Rates for obstetric intervention among private and public patients in Australia: population based descriptive study
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7254.137 (Published 15 July 2000) Cite this as: BMJ 2000;321:137
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
To the editor
Reply to paper entitled
Rates for obstetric intervention among private and public patients in
Australia: population based descriptive study
Roberts, Tracy and Peat's analysis of obstetric intervention in
Australia found that in Privately insured patients, financial
considerations were not implicated but time and practical factors possibly
were. This may be true in some instances. They also stated that there are
no obvious clinical reasons for intervention rates to be higher in private
than in public patients. There is evidence in the literature which offer
some explanation.
In Private practice, one is dealing with a different population of
patients. Often the women are older and career oriented, deferring
childbirth until later in life and have Private Insurance because they can
then usually afford it. Roberts, Tracy and Peat's analysis (Table 1 -
Frequency (%) of maternal and infant characteristics) supports this view.
Their figures at the two extremes of age groups 20-24 and 30-34, show a
significant difference in the likelihood of having Private Insurance.
This is not evident in the age group 25-29 where it seems to even out.
Other than the finding that Public patients have a significantly greater
parity and prolongation of pregnancy, all the other maternal and infant
characteristics between Private and Public patients were much the same. In
other words, looking at the profile of the 3 different age groups as
defined, the older a woman is, the more likely she will take out Private
Insurance, have a smaller number of children and not have a prolonged
pregnancy. That is, the likelihood of intervention relates more to a
woman’s age, medical awareness and choice than her Private Insurance
status.
If we now look at Table 2 and 4 and the Birth characteristics and
outcomes among primiparas and multiparas at low risk and compare the
various age groups in relation to their Private or Public status, there is
a significant difference in all the categories looked at between age
groups 20-24 and 30-34. It interesting to note that Privately insured
women had more episiotomies and fewer 3rd degree tears. This finding too
may be a reflection of the patient’s age directly (1) and insurance status
indirectly.
There is increasing evidence (2,3) that there is an incremental rise
in the risk of obstetric intervention with increasing maternal age.
Bearing in mind then that more women are embarking on childbirth at an
older age and in that age group they are more likely to be insured, the
findings of Roberts et al are to be expected. Their findings with
multiparas is similar and is consistent with other reports in the
literature. (3)
One of the very important issues therefore to consider is the impact
of age on the outcome of childbirth. Childbirth in older women may reflect
a progressive, age-related deterioration in myometrial function (2) and
this is an area of obstetrics that needs to be explored further. Most
clinicians would agree that whether or not a woman is Privately insured
does not greatly interfere with their decisions to intervene or not. Age
however may influence their decision. The link is between Age and
intervention and not Private insurance and intervention. Private insurance
in the older age group is coincidental and not a cause. To show the
influence of age on intervention, a full intervention analysis needs to be
made for each of the 3 age groups defined for both Private and Public
patients else bias creeps in. Their Age adjusted rates per 100 women for
obstetric intervention are pooled results and do not show the effects of
age.
A common thread amongst all countries is the fact that increasing use
of caesarean section is accompanied by decreasing use of instrumental
vaginal delivery. (4, 5) As older women are more medically aware, their
expectations and demands are greater. Women are now aware of the short and
long term sequelae of difficult childbirth and their impact on their
quality of life.(6,7) If therefore, modern obstetrics can offer women
safe predictable options and a dignified childbirth with minimal perineal
trauma, they will choose accordingly and are doing so. It is not a
question of defending a higher caesarean section rate as King states in
his editorial. (8) There is a significant morbidity in vaginal childbirth
even without intervention (9,10) and women are increasingly recognising
this.
It also needs to be recognised that many of the interventions
referred to are consumer driven and women are exercising their choice. To
relate the outcome of childbirth simply to their insurance status may not
only be misleading to the uninformed but also misused as has already
happened in the Australian Press (11).
References.
1. Angioli Roberto, Gomez-Marin Orlando, Cantuaria Guilherme, O’Sullivan
Mary J. Severe perineal lacerationsduring vaginal delivery: The
University of Miami experience, Am J Obstet Gynecol 2000; 182:1083-5
2. Rosenthal AN, Paterson-Brown,S. Is there an incremental rise in the
risk of obstetric intervention with increasing maternal age? BJO&G
1998; 105, 10
3. Wong S.F, Ho L.C. . Labour Outcome of Low-risk Multiparas of 40 Years
and Older- A Case-control Study. Aust NZ J Obstet Gynaecol; 38, 4, 388-
390
4. Paediatr Perinat Epidemiol 1993 Jan;7(1):45-54
5. Turner M. The Coombe Hospital, Dublin 1998 Personal communication
6. Sultan AH, Monga AK, Stanton SL. The pelvic floor sequelae of
childbirth. Br J Hosp Med 1996; 55: 575-579
7. Sultan AH, Stanton SL.Preserving the pelvic floor and perineum during
childbirth elective caesarean section? BJO&G 1996; 108, 731-4
8. King J. Obstetric interventions among private and public patients
Editorial, BMJ 2000;321:125-126
9. Wynne, M et al Disturbed Anal Sphincter Function Following Vaginal
Delivery Gut 1996;39:120-124
10. Kamm,M Obstetric damage and faecal incontinence Review article.
Lancet, 1994; 344, 730-3.
11. Sydney Morning Herald, Ragg, Mark, 20 Jul 2000 When women go private,
birth intervention is a specialty.
Competing interests: No competing interests
The study by Roberts et al engages us in the important task of
assessing obstetric intervention and maximising benefit whilst minimising
risks.
It is disappointing however that there is little attempt to address
the question of whether higher intervention rates improved outcomes for
mothers or their babies. It is very unusual for workers not to report
rates of stillbirth, neonatal death and admission to neonatal intensive
care units as measures of preinatal outcomes. Certainly these data are
recorded for the NSW Midwives Data collection form upon which this report
is based, and their absence puzzles me. Maternal mortality is also
recorded, but not reported by the authors.
I was also interested in the finding that women delivering in the
public system were twice as likely to sustain third degree tears as their
private counterparts, with no mention made of the incidince of fourth
degree tears. This raises a possiblity contrary to the view put by the
authors that private patients are exposed by interventions to an increased
risk of faecal problems in the long term.
Predictably, this report has received prominent media publicity in
Sydney, and used to further politicise the issue of maternity care. At
least the BMJ should remain a forum for scientific information and I
cannot understand why the article's reviewers did not require at least
some mention of maternal mortality and perinatal morbidity rates,
especially when the paper's conclusions state "information on the outcomes
associated with the various models of care may infleunce (womens') choices
Competing interests: No competing interests
Roberts, Tracy and Peat's analysis of obstetric intervention in
Australia contributes to a better understanding of the significant
variation in experiences of privately and publicly insured pregnant women.
Findings in Roberts et al 1 are consistent with a recent comparison of
episiotomy rates in NSW public and private hospitals 2, which indicated
that in choosing to purchase private health insurance, women were twice as
likely to experience an instrumental birth (forceps or vacuum). This was
in addition to increasing their probability of episiotomy by 60-85 percent
when delivering vaginally in NSW private hospitals 2,3. This is
interesting information in light of suggestions that Australian women may
perceive that choosing private health insurance for pregnancy purchases a
higher quality outcome for their pregnancy and birth than can be achieved
through the public system (Medicare).
Further to the comprehensive picture of intervention that Roberts et
al provide, is a concerning trend in the variations between private and
public hospitals. A longitudinal view of NSW Midwives data between 1993
and 1997 (using 60 hospitals for which data was comparable) reveals that
over this time, episiotomy rates whilst declining in public hospitals is
increasing in private hospitals 3. Episiotomy rates were 12-15 percentage
points higher in NSW private hospitals between 1993-1996 with a 16
percentage point difference in 1997. Multiple logistic regression
analysis revealed that even when clinical factors were controlled for
(such as instrumental birth), up to a 10 percentage point gap remained
unexplained by clinical factors relating to episiotomy 3. Even despite the
observed decline in 'private hospital' instrumental birth, from 22.2 to
20.3 between 1996 and 1997, the rate of episiotomy increased from 32.3 to
33.1 percent.
If women judge the benefits of private health insurance to outweigh
the risk of experiencing either episiotomy, epidural, induction of labour,
caesarean section or instrumental birth, then that is their choice as a
consumer. Presumably women purchase private health insurance specifically
for pregnancy because they believe that this provides them with benefits.
However, health insurers and practitioners have a responsibility to ensure
that women are in fact aware of the risks and benefits of their options
and are indeed making an informed decision. The impact that these choices
have on women's experience of pregnancy and birth should not be
underestimated as Roberts et al quite rightly emphasise. It is often said
that clinical practices should be justified using the best available
evidence, and one would hope that "practice styles" of midwives and
obstetricians reflects a commitment to this principle.
References:
1. Roberts CL, Tracy S, and Peat B. Rates for obstetric intervention
among private and public patients in Australia: population based
descriptive study. BMJ 2000; 321: 137-141.
2. Shorten A, and Shorten B. '(1999) 'Episiotomy in NSW Hospitals
1993-1996: towards understanding variations between public and private
hospitals', Australian Health Review 1999; 21:18-32.
3. Shorten A, and Shorten B. Women's Choice? The impact of private
health insurance on childbirth. 11th Biennial National Conference of the
Australian College of Midwives Inc, 1999, 2nd- 4th September, Wrest Point
Convention Centre,Hobart, Australia..
Competing interests: No competing interests
The relationship between epidural analgesia and instrumental delivery needs careful interpretation.
Editor - I was interested to read the article by Roberts and
colleagues 1. I would like to make a few comments on the relationship
between epidural analgesia and instrumental delivery.
Roberts et al observed that the epidural analgesia began a cascade of
obstetric interventions leading to a low probability of a non-operative
birth. They also noted that the private patients had higher age adjusted
rates of instrumental delivery, especially after an epidural. Another
important observation was that the use of augmentation or induction
without epidural did not noticeably increase the probability of an
instrumental birth. Do these observations really mean that the epidural
analgesia is responsible for increasing the incidence of instrumental
birth? I feel to express my reservation on this matter because of the
following reasons.
This study was based on statistical analysis of the data collected
retrospectively 1. There are other prospective randomised double blind
trials which investigated the effect of epidural analgesia on the outcome
of labour 2 3. One of the previous investigations found that the epidural
analgesia did increase the incidence of instrumental delivery and also
prolonged the duration of labour 2. However, a more recent study has
proved that the use of regional analgesia was not associated with increase
in either instrumental delivery or operative delivery 3. These
contradictory outcomes from these studies prove the complexity of the
issue 2 3. The decision on delivery by instrumentation depends upon many
factors. These factors often based on clinician's subjective judgement.
Epidurally administered local anaesthetic solution provides labour
analgesia, obtunds physiological reflexes and produces motor blockade
depending on the concentration of the solution. The method of epidural
analgesia varies from place to place or even from person to person too. A
high concentration of local anaesthetic solution in the epidural space is
thought to responsible for severe motor blockade leading to a prolonged
labour and a higher instrumental delivery rate. Epidural analgesia based
on lower concentration of a local anaesthetic solution with an opioid
provides good analgesia, less motor blockade and lower instrumental
delivery rate 4. Based on this concept, some maternity units provide
"mobile epidural" service.
A mixture of low concentration of local anaesthetic and opioid for
epidural analgesia during labour is commonly used in modern obstetric
anaesthesia practice. This mixture provides good pain relief without
significant motor weakness. Thus, it is unlikely that the duration of
labour would be significantly longer or the instrumental delivery rate
would be higher.
Roberts et al detected different outcomes between the private and the
public patients with epidurals in respect to instrumental delivery and
caesarean section rate. This may indicate that the clinician's decision
varies according to social circumstances too. Thus, the relationship
between epidural analgesia and instrumental delivery may not be
straightforward. Before making any conclusion on this relationship several
other factors should be kept in mind.
References
1. Roberts CL, Tracy S, Peat B. Rates for obstetric intervention among
private and public patients in Australia: population based descriptive
study. BMJ 2000; 321: 137-41.(15 July)
2. Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, Yeast
JD. The effect of intrapartum epidural analgesia on nulliparous labour: a
randomised controlled prospective trial. Am J Obstet Gynecol 1993; 169:
851-8.
3. Loughnan BA, Carli F, Romney M, Dore CJ, Gordon H. Randomised
controlled comparison of epidural bupivacaine versus pethidine for
analgesia in labour. Br J Anaesth 2000; 84: 715-9.
4. Olofsson CH, Ekblom A, Ekman-Oreberg G, Irestedt L. Obstetric
outcome following epidural analgesia with bupivacaine-adrenaline 0.25% or
bupivacaine 0.125% with sufentanil - a prospective randomized controlled
study in 1000 parturients. Acta Anaesthesiol Scand 1998; 42: 284-92.
Dr Nanda Gopal Mandal, Specialist Registrar, Department of
Anaesthesia, Southampton General Hospital, Tremona Road, Southampton, SO16
6YD, UK.
Competing interests: No competing interests