Commentary: public and private intervention rates in obstetric practice

Abstract

Dr Jodie Dodd is a maternal fetal medicine fellow, and Professor Jeffrey Robinson is head of Department of Obstetrics & Gynaecology, University of Adelaide.The paper by Shorten and Shorten published in the last edition of Australian Health Review highlights differences in intervention rates (induction of labour, caesarean section, use of epidural analgesia) between women receiving private obstetric care and those receiving public obstetric care (Shorten & Shorten 2004).Similarly, the authors highlight the more frequent occurrence of "less favourable birth outcomes such as emergency CS, instrumental birth, episiotomy and (perineal) tear requiring suturing" in women giving birth in private hospital settings. These differences persisted after controlling for the risk profile of the woman or development of complications during birth (Shorten & Shorten 2004). These findings are not new in Australia, having been reported previously by King (1993 and 2000), and Roberts and colleagues (2000 and 2002). However, Shorten and Shorten's link to subsidies for private insurance raises a new concern.The global interest in obstetric intervention rates and in particular rates of caesarean section has been underpinned by the assumption that there is in fact an "ideal" rate of intervention, where benefits outweigh risks. Much of this discussion developed after the World Health Organization published a statement to the effect that a caesarean section rate of 15% was appropriate (WHO 1985). However there has been little critique of the derivation of this figure and there is a lack of evidence in the scientific literature supporting it. The rate of any particular intervention should not be considered in isolation - what is important is how the intervention relates to increasing or decreasing maternal and infant mortality and morbidity.