(Image by StockSnap from Pixabay)

In recent weeks, there has been some debate over private maternity care in Ireland. It stems from a (possibly unintended) consequence of the new SláinteCare Consultant contract, in particular the prohibition on caring for private patients on public or voluntary hospital grounds. More generally, one of the surprisingly confusing or even daunting aspects of pregnancy, particularly unplanned pregnancy, can be trying to navigate the complex web of private, semi-private and publicly-funded maternity care options available. Given this background, we thought we’d outline the various issues involved, as well as offer some insight on maternity care options in Ireland.

Historically in Ireland, many hospital consultants employed by the HSE were essentially employed on a part-time basis, being free to treat private patients outside of their contracted public hours. However, the consultants were able to use the facilities in public or voluntary hospitals (which are hospitals that are funded but not owned by the State) to treat their private patients.

Under the new SláinteCare contract, consultants will be employed by the HSE on a full-time basis, and any private work they undertake must take place outside of those hours and in private facilities. However, there are no private maternity hospitals in Ireland. There are three standalone voluntary maternity hospitals in Dublin, two HSE maternity hospitals (one in Cork and one in Limerick) and several maternity units within HSE or voluntary hospitals throughout the country. At the moment, women who opt for private maternity care have their babies delivered in public or voluntary hospitals, under the care of a private consultant. That will no longer be possible under the SláinteCare contract, which essentially means an end to private maternity care.

Given this background, it’s worth considering the different types of maternity care available and the various differences between public, semi-private or private care.

Public maternity care

Every woman who lives in Ireland is entitled to public maternity care. It is covered by PRSI contributions, although women with no PRSI contributions (eg, someone who is out of the workforce because they are studying or undertaking home duties) is also covered for maternity care. Public maternity care is provided by a woman’s GP and the maternity hospital or unit of her choice, under two main options, consultant-led care and midwife-led care.

Midwife-led care: hospital based

Midwife-led care is an option for women having a low-risk pregnancy. A woman typically visits her GP when her pregnancy is confirmed and books her pregnancy with the hospital of her choice (there are no geographic restrictions on which hospital you book with). She has her first visit with a midwife from the maternity hospital towards the beginning of her second trimester. Antenatal visits with the midwives may take place in the hospital, or in a HSE clinic in the community, depending on the arrangements made by the hospital. Her next visit is usually with her GP about a month later, and the next visit with the maternity hospital is usually around 20-22 weeks. At this stage, an anomaly scan may be offered, although some maternity hospitals offer this scan to all women and other hospitals to certain women only (the as yet unimplemented National Maternity Strategy recommends an anomaly scan for all women). From the third trimester (27 weeks), the woman has fortnightly antenatal visits, alternating between her GP and the maternity hospital, and weekly antenatal visits from 37 weeks until the baby is born.

The baby is born in the maternity hospital under midwifery care. Labour ward facilities are the same for all deliveries, but in some older hospitals, any nights spent in hospital by a public patient are spent on public wards rather than in single-occupancy rooms. This can be difficult for postpartum women, especially if their baby is fussy or if they are struggling to breastfeed. Best practice is that all women have their own room for them and their baby following their delivery, and that is the vision for the new National Maternity Hospital, for example. Typically a woman spends three nights in hospital if she had a vaginal delivery and five nights in hospital if she had a c-section. However, some hospitals may offer an early transfer home, with midwives visiting you and your baby over the next week to do postnatal checks at home rather than in the hospital. After the woman is discharged from hospital, there is a GP visit for the baby at 2 weeks and for the woman and the baby at six weeks.

Research has found that outcomes for low risk women under midwife led care are the same as consultant-led care, but with fewer interventions, and so midwife-led care is a good option for many women. The main disadvantages to this model of care is a lack of continuity in care providers. Antenatal visits take place with the antenatal team, and you will most likely see a different midwife at each clinic visit. Another midwife, from the labour ward team, will care for you during labour, and a different team of midwives provide postnatal care to you and your baby. Another disadvantage is that there are often long waiting times in the antenatal clinics (a friend of mine used to show up for her antenatal visit, take a ticket, and go to the cinema. She would come back after the film and her number would still not have been called). Finally, midwife-led care is not available in all maternity units in Ireland, with some units offering consultant-led care only.

Midwife-led care: community based

Some hospitals offer midwife-led care via a specialist team of midwives called Community Midwives. This pattern of care is very similar to the above, with two main differences. The first is that the same team of midwives covers antenatal, labour and postnatal care, so there is more continuity of care. The second is that antenatal care takes place in satellite clinics, rather than in the maternity hospital, and appointments usually happen as scheduled, so you can skip the waiting time.

The Community Midwives usually facilitate an early transfer home, where mum and baby can go home six to twenty-four hours after the birth, and the midwives provide postnatal care via home visits. HSE homebirth schemes are also usually provided by Community Midwives.

If you think the Community Midwives sounds like a good option for you, book in as soon as you get pregnant! They tend to fill up pretty quickly.

Consultant-led care

In practice, for low risk women, this model of care looks pretty much identical to hospital based midwife-led care. The only difference is that you are under a consultant’s care, but you are unlikely to ever actually see the consultant. Your antenatal and postnatal checks will be with a midwife or perhaps a doctor on the consultant’s team. You may get a scan at 12 weeks, depending on the team and on whether there is a midwife or doctor available to perform the scan. (All antenatal visits include checking the baby’s heartbeat using a Doppler machine, however.)The anomaly scan at 20 weeks again depends on the hospital’s policy.

If you are a public patient but have a medium or high risk pregnancy, midwife led care is not an option and so you will automatically have consultant-led care. The particular model of consultant-led care will vary depending on the nature of the risk. For example, if you have gestational diabetes, you will typically be seen by a specialist team of midwives, with referrals to the doctors or consultant as appropriate. The same team of midwives will care for you and your baby during your antenatal period and during labour. If you are having a multiple birth of triplets or more, you will typically see a consultant at each visit. If there are concerns about the baby’s growth or health, your baby’s antenatal care will be provided by the foetal medicine team, while your antenatal care (checking blood pressure, urine, etc) takes place as part of a standard public antenatal clinic. Higher risk pregnancies therefore often mean greater continuity of care for the woman, with the highest risk women typically seeing the same consultant and/or team of midwives throughout pregnancy.

Semi-private care

Some hospitals offer semi-private care as an option. Semi-private care is consultant-led only; there are no midwife-led semi-private options. You will need to choose a consultant whom you wish to care for you and book in with them yourself. Your GP may be able to recommend a consultant, but check what their fee is as they can vary substantially, even amongst consultants in the same hospital. Under semi-private care, antenatal care is provided by the consultant’s team of doctors and midwives, and you may see the consultant at some antenatal visits for a low-risk pregnancy. If your pregnancy is higher risk, you are more likely to see your consultant rather than their team at antenatal visits, although this can vary depending on your consultant and your risk factors. You may get more scans than a public patient, depending on the particular pattern of care offered by your consultant. If you spend any nights in hospital, they will be in a semi-private ward, which is usually smaller than a public ward.

Most health insurance packages will cover the cost of three nights stay in a semi-private ward or five nights in a private ward if you had a c-section, but you must pay the consultant’s semi-private fee. You will also have to pay for any blood tests or scans that you get, although some insurance companies may cover a portion of this. If you need to spend more than three (or five) nights in hospital, you typically have to pay for those yourself, although again this depends on your insurance plan. Finally if there is no space in a semi-private ward you will be placed on a public ward but will still have to pay the semi-private fee.

It’s generally not possible to switch from semi-private care to public care halfway through, so make sure you’ve thought through all the pros and cons before making a decision.

Private care

If you opt for private care, you will be seen for all antenatal visits by your consultant in their private practice, wherever that is based. This is the case whatever your risk level. Again, you will need to choose a consultant yourself and book in with them – don’t forget to check what their fee is in advance. You will be liable for the consultant’s fees and scans and tests, while health insurance will cover the cost of a private room in hospital (if available – if one is not available you will be on a public ward but will pay the cost of the private room). When you go into labour, you will be cared for by the midwives in your maternity hospital with the consultant attending the birth, if they are available. If you are planning a c-section, your consultant will carry this out, whereas if an emergency c-section is required your consultant will carry it out if available, otherwise another consultant will perform the section.

Self-employed midwives

There are a number of self-employed midwives who provide a HSE or private homebirth service throughout the country. These midwives have a working relationship with the local maternity hospital, with formal arrangements for transfer to the hospital in the event of complications during a homebirth. The HSE funds the homebirth service in particular catchment areas, while most health insurance companies will cover the cost of a homebirth with a private midwife. The midwife will provide all antenatal and postnatal visits at your home, along with the actual birth.

The bottom line

People have many different reasons for choosing public, semi-private or private care, but the main reasons cited by women for opting for private care seem to come down to one or both of two main things: continuity of care, and a private room. Most women prefer the idea of building a relationship with their care provider during pregnancy, rather than meeting a stranger for every visit, including labour. For low-risk women, the only way to ensure continuity of care with one care-giver is via a private consultant or homebirth service. The only public option to come close to continuity of care is the Community Midwives, and this service is not available in all maternity hospitals.

The National Maternity Strategy highlighted lack of continuity of care as a real issue for many women, and proposes a new model of care to ensure that all women under all pathways of care have continuity. Many aspects of this Strategy are as yet unimplemented, and unless things accelerate, continuity of care for any low-risk women may become a thing of the past once the SláinteCare contract is implemented. In any event, all women should have continuity of care, not just those who are able to pay for it. This is recognised as the target model of care by the HSE and the Department of Health. We should hold them to account.

One final note: if you’re pregnant and still daunted by the various models of care, drop us an email. We’d love to help you navigate them.

Muireann