Australians are fortunate in having a universal health service that provides care for everyone based on taxation. Naturally the health system needs regular “tweaking” to keep it working well for those who use it. However some of the adjustments of recent years are producing consequences in maternity care that are not only unplanned, they are very costly and producing unacceptable levels of morbidity in Australia’s healthy and wealthiest women.
In a bid to raise the uptake of private health insurance which had reached an all time low in 1999, the Commonwealth government introduced an uncapped 30% private health insurance rebate. This encouraged any woman who could afford it to take out private health insurance.
The intention was sound; that is young people use services less therefore their demand against funds would be lower than older and aging groups. However, childbirth is the most common cause of hospitalisation in Australia and subsequent claims have resulted in ever escalating direct and indirect costs.
The beneficiaries of this funding adjustment are private hospitals and privately practicing obstetricians. They have by default become the chosen providers of maternity care, despite the fact that midwives provide a similar and safe service that is less costly.
Paradoxically, private hospital care in association with private obstetric care in childbirth is associated with horrendously high rates of operative birth amongst low risk first time mothers.
Research undertaken ten years ago, even before the government incentive to encourage women to take up private health insurance, showed that among low risk private patients under private obstetric care with an epidural, the most likely birth outcome was an instrumental delivery with an episiotomy. Among similar public patients, the most likely outcome was a noninstrumental vaginal birth without episiotomy.
The second major adjustment to the health system which has had unintended consequences was introduced in 2004 in the form of the new Safety Net. This covers 80 per cent of out of hospital medical expenses for families once their out of pocket, out of hospital, expenses exceed $700 in a calendar year.
Sadly this attempt to improve access has resulted in maternity services not currently providing value for money — either to consumers or to funding bodies. This is a particular issue for rural women.
The advent of the Medicare Safety Net resulted in a rise of more than 250% in the earnings of private specialist obstetricians reported in the media in 2007 since the safety net was introduced. This increases pressure and costs on the health system as a whole. Some privately practicing obstetricians are charging $20,000 dollars for a normal birth and our health system pays the gap insurance to allow them to do so.
Exacerbating these cost blow outs, operating rooms in both public and private hospitals are now so busy with operative birth that other necessary surgery is delayed or cancelled.
In addition to this, large population based studies show increases of avoidable death and injury of mothers and infants associated with the trend to operative birth, especially caesarean sections. The injury again adds costs as babies spend avoidable time in hospital nurseries or women experience infections from abdominal wounds.
This then is the paradox. Tweaks designed to improve our system have resulted in out of control costs, increased suffering and injury to women and infants, and obstetricians now expecting to earn a million dollars a year — most of which is coming from Government money (our taxes) via normal healthy women who do not need their care.
These are important issues that deserve a thoughtful response from the Federal Government’s maternity services review.
Professor Lesley Barclay, Associate Professor Sally Tracy and Associate Professor Sue Kildea are from Charles Darwin University, Darwin
This thread illustrates the difficulty in running evidence based health policy debates in the media.
The academic midwives who have failed to identify themselves as such should know the references for my statements.
For others
1. Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth (review) 2005 The Cochrane collaboration.
Hodnett ED. Continuity of caregivers during pregnancy and childbirth 2005 The Cochrane Collaboration
2.Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth (review) 2005 The Cochrane collaboration. John Wiley & Sons.
3. Bastian et al “Perinatal Death associated with home birth in Australia: population based study .BMJ Volume 317(7183) 27 1998, 12th Report of the Perinatal and Infant Mortality Committee of Western Australia, Deaths 2002-04 ; Intrapartum Care of healthy women and their babies during childbirth, National Institute of Clincial Excellence UK Sept 2007
Everything I stated is based on statistically significant differences documented in these papers. One can ignore statistically significant findings if they don’t suit one’s arguments, but it surely must be an inconvenience that they remain facts.
7 of the 11 “midwife led care” groups in the Cochrane review quoted by Dahlen in fact included scheduled routine visits with doctors for between 2 and 6 visits per pregnancy, so I am not sure what aspect of such care contributed to the outcomes.
My practice costs quoted are net costs after government indemnity subsidies. At no stage have I opposed govenment indemnification for midwives, in fact it is absolutely essential that the government provides this.
In coninuously denigrating serious and respectful attempts to debate health policy by the medical profession as nothing other than promotion of self interest, you deny the women of Australia a proper debate, and force them to make political rather than health care choices
It’s an interesting debate on all comlpicated fronts, women consumers of maternity services; professional providers; political and bureacratic heirarchies and institutions. Problem solving can be quite simple. Back to the future with the benefits of current knowledge, wisdom and experience. I am a lucky and most priveleged midwiife, having worked a large part of my career with some amazing medical colleagues (GP’s and Obstetricians). Mutual respect for each others skills was (and could still be) the key compenent of how we solve this 21st Century mess of the health industry. The most important key to all of this is the women and when we learn the simple skill of listening and responding to women, it will be easy to right balast of this listing ship. The last 22 years I have had the privelege of working in a personal relationship with women, some up to baby number six in our partnerhsip. In our ‘zest to be the best ‘we have taken from women the most precious and important experience of their life, the enjoyment (for most) of pregnancy, the beauty of the womanly art of birthing and the incredible will and skill of the newborn to find its way to the breast soon after birth, all in the name of survival and continuation of the species. I put to my obstetric colleagues these challenges. Let the past go, meet with us around the table, talk about the way forward AND MOST OF ALL INCLUDE THE WOMEN. Together, without power, control and with a mulititude of trust we can lead the politcal debate, turning the tables, returning to the respect and trust we once had , making this lifetime journey powerful for all women, regardless of what type of care they need. And for the 21st Century I ask our obstetric colleagues to consider – coming out of your institutional life, join us in the home or on country with with the women, experience first hand the incredible mammalian ability of women to do what they know best, giving birth to and breastfeeding their babies, most often unassisted
I think this article makes some good points, although it’s important to note there are a number of drivers to operative delivery, including the legal system and women’s own preferences. And I’m afraid I simply don’t believe the million dollar income figure: maybe there’s one mad bastard who works 100 hours a week to earn that much, but it’s hardly representative.
My declared conflict of interest is that I am 30 weeks pregnant and having to fight to receive midwifery-led care – my pregnancy is low risk, and my 2nd, so I definitely know what I want.
One of the incredible poor outcomes of the current funding model is that women can use private insurance to access obstetric care but not midwifery care – my experience is that midwifery care comes into its own during the postnatal period, and it is only effective when the mother has an existing relationship of trust based on the several months contact antenatally and of course at the birth. I don’t think it’s an accident that many of my friends who birthed without continuity of midwifery care rarely breastfeed for more than a few weeks.
I simply cannot believe that Australian women’s bodies are more prone to complicated pregnancy and labour, or that women who can afford private health insurance also have bodies that develop complications more readily – but this seems to be the conclusion obstetricians would have us believe by saying the higher rate of intervention in private hospitals, and in Australia compared to other countries, is health-related rather than systems-related.
In my battle for midwifery-led care, the overwhelming sense I get from the obstetricians is the belief that my midwife (or any other) will ignore signs of complication and refuse to let me see an obstetrican – in reality, in my last pregnancy my midwife was the one that convinced me I needed to be hospitalised when I developed highblood-pressure. And she is committed to me having choice – she wouldn’t refuse to do anything if that was what I wanted. Indeed, my experience is midwives are more aware of best practice, and what constitutes evidence, than obstetricians (e.g. one obstetrician I know tried to use a study based on n=15 to convince me that hospitalisation provided better outcomes than home based care – even an undergraduate knows better than that).
Another perspective on this unfortunate area of conflict between obstetricians: midwives: consumers of healthcare. It’s a shame that issues of combined care and responsibility so frequently degenerate into arguments over “turf”, and that “evidence” in the literature, frequently contradictory and always overlapping, is so often used as a weapon rather than an education.
Another group of care providers may not fit so clearly into the “dark knight” corner alluded to by Prof Tracy and co-writers, and that is the obstetricians providing care in the public system, of whom some are academics. Collaboration is possible with the right amount of respect, and there are successful models of care that involve all in the provision of maternity care with overlapping and symbiotic roles. Frequently it is the public obstetricians who are providing medical assistance and review to those pregnancies that require that level of help, without compromising the primary care role of the midwives themselves.
Unfortunately the NSW medical system does so little to encourage trainees to work in public or academic practice. It is an astonishing failure of our system that many large teaching hospitals are unable to fill public or academic specialist posts with suitable candidates. These posts would be snapped up in other countries, but when there is such financial disproportion between public and private practice, there is little incentive for trainees to remain in the public system.
We must remember the futility of public arguments over pregnancies and the fact that this simply denigrates all. As obstetricians, we (I’m an academic one) should “take a hard look at ourselves” as a speciality, and try to work out what it is that may drive women away from our care. Equally, midwives need to approach the current potential for changes in maternity provision in a mature manner, and work with obstetricians (where this is possible) to design a collaborative role for the future.
As all who contribute to