Birthing is significantly safer for women and babies under the continuous care of obstetricians in private hospitals, upcoming research will reveal, as calls grow for an urgent rescue for Australia’s diminishing private maternity units. Starkly different rates of neonatal death and birth injury apparent across different models of maternity care have been revealed in early figures from one of the biggest births datasets ever examined, prompting demands for greater transparency of perinatal outcomes for expectant mothers and a guarantee of birthing choice. There were almost 200 excess neonatal deaths annually in public hospitals compared with private hospitals, and 700 more babies with low APGAR scores recorded across three states in the public system. A growing body of already published research cements the new high-level data and has shocked researchers, health professionals and policymakers. Monash University professors Emily Callander and Helena Teede presented recent research and a preview of upcoming research on birth costs and outcomes in Australia at a recent meeting of the National Association of Specialist Obstetricians and Gynaecologists, following similar presentations at other scientific meetings.
Professor Callander, the nation’s only economist specialising in maternal and women’s and children’s health, said she did not expect to see such stark differences in outcomes. “For 25 years this situation has been left unaddressed and these major differences between public and private care have been overlooked,” Professor Callander told The Australian. “This is on a background of a rapid escalation in poor maternal health in pregnancy that has been demonstrated across Australia.” The most recent results from this large database of 350,000 births across three states between 2016 and 2019 demonstrated statistically significant differences in adverse outcomes for mothers and babies depending on whether their antenatal care and birth took place in multiprofessional non-continuity public maternity units, or under the continual care of a private obstetrician in a private hospital. Professor Callander told NASOG’s recent Australian Birth Forum that her research aligned with prior findings and indicated that those who gave birth in the obstetric-led continuity of care in private hospitals, which on average recorded higher rates of caesarean sections, had half the risk of neonatal death of their baby.
There were almost 200 excess neonatal deaths in public hospitals compared with private hospitals each year across NSW, Victoria and Queensland. The forum was also told that the data indicated almost 700 more babies were born with low APGAR scores, which take in factors such as how well the baby is breathing and whether they are born in distress. The upcoming research bolsters accumulating findings in Australia, which have been reflected internationally, for a quarter of a century that have consistently found that neonatal mortality in multiprofessional noncontinuity public care – compared with private obstetric-led models of care – result in approximately double the rates of babies dying. Recent state-based studies have shown that baby deaths were 53 per cent higher, stillbirths were 56 per cent higher and death soon after birth was 48 per cent higher in multiprofessional public care versus obstetric-led continuity-of-private care. These studies had extensively matched similar cohorts of mothers, adjusting for factors such as socio-economic status, demographic and clinical characteristics to ensure the data was comparing like-for-like women.
Professor Teede, who specialises in women’s health and equity at Monash University and is a physician working in pregnancy care, said Australia’s maternity systems had been largely “blinded” to this information. “Maternity care has made massive inroads, but we have seen some of those inroads slip,” Professor Teede said. “We have been largely blinded for decades to the deteriorating outcomes due to lack of data access … and we’ve been largely paralysed in terms of our response to these rising adverse outcomes. “The recent launch of the Maternity Guidelines and funding for the Stillbirth Alliance are important steps yet far more work is needed.” The declining access to private birth is occurring amid an international backdrop of enormous changes to public health systems, particularly in the UK, which has recently moved to dismantle NHS England, a key trigger being the decline of patient safety including in maternity care. Eighteen birth units have closed in private hospitals in Australia over the past seven years, about 10 of them in the past three to four years.
Darwin and the entire Cairns region now do not have any private birthing options, and Hobart’s options are severely limited. Former federal health minister Greg Hunt, who gave a keynote address at the Australian Birth Forum, said the early research findings from Professor Callander and Professor Teede, along with the critical decline of the private birthing system, should prompt urgent reform. “This is about the safety and the health of newborn children and their mums,” Professor Hunt said. “This is about declining rather than improving birth outcomes.” National laws to enshrine safety, access and affordability of care for expectant mothers to guarantee choice in birthing options have been put forward as part of a proposed birth road map to address declining outcomes, growing costs and critical threats to universality of maternity care. There are also demands for immediate access for private obstetricians to have access to deliver babies in public hospitals. This is currently denied in Cairns, where the town’s seven private obstetricians are all no longer delivering babies. Hospitals gain greater access to Medicare funds if babies are delivered by publicly employed obstetricians.
NASOG president Gino Pecoraro said: “Private obstetrics in Australia is fighting for its life. Doing nothing is not an option. When private units close, the pressure on the public units is insurmountable.” The number of births in public and private systems has declined precipitously in recent years as Australia’s fertility rate hit an all-time low, but many mothers who wanted to birth privately are now flooding the public system. At the same time, comorbidities are placing huge pressure on public birthing units. Royal Australia and New Zealand College of Obstetricians and Gynaecologists president-elect Nisha Khot described maternity care as the “canary in the coalmine” indicating the pressure that public health systems are under. She said that meant it was even more critical not to let private hospitals be pushed to the brink as the nation was currently seeing. “Maternity care is the canary in the coal mine for what could face health systems in the future,” Professor Khot said. “When you are being slowly boiled, you don’t realise the temperature as it is going up. We critically need greater transparency of data. We need to challenge some of the dogmas in this space. This data clearly shows the safety and quality of the care that is available in private health systems in Australia. The public system produces the next generation of health care specialists and births the majority of babies.”
Professor Hunt’s intervention comes after Queensland was rocked in February by a revelation in the latest Productivity Commission Report on Government Services of a perinatal death rate of 11.5 per 1000 births, or more than 1 per cent – prompting a clinical review. Nationally, there were 2446 perinatal deaths in 2022. “That the perinatal death rate in Queensland has increased to 1 per cent, I find extraordinary,” Professor Hunt said. “That is a figure that if the ministers and policymakers were truly aware of it, it’s a jaw-dropper. We have to do something about this.” Professor Hunt has laid out a possible “birth road map” – based on safety, affordability and access to data – to deal with fragmented systems and declining outcomes and the critical threat to private hospital birthing units. It includes: a call for a national safety standard and database for all models of birth; affordability support through Medicare items and reforms to private health insurance tiers; the establishment of uniform national laws to enshrine data transparency; and the use of the lever of the National Partnership Agreement on health to guarantee private obstetricians access to deliver babies in public hospitals.
Professor Callander said: “What we’re seeing essentially is poorer outcomes in multiprofessional public-hospitals models of care, and it’s being delivered at a higher cost to all funders. “Our work including this study really reflects the importance of having impartial data that’s routinely reported so that all findings, no matter how unpalatable they might be, are actually addressed.” In a research paper published in the Medical Journal of Australia in 2009, a team led by obstetrician and medical professor Steve Robson, a co-author of the forthcoming paper and an expert columnist for The Australian, showed that outcomes for mothers and their babies at low risk were significantly worse in public hospitals where they did not receive continuity of care with specialist obstetricians. Recent studies are more detailed and statistically rigorous and have revealed declining outcomes and rising costs. The data highlights differences across models of care in multiple states and shows that outcomes have not improved over 15 years.
Costs in all hospitals have risen exponentially in recent years but the rises are highest in maternity care, where rising body mass index scores and rates of hypertension and diabetes have contributed to the increases. Rates of litigation are also climbing in public hospitals but are not reported. Professor Callander has previously shown that there was a 65 per cent increase in the costs to public hospital funders between 2012 and 2018. In the private system, substantial increases in the cost of private health insurance have driven more patients into the public system, driving public hospitals’ costs higher, and at the same time have left private hospital operators with decreasing revenue. The cost of managing complications such as massive haemorrhages or baby resuscitation is greater in public hospitals because these complications are also much more common, sometimes due to intervention only being delivered at an emergency stage rather than being planned. Professor Teede said the established and rising risks, declining outcomes, access and affordability in maternity care, and the differences across models of care bolstered the urgent need for a clinical care registry that would inform consumers, health professionals and government on best models of care to keep pace with these changes. It is also vital that this is supported by a National Maternity Learning Health System to drive improvement.
“We now have unique insight from an incredible linked data asset that has taken Emily 10 years to integrate,” Professor Teede said. “Very few countries are now in a position to really have the insight that we can provide moving forward. “This deterioration in outcomes has happened here and, in the UK, and elsewhere, with changing social trends in cost of living, having babies later and increasing health challenges before and during pregnancy. “But what has happened is, especially in the public system, we haven’t had the data to inform or drive the changes in practice and the change in risk appropriate care now lags behind what it needs to be to match those trends.” While the recent large-scale study confirms that close involvement of specialist obstetricians promotes safer and less costly birth care, proposed rescue options offered up by Private Healthcare Australia suggest adding solo midwifery as a solution. But Professor Hunt said changes to the private health insurance tier system that have led to the steady creep of downgraded insurance cover for families, and changes to what is known as the risk equalisation pool, should be immediately examined.
The Australian College of Midwives responded to the early findings of the Monash study by saying it “reinforces that continuity of midwifery care improves outcomes and offers better value for the health system”. “While there are up to 42 per cent of maternity services with a continuity-of-care model, only approximately 10 per cent of Australian women giving birth can access these models,” said Alison Weatherstone, chief midwife at the college. “In Australia, only one-third of maternity services provide continuity of care by a known care provider.
Source: The Australian
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