Christina Finn
CONTRACTS, INSURANCE, EMPLOYMENT law. All of these matters were discussed in the last two weeks during the stand-off between the government and the Rotunda Hospital.
In the end, there was much praise for Health Minister Jennifer Carroll MacNeill who won out, with the hospital conceding that consultants on public-only contracts will not treat private patients.
The health minister isn’t stopping there. In an interview with The Sunday Times today, the minister said she now has a laser focus on ensuring that consultants on the public-only contracts are fulfilling their roster obligations by working later into the evenings and over the weekend.
While the government and the consultants fought over who was right and who was wrong and whose legal advice trumped whose, the crux of the issue, women’s voices, and they wanted from Ireland’s maternity care, went largely ignored.
When this controversy first erupted, The Journal asked women to get in touch to share their stories about the Ireland’s maternity care, in the public, semi-private and private system.
Continuity of care
There were lots of responses. Many women spoke about having a very good experience in the public system and spoke about the hard-working midwives and doctors.
Others opened up about some very difficult experiences, and how at times in the maternity system they felt they weren’t listened to. Other women spoke about the kind of service they wanted or expected, with some stating that to get that, they chose to pay.
What came out from all the responses was that women, in one of their most vulnerable times of their lives, wanted the best standard of care, whether that was public or private.
Not only that, they want continuity of care.
Women who have gone through a particularly traumatic experience in the past or have worries about the future want a system that supports them when they call on it.
Many women say they have got that care and support in the public system, while others say they have not.
It is not that women fear the public system – as some commentators have said in the last week – it is that they want the best offered to them in the public system.
Many women want the same options, offers of support and reassurances that some women say are on offer to them in the private model. And women are right for demand that for the public system.
What do we want from maternity care?
As the Rotunda controversy dies down, we run the risk now of quickly moving on without questioning: What kind of maternity care do we want under Sláintecare?
During her interview with RTÉ’s David McCullagh last week, the health minister said women in the public system should be able to choose if they want consultant-led care or midwifery-led care if they are having a baby in the public system.
Who can disagree with that?
The ambition of Sláintecare and the public-only contract is to ensure that one day, there is equality across the entire healthcare system, including maternity care.
What women care about is that when they are in the maternity care system, can they see their doctor or midwife, preferably the same one, throughout their pregnancy, just like, as the minister points out, occurs in cancer treatment.
To that degree, The Journal asked the HSE and the Department of Health to outline what the current state of play is when it comes to public maternity services.
A statement from the HSE and the Department of Health to The Journal regarding what is offered to women in the public system stated that continuity of care is a key objective of the National Maternity Strategy.
‘No guarantees’
However, the HSE said “in practice, there is no guarantee that a woman in the public system will see the same consultant obstetrician or the same individual midwife at every appointment”.
It said in most instances, women are cared for appropriately by a multidisciplinary team and may see different members of that team over the course of their pregnancy, labour, and postnatal care.
“For women receiving care through midwifery-led services, continuity is typically provided by a team of midwives rather than by a single named midwife. Similarly, women may request to be under the care of a particular consultant, and maternity services will seek to accommodate such requests where possible, particularly where there has been an established clinical relationship in a previous pregnancy.
“However, this cannot always be guaranteed and is subject to service availability and clinical requirements,” said the HSE.
Another issue that was raised by a lot from women who reached out to The Journal was additional scans and appointments.
Many women who had been through years of IVF or had difficult pregnancies or multiple miscarriages, spoke about wanting scans before the 12 weeks and throughout their pregnancy.
It might not be out of clinical need, but it was for their mental health, women said, an important issue that we are only scratching the surface on in recent years.
Women said this was important for their peace of mind, which is all women want throughout their pregnancy.
What is offered to women under the public system?
In terms of additional scans and appointments, the HSE said public maternity services provide care, investigations and ultrasound scans in accordance with national clinical guidelines and individual clinical need.
“Additional scans or appointments are generally arranged where there is a clinical indication. Public maternity services do not routinely provide additional scans when no clinical need is identified,” said the statement.
Whether it is through public or private, some women want a doctor or midwife throughout their journey, some want more than two scans, particularly if they have issues in the past, but even if they have not, they want a system that can offer them those reassurances.
One woman who got in touch with The Journal said she chose to go private after experiencing multiple miscarriages.
She said after losing her first two babies, she wanted to have tests to find out what was going wrong. She said the hospital told her that those sorts of tests are not done until she loses her third child, so she could come back then.
Asked about this, the HSE said it recognises the emotional and physical impact that a miscarriage can have on women, partners and families.
It said that under its National Clinical Guidelines, recurrent miscarriage is defined as two or more consecutive first-trimester pregnancies, and while investigations may begin after two consecutive miscarriages, some tests are only carried out after the third miscarriage.
Consultants and specialist midwives run recurrent miscarriage clinics is some parts of the country, where investigations such as blood tests, may be suggested. But the HSE also said that not everyone will have access to a recurrent miscarriage clinic in their area.
In this instance, the treating GP or hospital may refer individuals to a doctor or specialist midwife for further investigation and support. The HSE also pointed to the “Recurrent Miscarriage – Information and support” booklet, which is accessible online.
Caesarian sections is another hotly debated topic when it comes to maternity care, with the insulting saying ‘too posh to push’ even finding its way into this debate over the last two weeks.
Elective C-sections not routinely offered in public system
Some women told The Journal they chose to go private to have a c-section after experiencing traumatic vaginal births such as having a third degree tear.
Asked about elective C-sections and whether they are on offer to women in the public system, the HSE said that all women have the opportunity to discuss their care plan and birth preferences with their medical team during pregnancy.
While Caesarean sections are an important and often necessary intervention, they carry risks, including infection, haemorrhage and longer recovery times, said the HSE.
A primary Caesarean section can also increase the risk of complications in future pregnancies, including placenta previa and placenta accreta and “for these reasons, elective Caesarean sections are not routinely offered solely on request”.
However, a planned Caesarean may be recommended in some circumstances, including if a woman has had one previously, if the baby is in the breech position, in cases where a vaginal birth is considered clinically difficult or unsafe and in situations where a baby requires surgery shortly after birth, and a timed delivery is important.
Keep women’s experiences at the heart of the debate
This controversy should spark a debate about what our public system under the Sláintecare model looks like.
Maternity care in Ireland right now is provided in line with the National Maternity Strategy (NMS), ‘Creating a Better Future Together’ which dates from 2016.
It is a 10-year plan which means we are in line for a new strategy soon, but sources indicate it’s not likely to be published in the short-term.
Labour’s health spokesperson Marie Sherlock said this week that there is a need to have an “honest conversation about where we are in regard to maternity care in this country, and chart a path forward to delivering best in class public care”.
The idealism from the health minister, which everyone hopes is achieved one day, is the end goal.
Yes, women should have consultant-led care or midwifery-led care if they choose, but as the HSE has confirmed, that is not always possible.
Yes, women should have continuity of care, the same doctor throughout, but again, that is not always feasible.
Yes, women who need extra reassurance should be able to request additional scans or appointments, but again, this isn’t often accommodated.
The public system may one day be everything it promises to be, and a better public system remains the goal. But today’s debate should start with the people experiencing today’s reality in Ireland’s maternity services.