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PAPERS: Christine L Roberts, Sally Tracy, and Brian Peat Rates for obstetric intervention among private and public patients in Australia: population based descriptive study BMJ 2000; 321: 137-141 [Abstract] [Full text]

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

Allison Shorten   (17 July 2000)

Can we have more information , please?

Andrew Pesce   (23 July 2000)

Scientific Truth or Politics?

Isidor J Papapetros   (23 July 2000)

The relationship between epidural analgesia and instrumental delivery needs careful interpretation.

Nanda Gopal Mandal   (24 July 2000)

Private versus public health insurance for pregnancy: Women's choice? 17 July 2000
Allison Shorten, Lecturer in Midwifery University of Wollongong Send response to journal: Re: 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..
Can we have more information , please? 23 July 2000
Andrew Pesce, Staff Specialist Westmead Hospital, Sydney, Australia Send response to journal: Re: Can we have more information , please?	The study by Roberts et al engages us in the important task of assessing obstetric intervention and maximising benefit whilst minimising risks. It is disappointing however that there is little attempt to address the question of whether higher intervention rates improved outcomes for mothers or their babies. It is very unusual for workers not to report rates of stillbirth, neonatal death and admission to neonatal intensive care units as measures of preinatal outcomes. Certainly these data are recorded for the NSW Midwives Data collection form upon which this report is based, and their absence puzzles me. Maternal mortality is also recorded, but not reported by the authors. I was also interested in the finding that women delivering in the public system were twice as likely to sustain third degree tears as their private counterparts, with no mention made of the incidince of fourth degree tears. This raises a possiblity contrary to the view put by the authors that private patients are exposed by interventions to an increased risk of faecal problems in the long term. Predictably, this report has received prominent media publicity in Sydney, and used to further politicise the issue of maternity care. At least the BMJ should remain a forum for scientific information and I cannot understand why the article's reviewers did not require at least some mention of maternal mortality and perinatal morbidity rates, especially when the paper's conclusions state "information on the outcomes associated with the various models of care may infleunce (womens') choices
Scientific Truth or Politics? 23 July 2000
Isidor J Papapetros, VMO Bankstown-Lidcombe Hospital Sydney, Australia Send response to journal: Re: 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.
The relationship between epidural analgesia and instrumental delivery needs careful interpretation. 24 July 2000
Nanda Gopal Mandal Send response to journal: Re: The relationship between epidural analgesia and instrumental delivery needs careful interpretation.	Editor - I was interested to read the article by Roberts and colleagues 1. I would like to make a few comments on the relationship between epidural analgesia and instrumental delivery. Roberts et al observed that the epidural analgesia began a cascade of obstetric interventions leading to a low probability of a non-operative birth. They also noted that the private patients had higher age adjusted rates of instrumental delivery, especially after an epidural. Another important observation was that the use of augmentation or induction without epidural did not noticeably increase the probability of an instrumental birth. Do these observations really mean that the epidural analgesia is responsible for increasing the incidence of instrumental birth? I feel to express my reservation on this matter because of the following reasons. This study was based on statistical analysis of the data collected retrospectively 1. There are other prospective randomised double blind trials which investigated the effect of epidural analgesia on the outcome of labour 2 3. One of the previous investigations found that the epidural analgesia did increase the incidence of instrumental delivery and also prolonged the duration of labour 2. However, a more recent study has proved that the use of regional analgesia was not associated with increase in either instrumental delivery or operative delivery 3. These contradictory outcomes from these studies prove the complexity of the issue 2 3. The decision on delivery by instrumentation depends upon many factors. These factors often based on clinician's subjective judgement. Epidurally administered local anaesthetic solution provides labour analgesia, obtunds physiological reflexes and produces motor blockade depending on the concentration of the solution. The method of epidural analgesia varies from place to place or even from person to person too. A high concentration of local anaesthetic solution in the epidural space is thought to responsible for severe motor blockade leading to a prolonged labour and a higher instrumental delivery rate. Epidural analgesia based on lower concentration of a local anaesthetic solution with an opioid provides good analgesia, less motor blockade and lower instrumental delivery rate 4. Based on this concept, some maternity units provide "mobile epidural" service. A mixture of low concentration of local anaesthetic and opioid for epidural analgesia during labour is commonly used in modern obstetric anaesthesia practice. This mixture provides good pain relief without significant motor weakness. Thus, it is unlikely that the duration of labour would be significantly longer or the instrumental delivery rate would be higher. Roberts et al detected different outcomes between the private and the public patients with epidurals in respect to instrumental delivery and caesarean section rate. This may indicate that the clinician's decision varies according to social circumstances too. Thus, the relationship between epidural analgesia and instrumental delivery may not be straightforward. Before making any conclusion on this relationship several other factors should be kept in mind. References 1. Roberts CL, Tracy S, Peat B. Rates for obstetric intervention among private and public patients in Australia: population based descriptive study. BMJ 2000; 321: 137-41.(15 July) 2. Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, Yeast JD. The effect of intrapartum epidural analgesia on nulliparous labour: a randomised controlled prospective trial. Am J Obstet Gynecol 1993; 169: 851-8. 3. Loughnan BA, Carli F, Romney M, Dore CJ, Gordon H. Randomised controlled comparison of epidural bupivacaine versus pethidine for analgesia in labour. Br J Anaesth 2000; 84: 715-9. 4. Olofsson CH, Ekblom A, Ekman-Oreberg G, Irestedt L. Obstetric outcome following epidural analgesia with bupivacaine-adrenaline 0.25% or bupivacaine 0.125% with sufentanil - a prospective randomized controlled study in 1000 parturients. Acta Anaesthesiol Scand 1998; 42: 284-92. Dr Nanda Gopal Mandal, Specialist Registrar, Department of Anaesthesia, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.