More C Sections in Private Obstetric Care – But What’s the Full Story?

On 14 March 2022, The Conversation published a story titled More c-sections in private obstetric care

The article references a study which showed an increased likelihood for an unplanned caesarean birth in a private hospital setting.

NASOG President, A/Prof Gino Pecoraro commented on the article on Twitter and in a response to Medical Republic.

Articles like this play a key role in raising the profile of private healthcare in Australia, but rarely in a positive light and often without consideration of the range of individual circumstances that impact the decisions made by specialist obstetricians with each and every one of their patients.

Key to NASOG’s role is promoting the full perspective of private practice and encouraging government and community to consider all sides to the story. We strongly encourage members and supporters  keep doing the same.

A/Prof Pecoraro’s article is shown below. If you feel strongly about this issue, add your comments on the original article.

While this study is interesting and an import focus for discussion, it does not tell the whole story. All obstetric outcomes are important, including patient satisfaction data, rates of “birth trauma” and long term effects of childbirth on women, not just the mode of delivery.

Other studies, from Melbourne and Brisbane , suggest private obstetric patients when matched for complexity, maternal age and co-morbidities etc, have some beneficial outcomes when compared with their public sisters.

Tudehope in his 2017 Brisbane paper, reports a decrease in the perinatal mortality rate for mothers delivering in the private sector and concluded “differences in clinical practices seem to be partly responsible.” There are similarly lower reported rates of 3rd and 4th degree tears in private obstetric patients which might also be as a result of differing practise between the 2 systems.

As with all retrospective data analysis, potential confounders can exist and the authors admit that an RCT to get a definitive answer would be unethical to undertake so this type of research is what we must rely on .

I believe it is an oversimplification to suggest that the method of remuneration in the different sectors is the major or only incentive to offer obstetric treatment – the use of the word “intervention” to describe obstetric treatment is perjorative and plays into the emotive nature of this conversation.

In fact the continuity of care that private obstetrics offers women means that 1 doctor is responsible for her care and outcomes rather than a team of obstetricians and this in itself may change the risk acceptability for both woman and obstetrician.

As briefly alluded to in your article, the litigation burden carried by private obstetricians might be what drives the higher section rate and this could be minimised by having private obstetrician indemnity insurance premiums capped or kept at the same rate as public hospital obstetricians and midwives.

Another issue to consider is the effect of the NSW public health policy “Towards Normal Birth” which was in place during at least part of the study period. This government policy affected women’s choice and precluded publically treated women from accessing an elective c section in public hospitals without a “medical indication” .

Many women considering an elective c section (or just wanting the option) during this time, opted out of the public sector. While the authors report that women definitely wanting elective sections were excluded from the data, this data can be difficult to analyse and tease apart. It would not be unreasonable to assume that these women had a lower tolerance for some procedures like operative vaginal delivery or risk generally and this may have affected the rates of c section that were performed.

While this is an interesting study and rightly should promote discussion and reflection, it is by no means the entire story. Sensational headlines aside, Australia depends on both public and private maternity systems to survive and thrive if we are going to meet the obstetric needs of our population both now and into the future.

“Perinatal mortality disparities between public care and private obstetrician led care- a propensity score analysis” Adams, Tudehope et al BJOG 2018 Jan;125 (2) : 149-158

“Pregnancy outcome at term in low risk population: Study at a tertiary Obstetric Hospital” Permezel et al J. Obstet Gynecol Res Vol 41, No 8, 1171- 1177 August 2015

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