Niamh Griffin: Rotunda row is over but women are left asking — where is our maternity strategy?

In the wake of a controversy sometimes framed in terms of choice, a maternity advocate said: 'We need to talk about the choices that we don’t have'

On Monday evening, the Rotunda maternity hospital in Dublin agreed to stop offering private maternity care carried out by consultants on public-only contracts. Picture: Leah Farrell/RollingNews

The row between the Rotunda maternity hospital and the health minister has been resolved, but it has brought into the open a concern quietly shared by many pregnant women and obstetricians.

An ongoing Government plan to ease all private care out of public hospitals has a unique impact on maternity services because there are no private maternity hospitals left to offer an alternative.

Why is there no private maternity hospital?

The last private maternity unit closed at Mount Carmel in Dublin in 2014 after liquidators were appointed by the High Court.

In Cork, the Bon Secours maternity unit closed when care for the region was centralised at the new Cork University Maternity Hospital (CUMH) in 2007.

Health minister Jennifer Carroll MacNeill said there is no private maternity hospital now because “they can’t get the insurance to do that, because the cost of a birth injury, of cerebral palsy or a different birth injury, is so great that only the State is in a position to underpin that”.

What did the Rotunda Maternity Hospital want?

It argued that consultants on public-only contracts could offer private care so women had more options in pregnancy. These options were public obstetric care and private obstetric care in hospitals.

However, on Monday evening, it agreed to retract the private care based on its fear of losing state funding.

“The board continues to believe in the importance of choice for women and that a compromise solution for maternity care should be sought through dialogue with the Department of Health and the HSE,” it also said.

This leaves the door open, but comes after previous discussion with the HSE and Ms Carroll MacNeill, so maybe women should not hold their breath.

Earlier on Monday, public expenditure minister Jack Chambers backed the health minister, making clear that what he called an à-la-carte approach to State deals is not acceptable.

There would have been concerns that other hospitals might have requested similar derogations or exceptions if this had continued.

What choices do women want in pregnancy?

Around the time the new contract was agreed with doctors, Professor Declan Keane, former master of the National Maternity Hospital, told the Irish Examiner: “At one stage during the Celtic Tiger I’d say 40% of our patients were private or semi-private, now it’s down to about 32%. That would be pretty much the same in all of the Dublin maternity hospitals; it is fairly similar in Cork and Limerick. Some of the smaller units would be less than that.”

For context, CUMH and the Dublin hospitals can see up to 8,000 births each a year.

Women's choice and control 

UCC researchers identified private care as important in their study of women’s perceptions of choice and control during pregnancy and birth in 2021.

“Women who availed of private maternity care reported higher levels of choice and control than those who availed of public maternity care,” it found. However, the authors also heard from women who could not afford private care or who did not want private obstetric care.

It flagged “limited options in terms of birthplace choices” as one issue.

This was the unspoken issue in the Rotunda row, according to Krysia Lynch, a maternity advocate closely involved with creating the national maternity strategy in 2016. She sees the discussions as “a massive opportunity” to act on unfulfilled pledges from the strategy. She said: 

We need to talk about the choices that we don’t have.

“What about other choices women have asked for, what about birth centres, midwifery-led options, private midwifery, water births, more Domino schemes [midwifery-led care in the community] and all the other choices that people want but are not getting?”

Focus on medics over patients

She feels that the focus on consultants’ working conditions has eclipsed pregnant women. Women are told, she said, private care is best, and she said: “I feel that people who have the means take that option because they want the best for themselves and their babies.”

As preparation for a new 10-year maternity strategy begins, she urged: “If you want to talk about choice, you have to offer genuine choices that are essentially different from each other.”

Women commenting online this week point out that despite improvements in post-natal care, options such as more homebirth services or birth-centres — a halfway option between a homebirth and a hospital birth — have not appeared yet.

Limited access to scans in public care was raised. Older first-time mothers are more likely to prefer private care, a Trinity College Dublin study noted in 2020. Anecdotally, women who experienced difficult first births might prefer a private route and women who have gone through fertility treatment.

What next?

Under the new contract, consultants can only do private work off-site after their HSE obligations are met. It offers a starting salary of €238,221 plus allowances and on-call and callout payments.

Figures released to Labour TD Marie Sherlock show that out of 235 obstetricians nationally, some 124 were on this contract, including new hires and doctors who had switched over by February.

In CUMH, up to last week, 66% of its consultants were on this, and 85% in the maternity unit at University Hospital Kerry.

Many women could now fairly ask if the Government will pursue its maternity strategy promises as diligently as it has pursued doctors’ contractual obligations.