This observational study found that the Great Economic Recession in the Republic of Ireland was accompanied with a decrease in demand for the private and semi-private packages of maternity care and an increase in the demand for publicly funded maternity care. However, despite economic recovery and an increase in both male and female employment rates nationally, the demand for private and semi-private packages of care did not recover. The longitudinal analysis showed also that women who choose private care in their first pregnancy usually opted for private care in their subsequent pregnancies, and, likewise, women who choose public care in their first pregnancy usually opted for public care in their subsequent pregnancies.
The Irish health insurance system is based on the key principles of community rating, open enrolment, lifetime cover, and minimum benefits . Between 2009 and 2017, there was a significant exodus of younger people from the PHI market from 36 to 30% in the 18–39 years age group . As a result, the Irish Government introduced the Lifetime Community Rating (LCR) loading in 2015 which penalises adults who take out PHI for the first time after 35 years of age . The loading rises steeply again after 45 years of age. In the 19–39-year age group, the number of people taking out PHI had fallen from 675,000 in 2009 to 484,000 in 2014 . The LCR has resulted in an increase in adults taking out PHI in this age group to 506,000 in 2017.
The decrease in women choosing private maternity care may be explained in part by the decrease in younger women holding PHI. However, the increase in female employment after the recession and the introduction of the LCR have not been accompanied by an increase in demand for private care. It may be the case that this cohort of women is challenged fiscally by, for example, the costs of mortgages and childcare. It is interesting, but not surprising, that the largest decrease in women opting for the private package of care were women in the professional or management class. Families in this category may have faced a cut in salary and an increase in income tax during the recession. In contrast, women who were not in employment were less likely to have chosen private care before the recession, and their take home income may have been socially protected as a result of government policies. However, these findings we believe require detailed study.
In May 2018, the Houses of the Oireachtas Committee on the Future of Healthcare (Sláintecare) report was published . It was a unique crossparty political consensus on a major health reform in Ireland. A 10-year-costed plan recommended a whole system reform with a universal single-tier health service where patients are treated solely on the basis of need. Although an Implementation Office was established by the Department of Health, a single-tier system is not imminent, and the health services are currently prioritising the management of the COVID pandemic. No specific recommendations were made in the report for funding maternity services. In an analysis from the ESRI using the hospital discharge data from public hospitals in 2015, public maternity patients accounted for a 6.0% activity share, and private patients, a 1.4% activity share .
In the absence of an increase in per diem charges to private patients, a falling demand in those opting for private care will lead to a decrease in publically funded hospitals’ revenue. The growing increase in the demand for the public package of care means that there will be little or no reduction in ongoing hospital costs. As pregnancy and delivery rates are beyond the control of the health services, funding shortages cannot be solved by methods applicable for other services, for example, waiting lists for elective surgery. As there are no private maternity hospitals left in Ireland, removing private maternity practice from public hospitals as proposed by Sláintecare also poses challenges . Given the prohibitive costs of obstetric negligence insurance, it is unlikely that private hospitals will open private inpatient maternity services in the future.
In Ireland, choice is important to women when it comes to maternity care [4, 14]. In particular, they prioritise safety for their baby and the continuity of care over a hospital’s facilities. A qualitative paper found that women who choose private care felt an added sense of security in labour due to the continuity of care with their obstetrician . The abolition of the private and semi-private packages of care in public hospitals would deny women who have been paying PHI, perhaps for many years, of choice. It is notable in our study that the continuity of care packages was maintained from one pregnancy to the next.
Younger women who pay PHI are generally healthy, and the national policy of community rating means that younger subscribers to PHI subsidise older subscribers . A recent Irish study has shown decreasing percentages of ‘very healthy’ and ‘healthy’ women with PHI coverage between 2009 and 2017 . Despite the LCR, the absence of benefits for maternity care may lead to a further exodus from PHI of younger, healthy subscribers who face more immediate financial demands.
The Great Economic Recession and subsequent recovery had a dramatic impact on Ireland, which makes it an interesting case study on the link between the economy and the purchasing of PHI . In general, increasing age, higher educational achievement, and higher incomes are associated with increased PHI coverage. This is consistent with our observations in maternity care. However, it is notable that the recession and the increase in unemployment rates nationally were associated with a decrease in demand for private and semi-private care and that the subsequent recovery and decrease in unemployment rates has not seen a decrease in women opting for public care. It also remains to be seen what impact the COVID-19 pandemic and the anticipated acute economic recession will have on maternity services over the next decade.
This study has strengths. The clinical and sociodemographic characteristics were recorded at the first antenatal visit by a trained midwife in a standardised way over 9 years. The hospital population is large and broadly representative of the national obstetric population . Due to the large sample size and pseudoanonymisation of the study subjects, we were able to analyse the data of women who delivered more than once over time and analyse the changes in packages of maternity care from one pregnancy to the next.
A potential weakness is that we do not have information on which women had private health insurance but chose not to opt for a private package of care. In addition, the semi-private package of care is unique to the three large Dublin maternity hospitals and is not available outside the capital. Nonetheless, the increase in demand for public care is likely to have been replicated in the 16 other maternity hospitals nationally.
This detailed analysis on annual trends in the demands for the different packages of maternity care in a large hospital in Ireland’s capital provides information that should help shape the implementation of the National Maternity Strategy and the Sláintecare Report [12, 15]. In particular, it demonstrates that future enrolment in PHI, and the demands for private maternity care cannot be modelled based on the rates of female employment alone.