The most powerful force in the battle over the future of maternity units at Monaghan and Dundalk may not, in the end, be public opinion, the Minister or the members of the health board. What matters most may be the attitude of insurance companies.
The apparent inability of the North Eastern Health Board to get insurance cover for the threatened units may spell the end for the maternity units as they now operate.
Whatever political pressures are brought to bear, it is unthinkable that the NEHB could continue to run these units without insurance.
If and when the NEHB gets its meeting with the Minister for Health and Children, the insurance issue is likely to hang over that meeting like a cloud.
It is an issue which may well arise in changes - perceived as cutbacks - in other hospitals, especially smaller hospitals.
What is behind the insurance company's attitude is the failure by the two hospitals to meet the guidelines set by the Institute of Obstetricians and Gynaecologists.
The Institute says a minimum of 1,000 births a year are needed to enable consultants to maintain their expertise and trainees to learn skills. Monaghan Hospital had only 344 births in 1999. Louth Hospital, Dundalk, had 497. Each unit has only one consultant. This recommendation led a review group to recommend that the consultant-led maternity service at both hospitals be ended.
At Dundalk, the State's first midwife-led maternity unit would replace the consultant-led unit. Potentially difficult births would, as far as possible, be anticipated by screening and would take place at Drogheda.
Monaghan would provide gynaecology services and "outreach" maternity services. The proposals have been strongly resisted locally and by members of the North Eastern Health Board. In Dundalk, tens of thousands of signatures have been collected by campaigners who believe more beds would attract more pregnant women and bring the numbers up to the magic 1,000.
In Monaghan, the Sinn Fein TD, Mr Caoimhghin O Caolain, has been running strongly on the issue.
The odds against the campaigners are high, though. The consultants at both hospitals have stated that they cannot provide an adequate service as matters now stand. But most of all, there is the attitude of the insurance companies.
pomorain@irish-times.ie