private patient over their public duties.
On the other hand, the Rotunda has argued that private care made its hospital safer because it meant more consultants were on site.
It is understood there have been recent cases in the Rotunda where a public patient has become very sick, and has benefited from the chance presence of a consultant who was only in the hospital to treat their private patient.
The counter argument to that, which is being made privately by some clinicians, is that all patients would then be safer if more consultants spent more time rostered on-site. At the moment, many consultants can work their on-call hours from home, according to numerous sources involved in maternity care.
Ireland has no private maternity hospital, for more reasons than just insurance. It is unlikely that such a stand-alone facility would be sustainable without a reliance on public care, with some even arguing that it could be less safe than a public hospital.
Prof Jennifer Walsh, master at the National Maternity Hospital, said earlier this month that a private maternity hospital was something that “as the master of a maternity hospital ... I would not like to see – I would see that as a hugely backward step.”
Two consultant obstetricians said a private maternity hospital would not benefit from co-location with a large public hospital for safety reasons; staff on public-only contracts would still need to fulfil their public hours while working at a stand-alone private unit.
Louise Bailey, based in Trim, Co Meath, has four children between the ages of 11 and 20, all born through the public system in the Rotunda.
Bailey says she had an “excellent” experience at the hospital. She takes issue with the use of patient safety as an argument for private care.
“I find it quite offensive, actually, to the hospital staff. Yes, the implication is that they’re not doing their duty of care,” she says.
“I do understand from talking to my friends that a lot of them are just really scared if they had high-risk pregnancies, and took the private option because they were really scared.
“But I’d just be curious where the evidence is on that, and if the public care isn’t standing up to scrutiny, well, then there’s something wrong, because everybody should get equal care.”
Continuity of care does not have to be led by a consultant. The 2016 National Maternity Strategy was a decade-long national plan for new and better maternity services.
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Its ambition was that every woman would have a named lead healthcare professional for her pregnancy – either a consultant or a midwife – who would be responsible for her care.
Under the strategy, maternity services would be less hospital-based and consultant-led, and new “Alongside Birth Centres” – where midwifery-led care and home births would be available for normal-risk pregnancies – would be developed across the State.
Although there have been improvements to maternity services under the 2016-2026 plan, women are still as far away as ever from having continuity of care in the public system. There are still only two midwifery-led units in the country: at Cavan General Hospital and Our Lady of Lourdes Hospital in Drogheda – the same two that existed when the plan was launched in 2016.
About 99 per cent of births in the State take place in a hospital, according to Central Statistics Office data.
Jane Beatty, who lives in Celbridge, Co Kildare, has four children between the ages of eight and 17. For her first two pregnancies, she gave birth in the Coombe, but during her second pregnancy she had a bad experience where she felt pressured to have an induction.
“On my third pregnancy, I just met someone who was having a home birth and I thought: ‘Oh, my God. I didn’t know we had that here.’”
Because she was living close enough to the maternity hospital and was assessed as being normal risk, she was able to have her final two pregnancies at home.
“The midwife would have been with you throughout pregnancy, so you know each other quite well. I felt in really good hands,” she says.
“I’m sure the consultants are great if you have a medical issue or a high-risk pregnancy, but midwives have great experience of helping women get through pregnancy and children in a natural way.”
Private care may end in the lifetime of the next national maternity strategy, which will also likely need to address the increasing risk profile for pregnancies.
A shortfall in funding for maternity hospitals that have relied on private care as a revenue raiser would also likely need to be addressed. And someone still has to account for the end of private maternity care, something that a lot of women passionately oppose.
“You cannot tell me that a mother shouldn’t be entitled to pay for the best care for her unborn child. And if I feel like that’s money well spent, I just can’t believe that it is being suggested to take that choice away from women,” Maria said.
“Why can I choose my dentist when I can’t choose who delivers my baby?”
