Aussie Debate Over Private Versus Public Hospitals
Following a series of what could be called pro-obstetric and anti-midwife headlines in Australian publications, the article “Private birth has benefits for babies” was posted by the Sydney Morning Herald on February 16. The authors of the study featured in the article tout the benefits of all obstetric intervention, essentially thrusting the onus of proof back on advocates of a less-is-more philosophy about childbirth.
Babies born to women in private hospitals are less likely to need resuscitation at birth or admission to intensive care than those born in a public hospital, a national study has found.
Obstetricians say the study, published in the Medical Journal of Australia, debunks widespread criticism of the high intervention rates for women in private hospitals.
The authors, from the Australian National University and University of NSW, say the findings challenge the long-held orthodoxy that increased rates of obstetric intervention, such as caesarean and induction, are "bad" for women and their babies.
The study was released early online in anticipation of the Federal Government's maternity services review, which could come out as early as this week.
Viv from Hoyden About Town promptly addressed flaws in the study in her post “What the media isn’t asking about that private hospital birth study (or, Bayes’ Theorem for Dummies)” on February 17.
It doesn’t surprise me one little bit that a middle-class and wealthier population is going to have healthier babies, because they have the privilege of discretionary income to devote to supplementary aspects of pregnancy, while most people who don’t have private healthcare do not (one of the reasons they don’t have private healthcare, in fact).
To bring Bayes’ Theorem actually into the post: the researchers have taken a narrowly sampled sub-population already predisposed to having healthier babies, compared them to a far more broadly sampled population not generally sharing that same predisposition, and having discovered that their subpopulation does indeed have healthier babies, have then concluded that it is actually something they are doing to this subpopulation that is making a crucial difference.
On the same day, The Canberra Times then published the article “Midwives concerned birth study tells only one side of the obstetrics story.”
But Associate Professor of Midwifery and Australian College of Midwives national spokeswoman Hannah Dahlen said many other studies had shown the negative outcomes of obstetric intervention measures.
''There are at least 20 papers I can count now in the last two years that are saying the more caesareans you have, the more bleeding you have, the more times women lose their uteruses, the more babies that die in the next pregnancy,'' Professor Dahlen said.
She said the latest study did not take into account many important factors, such as obesity and low birth rate. ''Low birth weight is well known to be double in the public system,'' she said. ''You control for it when you look at adverse outcomes, because the strongest predictor of a baby dying or having adverse outcomes is a low birth rate and that should have been controlled for.''
ANU professor of obstetrics and gynaecology and senior specialist in maternal-fetal medicine at the Canberra Hospital, David Ellwood, said he believed the number of caesarean sections carried out was ''inappropriately high'', particularly in the private sector. He said the study did not take into account all of the relevant information about the differences in patients at public and private hospitals.
Then, on February 18, The Age’s article “Many more caesareans in private hospitals” reports that doctors at private hospitals perform twice as many cesareans and three times the number of inductions on healthy first-time mothers than those in Victoria's public hospitals.
Euan Wallace, chairman of the Victorian Government's Maternity Quality and Safety Committee, which produced the report, said intervention rates in public and private hospitals for healthy first-time mothers were concerning because there was theoretically no clinical reason.
He said he was particularly concerned about the possibility of women not being informed of the risks of induction, which includes an increased chance of caesarean delivery and other complications.
"I don't think we're worried about a woman who makes a fully informed choice for herself and her baby, but there are potentially lots of women being recommended induction of labour without being fully informed," he said.
In an effort to reduce the rate, the committee has set a new benchmark for hospitals, which says no inductions should occur for healthy first-time mothers without a clinical indication for the intervention. "We hope this will allow the hospitals to explore why is that happening and how they can decrease this intervention," he said.
Professor Wallace said a huge variation in induction and caesarean rates between public hospitals was also worrying because it suggested non-evidence-based practice increasing the risks for mothers and babies.
"Some hospitals had induction rates as high as 33.3 per cent, while others did not induce any of these mothers," he said. "It means that how a woman is looked after varies depending on where she lives in this state. We're uncomfortable with that."
Adverse outcomes of labour in public and private hospitals in Australia: a population-based descriptive study by Stephen J Robson, Paula Laws and Elizabeth A Sullivan is now online. Here is the abstract:
Objective: To compare the rate of serious adverse perinatal outcomes of term labour between private and public maternity hospitals in Australia.
Design, setting and participants: A population-based study of 789240 term singleton births in public and private hospitals in 2001–2004, using data from the National Perinatal Data Collection.
Main outcome measures: Third- and fourth-degree perineal injury, requirement for high level of neonatal resuscitation, Apgar score <7at 5minutes, admission to neonatal intensive care unit or special care nursery, and perinatal death.
Results: 31.4% of the term singleton births occurred in private hospitals. After adjusting for maternal age, Indigenous status, parity, smoking status, diabetes, hypertension, remoteness of usual residence, and method of birth, the rates of all adverse outcomes studied were higher for public hospital births. For women, the adjusted odds ratio (AOR) for third- or fourth-degree perineal injury was 2.28(95% CI, 2.16–2.40). For babies, the odds of a high level of resuscitation (AOR, 2.37; 95% CI, 2.17–2.59), low Apgar score (AOR, 1.75; 95% CI, 1.65–1.84), intensive care requirement (AOR, 1.48; 95% CI, 1.45–1.51) and perinatal death (AOR, 2.02; 95% CI, 1.78–2.29) were all higher in public hospitals.
Conclusion: For women delivering a single baby at term in Australia, the prevalence of adverse perinatal outcomes is higher in public hospitals than in private hospitals.
The Cesarean rate in Australia is 31 percent, which obstetricians say has risen due to older, fatter and more ethnically diverse mothers and has nothing to do with poor medical practice.