I gave birth to my three children over 30 years ago, one emergency caesarean and two vaginal births. I didn’t understand how much these experiences impacted me at the time; what I did know was that maternity care could be better. Many years and one hip replacement later, at 41 years of age, I began my journey to become a midwife. After four years, I qualified in 2011.
For 12 years of my career, I worked in a voluntary hospital providing antenatal care to those attending semi-private and, in later years, private care. For someone committed to the philosophy of midwifery-led care, it might seem a strange choice to make.
However, I saw semi-private as an opportunity to provide continuity of care (with fellow midwives) and continuity of care. I recognised those who would benefit from seeing the same midwife throughout their pregnancy, while also seeing this somewhat mirrored by consultant colleagues in private care.
At the same time, I witnessed my midwifery colleagues struggle to provide this continuity in overcrowded and understaffed public out-patients department. I believe very strongly in healthcare equality with equal access for all, so it was conflicting.
With this in mind, I viewed the events of the last few weeks with puzzlement. Why was obstetrics seemingly so unprepared for Sláintecare — the implantation framework was published in August 2018 by the then minister for health Simon Harris and the public-only consultant contract (POCC) introduced on March 8, 2023?
The unpreparedness within maternity care provision was baffling, especially given private maternity care is perhaps more affected by any other area. Within the dialogue, "choice" and "safety" were words kicked about more than the ball at the opening game of the Fifa World Cup.
The idea of maternity care without private healthcare as an option was deemed "alarming". Culturally, within our two-tier healthcare system, these two words are interlinked. People are grateful they have private general health insurance when faced with critical and non-critical medical conditions, yet when we consider other areas of general medicine such as neurology and cancer care, public healthcare is now the preferable referral option, and in some cases the only option.
So how is maternity care different? Unlike general medicine, most women accessing maternity care are healthy and don’t require specialised expertise — they could be cared for by midwives both in hospital and in community clinics.
Midwifery-led care and particularly a known midwife is much more cost effective, increases maternal satisfaction rates, fewer interventions, and improves clinical outcomes. Some may prefer to also see a doctor, and that option is open to them too.
Yes, clinics are busy, however, investment in Sláintecare and a single-tier system could improve this with more consultants (both public-only contract and non-public-only contract) available to see patients rather than just overseeing clinics.
So where do midwives stand within this discourse and how will their role change? For most women, whether their care is private or public, the midwife is the person they meet at their first visit — our role is to assess medical or emotional needs and supports, possible referrals to specialist clinics, from endocrine to mental health; we begin antenatal education at that first encounter, advising on nutrition to exercise to vaccinations.
Midwives discuss areas of social wellbeing, domestic violence, misuse of drugs or alcohol — the list is vast.
Most importantly, we support the first tentative steps towards the transition to motherhood. Again, whether public or private, in any care outside of scheduled appointments, the midwife will be a woman’s first point of contact, they will alert, refer and follow-up any issues that occur, they facilitate care in daycare assessments, any admission during pregnancy, fetal assessment etc.
When a woman arrives in labour (again, both public or private) the midwife does the first assessment, cares for the woman in labour, organises the epidural (if wished) supports the woman giving birth, whether physiological or Caesarean, and cares for her during her initial postnatal journey. The same midwives, our care adapted to every woman’s birth and her needs, not her hospital status of public or private.
So how is the argument for the continuation of private care centring around "choice" and "safety", when it shouldn’t be? How has choice in maternity care and carer suddenly been given a level of importance never seen before?
We have a maternity strategy nearing its 10-year conclusion, with very little expansion of midwife-led care (one of the strategy's primary aspirations) and no increase in midwifery-led units — still the original two units that opened in 2004.
With regard to safety, Ireland had its highest record of maternal deaths through suicide in the last MDE report, with black and Asian women twice as likely to die in pregnancy.
Research in Ireland has shown that the level of risk and safety does not influence a decision to choose private maternity care. That decision is centred on socioeconomic status, being born in Ireland and maternal age.
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