Private versus public health insurance for pregnancy: Women's choice?
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..
Rapid Response:
Private versus public health insurance for pregnancy: Women's choice?
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