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
Rapid Response:
Scientific Truth or Politics?
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