There were no chandeliers in the public ward where I spent my first days as a mother, at the oldest continuously operating maternity hospital in the world. The room echoed with cries, the well-worn floor bouncing under footsteps, the windows looking out on Dublin’s city centre.
Now the Rotunda hospital, where I’m due to give birth again soon, is counting down to its 1 millionth baby. It is also at the centre of a bitter debate over plans to reform Ireland’s two-tier state healthcare system, so that those who pay to “go private” in public hospitals no longer gain an unfair advantage over those who don’t.
A chandelier is the background for the Rotunda Private’s soft-lit webpage, which lists fees of up to €4,500 to be treated privately in this public hospital. Maternal healthcare in Ireland is provided free by the state, and there are no stand-alone private maternity hospitals in the country. But in the public hospital system, patients who can afford it can pay to access continuity of care with a private consultant, private scans and the right to request a private room after birth.
Ireland is an outlier in Europe by not providing free universal primary healthcare. But at least in public hospitals, its two-tier arrangements could finally be ending. A radical overhaul of the state healthcare system seeks to ensure equal access for every citizen. The “Sláintecare” plan was launched nearly 10 years ago with cross-party support and aims to deliver equal access to health services based on individual patient need, not on ability to pay. But it has still not been fully implemented.
Under the reform, hospital consultants on new public-only contracts are barred from carrying out private work in public hospitals. More than 60% of consultants have signed up to the new contracts in exchange for pay that can exceed €300,000 (with on-call duties and overtime). With no private maternity hospitals, giving birth is finally set to be made entirely public.
But a backlash has exposed both a worryingly low obstetrician-to-patient ratio, and the resistance of these highly paid senior doctors to a fairer, single-tier health system. Ireland has fewer hospital consultants than most countries in the EU, with many medical graduates emigrating. The lowest uptake for the new public-only contracts is in obstetrics and gynaecology, at just over half.
The extent of private activity in Ireland’s public healthcare system and the fight for a single-tier system puts us at the centre of a Europe-wide debate over separating the two.
The government recently prevailed in a long-running standoff with the Rotunda’s management by threatening to cut funding. This followed the revelation that, despite the ban, consultants on public-only contracts were still treating private patients in this public hospital, using public resources, while billing insurers for hundreds of thousands of euros of care, with the Rotunda’s board’s permission.
Allegations that private consultants gave financial gifts as high as €1,500 to public-only colleagues to deliver their private patients’ babies on weekends fuelled the controversy.
Senior figures at the Rotunda have argued that women should be able to choose between public and private. But if there is a shortage of consultants, surely all their time needs to go to higher-risk pregnancies whether the mothers can pay or not?
A Rotunda staff member who sees public and private patients assured me that births take place in the same delivery rooms, and that patients are meant to be seen according to need. “The sickest women often get the best care,” she said. She suggested the dispute was less about maternal “choice” than about a revenue stream that hospitals don’t want to give up. A fully public system was “the only way to have truly equitable care”, she said.
Beyond maternity, there are wider concerns about unfair use of public hospital resources for private healthcare. Despite Ireland being a wealthy country with high spending on health, public hospital corridors are often lined with patients on trolleys, sometimes waiting days for a bed, while children spend years in agony on lists for spinal consults.
Nearly half the Irish population relies on private health insurance, as in many cases this means they can skip the long waiting lists in public hospitals. I have basic health insurance, but I went fully public for maternity care during my first pregnancy, paying for prenatal testing, which I feel should be free.
As a public patient without complications, I was cared for by midwives at the Rotunda. Ireland has low maternal mortality but one of Europe’s highest C-section rates, and midwife-led care can offer less intervention and should be expanded, as the WHO advocates.
Midwives gave me freedom in labour, helped my baby latch, taught me to use a blanket with the smell of my skin to get him to sleep, while I bled in shared toilets and fed myself one-handed. Now, just a few years later, some of the free midwife-led antenatal classes I found crucial are stripped back. And not everyone in Ireland can access midwife-led care. Our government, seemingly championing public care, is also overseeing a crisis in midwifery staffing, driven by state cuts.
Around a quarter of pregnant women in Ireland go private or “semi-private”, an option that the state health service still officially says is available in all maternity units in the country. In practice, however, private maternity care is gradually being eliminated. At the National Maternity hospital, an unprecedented 150 women were turned away for private care in just six weeks in June and July, fuelling a campaign against women losing this “choice”.
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But any patient who requires it should be able to see a dedicated consultant obstetrician on a public-only contract. And while many women have traumatic experiences of giving birth in Ireland, surely we should be fighting for every pregnant person to have access to the care they need – not just those who can pay.
A health worker I know opted for private care for her second baby after experiencing missed complications and absent consultants during her first public maternity. But in her work she sees consultants “using the public system to their advantage and funding a lot of their private practice through it.”
Weeks ago, a still-developing body inside my belly flickered on ultrasound. I was told to come back in a month because of a borderline concern. As a public patient, I worried about falling through the gaps.
Since then, a brilliant midwife and public sonographers referred me to consultants including top foetal medicine specialists listed on the Rotunda Private site. I see them for nothing as a public patient. This is how the system is meant to work, escalating care according to need.
Yet it is gutting to know there is a perception that I could be risking my baby’s health by not “going private”, for the continuity of care that paying patients receive and which midwives have been demanding be made standard for all.
I trust the people working hard to provide strong public care, and we shouldn’t have to “go private” to feel safe. If everyone is equally relying on one system, there is real pressure for change.
There is a history in Ireland of bishops, doctors and conservative politicians railing against free healthcare for mothers and children, desperate to maintain control and profit.
I want a fully public, equitable health system. For that to work, those in power must ensure resources and accountability.
My Rotunda maternity ward looked across to a statue of Charles Stewart Parnell, the first president of the Irish National Land League – a mass movement against private monopolies. Ireland’s revolutionary proclamation envisioned “cherishing all the children of the nation equally”. What better way to cherish every child equally from their first breath than a fully public maternity system?
