Postcode lottery still a crucial factor in maternity care access
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Childbirth can be joyful and wonderful while also being fraught with decision-making for women and their families as they opt for public or private, hospital or home, midwife or obstetrician.
Since 2016 the National Maternity Strategy has aimed to give more choices to women with further changes to the public-private maternity options potentially coming under Slaintecare, however, those options still appear limited by geography or income.
Hailed as a radical policy, the strategy was part of the State’s response to heart-breaking infant tragedies which highlighted catastrophic flaws in some areas. A key plank in the strategy along with increasing safety was decreasing reliance on obstetricians and hospitals by offering more access to midwifery care.
The services are huge - 58,443 births last year, including almost 650 homebirths - and women’s experiences can vary from unit to unit or sometimes within a unit depending on who is in charge on the day.
Today, some counties offer combined community-hospital programmes but many do not. Some offer homebirths but again many do not. There are women who fulsomely praise their midwives and obstetricians, fundraising for hospitals in gratitude or welcoming community midwives as part of the family.
Complex fetal surgery on babies still in the womb is done at the Rotunda hospital, and Cork University Maternity Hospital (CUMH) led global understanding of Covid placentitis.
However, tragically we recently saw two confirmed maternal deaths, Tatenda Mukwata at University Hospital Kerry, and Laura Liston after a homebirth in Limerick.
New figures on severe complications linked to birth found that one in 168 maternities experienced issues including major obstetric haemorrhage during 2020. That was in the latest Severe Maternal Morbidity report from the National Perinatal Epidemiology Centre in Cork.
We have 19 maternity units but just two are midwife-led; Our Lady of Lourdes, Drogheda, and Cavan. In contrast, London offers 30 similar centres with many more around England.
It should be said while British maternity services are often held up as aspirational, NHS England is currently grappling with the fallout from an inquiry into the Shrewsbury and Telford trust. This found over a 20-year period 201 babies and nine mothers could have or would have survived if the trust had provided better care.
Overall though, it is possible to argue the NHS offers more options to women than Ireland does. For example, the HSE pregnancy website opens with “Find out what happens during birth, when you might need extra medical help, and read advice on recovering afterwards”.
In contrast, the NHS England page suggests: “Find out how to get ready for the birth including making a birth plan.”
It continues: “You can give birth at home, in a unit run by midwives (a midwifery unit or birth centre) or in hospital. Your options about where to have your baby will depend on your needs, risks and, to some extent, on where you live."
There were 613,936 live births in England during 2020, and for that year homebirths made up 2.4% across England and Wales, which could indicate 14,000 in England.
The HSE site does give information, after some clicking around, on birth plans, midwifery-led units, Domino midwifery-hospital schemes and homebirths but there does not appear to be a list of where exactly these are.
Women on Domino schemes see midwives through pregnancy and birth, attending community clinics with births mainly in the supporting hospital.
However, these public schemes are only available through some hospitals including CUMH, the three Dublin hospitals, Wexford General and Waterford University Hospital.
CUMH says the scheme is offered to low-risk women within a five-mile radius and includes GP and/or midwife support.
“The Domino team aim to empower and educate women to give them the knowledge, skills and confidence to birth without medical intervention in a calm quiet environment with the support of a midwife who is known to them,” the hospital said.
The benefits for women include continuity of care and a hospital-based birth with an early return afterwards. Private obstetrician-led maternity care is available in all units.
It is not yet clear how this system will work under Slaintecare as that reform policy aims to remove private healthcare from public hospitals. Newly hired consultants will be expected to commit to only public work.
Hospitals offer thousands of women private care, indeed plans for the new National Maternity Hospital to be built in Dublin include provision for 60 private rooms indicating they intend to keep this option.
Were Slaintecare to spell the end for private maternity care, it is not yet indicated how public care could be expanded to fill the gap. Women, as so often happens, have not been asked how they feel about losing the private maternity care option.
Concerns have already been raised by voluntary hospitals which rely on private money as to where their funding will come from instead.
Homebirths are available in some counties through private midwives or free through the HSE’s national homebirth programme.
Up to now, access to this has depended on whether midwives move to a particular area and are ready to offer the service. Two community midwives are needed to attend each homebirth, along with backup from the nearest HSE hospital.
The community midwifery system linked to the HSE is also changing. Expected to take about two years and to include changes in recruitment practices, this transition has already seen governance of services transferred from community to individual hospitals.
It is a system in flux and it is not yet clear how the national homebirth service will evolve under competing governance systems.
Terminations of pregnancy were listed in the Strategy under “population needs”.
Again geography is still a deciding factor here with just 11 of the 19 units supporting GPs who offer medical terminations. Over half of Irish counties have fewer than 10 GPs offering medical terminations.
It would be nice to think a pregnant woman in Bantry could have the same options as in Ballsbridge whether it comes to pregnancy care, birth options or terminations but we seem to be a long way from that just yet.