Alison O'Connor: Greater equality in maternity care should not mean levelling down

Women need all the facts about maternity care before making choices and deciding what is ultimately best for them and why.

Labour senator Rebecca Moynihan stated that doctors ‘are advocating to keep a better system for those that pay’.

It’s a head-scratcher alright for Irish women to be told inequality in our maternity services actually presents them with a better choice and they should fight for the status quo to remain.

That’s exactly how the row over the plan to phase out private maternity care is being presented by the Masters of two of the three maternity hospitals in Dublin. On first hearing the clarion call of these two men, there are echoes of feminist stirrings pondering this wrong about to be perpetuated on the fertile women of the nation.

But on closer inspection, you realise that rather than just one ‘c’ being involved here, as in choice, there is a second, and that is cash.

I speak as someone who went private with my pregnancies and would do exactly the same today, given that certain issues meant my pregnancy was “high risk” the entire way through. During hugely stressful gestations, there was nothing at all like the reassurance of being able to call my obstetrician’s wonderful secretary and mention whatever worry/query I had, safe in the knowledge it would be passed on.

There was always a response. I had huge trust in my obstetrician. In truth, I cannot remember the exact cost, it was 13 years ago for the last one. But regardless of the financial stretch, afterwards it felt worth every cent.

But why should I and others like me be able to get this sort of treatment, the guarantee of seeing the same familiar and reassuring face all the way through the pregnancy, the continuity of care? The regular scans? There is never a guarantee that your private obstetrician will be present at the actual birth, but there is a fairly high chance they will be there. 

It’s interesting to note that a guarantee all women do have is that there will always be a midwife present who actually provides the same level of care, whether you are public or private.

As Labour senator Rebecca Moynihan, currently pregnant with her first baby, put it this week in a tweet: “The doctors and people I have seen talking about ‘choice’ aren’t advocating for everyone, they are advocating to keep a better system for those that pay.”

The Government has signalled it intends to rectify this unequal situation — a good thing, surely — but not if you listen to certain high-profile obstetricians who are arguing for the continuation of private maternity care in public institutions.

The Master of the Rotunda Fergal Malone, speaking on RTÉ’s Drivetime, was really on a sticky wicket, given he said himself that two-thirds of the women attending the hospital are public patients. One third opt for private or semi-private care that can cost up to €5,000. 

If he is arguing that women who go privately would miss out enormously with this new proposal — where does it leave the women who attend publicly at the Rotunda under his watch?

He insisted that women in the public system in the Rotunda receive very good care, and as Master he was “very happy” to stand over that, however due to the volume of patients, “it is not possible to guarantee or to give any commitment to the same obstetrician or same midwife”.

In the case of a public patient who has previously had a traumatic birth, or felt they were not listened to on a previous occasion, the hospital does a “very good job” and listens to what happened to the woman, and her concerns and “do our very best to minimise that happening again”.

But for many patients, he said, that is not sufficient. They won’t feel sufficiently comfortable with that, and they may decide they want to “exercise their choice” of seeing a private obstetrician. He spoke of how around 10% of women having babies now are over 40, which makes for more complicated pregnancies and potential challenges. These women more often opt for private care. 

Professor Shane Higgins, Master of the National Maternity Hospital Holles St, joined Prof. Malone in expressing concern about the proposed change describing it as “chilling” and the death knell of the national maternity strategy.

Funny though, I spoke in recent days to a friend who was well over 40 when she got pregnant a few years ago. She opted to attend Holles St as a public patient and had hoped for a midwife-led birth.

“Because of my age, I ended up, despite being a public patient, attending Shane Higgins [one of the most experienced obstetricians in the hospital] anyway,” she said. 

Chatting to the other women in the waiting room, it seems as if the high-risk pregnancies were funnelled back in for this sort of care anyway.

Isn’t this exactly as it should be, and all the better if this was the general experience of women publicly attending all our maternity units around the country? Surely it is not too much to ask that all women would have a continuity of care, rather than maintaining a system where only certain women can afford it. Why not level up rather than down?

The new consultant contract agreed by Cabinet recently means that private care is being phased out of public and voluntary hospitals, including maternity.

Sláintecare

In 2019, the de Buitléir report into Private Activity in Public Hospitals stated that the Sláintecare vision is to provide an integrated health service which delivers care based on the needs of people and not their ability to pay, including maternity care. Difficult decisions, it pointed out, will have to be made to ensure this happens over the lifetime of the Slaintecare programme of reform.

So consultants who opt for this new Sláintecare contract can earn almost €300,000 including allowances, but they will not be able to see private patients on-site in public hospitals. 

But in reality, when it comes to maternity care, there are no off-site private options such as those that used to exist in the Bons maternity wing in Cork or Mount Carmel in Dublin. This is because of the incredibly high litigation costs involved in obstetrics, as well as astronomical insurance costs.

At any rate, there is no need for anyone to panic for quite some time. None of the consultants working currently, including obstetricians, will have to change their existing contracts. The chances are that women in their “fertility window” during these years will be long past any prospect of reproduction by the time this is eventually fully introduced.

We may not be talking decades, but we must reflect on the traditional snail’s pace of change in the Irish medical world. This time it is on the part of consultants, some of whom can earn hundreds of thousands of euro, some well above €300,000 a year, to deliver babies to women who are under their care as private patients.

Women need all the facts before making choices and deciding what is ultimately best for them and why.