Birth choices: At home or in hospital? Public or private?

While many changes are promised by the National Maternity Strategy published in January, birthing options, and conditions, currently vary greatly across the country.

Your location, economic circumstances and health insurance cover will dictate the choices of where, and with whom, you give birth. Most maternity care in Ireland is obstetrician-led care in hospitals, but with midwives in attendance during labour and birth. Arrangements will differ between hospitals and doctors, but private care means antenatal visits are with your chosen obstetrician, and they will be at the delivery of your baby, unless unavailable.

Semi-private care usually means you see a consultant, or one of their team antenatally, and a team doctor will attend the birth if needed. Public obstetric patients may see a range of doctors, or midwives at clinics, and will only have a doctor at the birth if needed. Private and semi-private wards meanwhile, generally offer far greater postnatal comforts than public facilities.

If your pregnancy is “low-risk”, public midwife-led schemes and clinics are available in some hospitals.These include Domino (Domiciliary In and Out) services at the three Dublin maternity hospitals, Waterford maternity hospital, Wexford hospital and Cork University Maternity Hospital. Midwife-led maternity units are also attached to Cavan General Hospital and Our Lady of Lourdes in Drogheda.

Home births are possible with the community midwife teams at Dublin's National Maternity Hospital and Waterford, but only under strict criteria. There are currently 19 self-employed community midwives in 10 counties providing care and home births under the HSE's free National Home Birth Service. A private company, Neighbourhood Midwives, also offers home births to women in Dublin, and parts of Leinster. Even with a home birth you will still need access to a hospital if further medical attention is needed.

When choosing where, and with whom, you will give birth remember that policies and practices vary greatly between maternity units, and even between individual care providers within units.

And while interventions during labour and birth may become medically necessary, some hospitals routinely intervene in labours – eg by breaking your waters or by inducing labour – or may restrict your movements or birthing positions. Foods and oral fluids may also be restricted. You need to know what these policies are, and how they may affect your labour and birth. The range of birthing aids will also vary .

The Coombe Women & Infants University Hospital in Dublin is the only unit that permits births in water. Since 2013 about 260 women have used the pool for pain relief during labour, and of these 70 women have chosen to give birth in water.

Some of the issues to consider before deciding where you will give birth include:

What type of care will suit YOU best? Will a midwife be with you throughout labour? Will a doctor attend the birth? What type of interventions – eg the use of oxytocin – are regularly used during labour and birth, and why? Is epidural pain relief available 24/7 if you need it? Is continuous monitoring routinely used during labour irrespective of risk status? Will your carer/hospital facilitate an intervention-free labour and active birth if this is what you want? What labour and birthing aids will be available to you? Is skin-to-skin contact between mother and baby (or partner and baby) facilitated after birth? What is the policy about delayed cord clamping? How long do you stay in hospital after the birth, and are early discharge schemes available?

A valuable resource is the consumer guide to Maternity Care Services from Cuidiú at bump2babe.ie which outlines units around the country and provides statistics, including percentages of inductions, Caesarean sections and episiotomy. Check locally in case policies and services have changed. Further information on Home Birth is available from the National Home Birth Service page on the HSE website and from homebirth.ie and homebirthireland.com

If you discover you are having multiple births, or develop complications, you may have to reconsider your birthing choices during pregnancy, or even while in labour.

"Some women write a birth preference list – almost like a wish-list for how they would like labour and birth to go. It's a guide for the midwives and doctors on the labour ward,"says Paula Barry, midwife at the Coombe Hospital.

“Sometimes birth-plans do not go according to plan, but the main thing is to be positive, and to be aware that things can happen. I advise women to keep an open mind and not get fixated on one particular thing. There is always a Plan B and midwives and doctors are there to guide and assist them.” Louise Ní Chríodáin