Sunday, May 18, 2008

IS THERE HOPE IN THE BUDGET FOR FEWER CAESAREAN BIRTHS?

Since the federal Treasurer announced the new budget a few days ago, there has been a lot of public comment about the changes to Medicare, and the anticipated exodus from private health insurance. The income threshold for the Medicare levy will rise from $100,000 to $150,000 annually for couples. The Sunday Age today proclaimed on the front page that "Medicare blunder could cost $1.76bn".

I wonder if anyone included in the sums the reduction in claims on the Medicare safety net, whereby uncapped thousands of dollars are shifted from the public purse to the pockets of private obstetricians for every pregnant woman booked with them? I wonder if anyone has assessed the expected reduction in costs when women who would have booked in private obstetric care, thanks to their private health insurance arrangements, move into public maternity care? I wonder if anyone has considered that women and babies may be better off when they give birth in public maternity services?

I am not opposed to private health care per se. If I was sick and needed a stay in hospital for any reason I would prefer a private room to a busy shared 4-bed ward. I would prefer the food at Frances Perry House to that downstairs at the Royal Women's. These preferences seem obvious to my mind. I would prefer to be admitted under a doctor who respected me as a person, and did not treat me as the next case (not necessarily the case in the private-public debate, but we often have confidence in a known doctor over the unknown).

However, the fact is that most women who are having babies in private hospitals are not sick. They are victims of the 'inverse care law' - that those who least need the care receive the most. Obstetricians are medical specialists: surgeons. It is no wonder that they like to perform surgery rather than work in harmony with unpredictable female natural processes. They have no expectation to accept normal birth, whereas midwives are, by definition, expected to protect normal birth.

I have been looking at some of these figures.
There is some evidence that within Victoria's public maternity services efforts are being undertaken to reduce unnecessary intervention into normal birth. The Vic Maternity Services Performance Indicators have been published annually since 2002. The statisticians have looked at what happens to 'standard primipara' - healthy women aged 20 to 34 years, giving birth to their first baby, with no complications prior to the onset of labour. In other words, the mothers who are healthy, young, and least likely to have problems in birth. The rates of Caesarean births for standard primiparae in public and private hospital care are 18.5% and 26%.

Overall Caesarean rates in Victoria have in the past decades been rising by about 2% each year, and are currently around 30% -- 27.7% of all public hospital births, and 37.3% of all private. (Source: Hospital profile of Maternal and Perinatal Data, Victorian Perinatal Data Collection Unit, 2006). The most common reported indication for Caesareans is a previous Caesarean. It is logical that as the number of primary Caesarean births increases, the number of repeat surgeries will also increase.

I now ask the question, how many women who have private health insurance, and have their babies in private hospitals, are likely to move to public hospital care as a result of the provisions of the 2008 Budget? How many Caesarean births will be avoided by this exodus?

Here are some figures to consider:
In 2006 there were over 68,000 births in Victoria: 43,800 public and 24,500 private.
If 20% of the private hospital bookings moved to public, approximately 4,900 women would move from a 37.3% risk of Caesarean surgery (n=1,828) to a 27.7% risk (n=1357). On this calculation 471 women would avoid Caesarean surgery in one year.

That might sound like a small number out of almost 70,000 births in the year, but to those women, it would be hugely significant. And if some of those women who avoided the primary caesarean were giving birth to another child in a couple of years' time, the relative ease of the second vaginal birth should not be forgotten.

I’m not saying that a 27% risk of Caesarean birth for ‘standard primipara’ in the public system is acceptable. By no means! West Gippsland Hospital at Warragul has had a strong focus by midwives and doctors on reducing unnecessary Caesareans, and their rate for the same time (standard primipara, 2006) is less than 10%. But I am saying that 27% risk is preferable to a 37% risk when comparing like with like. Fewer maternal complications in this and subsequent pregnancies; fewer babies needing to be separated from their mothers at birth; fewer women developing postnatal depression; and so on.

Perhaps the changes are going to cost the government a lot of money in revenue, through raising the Medicare levy threshold. It's likely that private health insurance companies will feel the strain of reduced numbers, and reduced premiums paid into their coffers. It's also likely that the private hospitals and obstetricians will object to reduced business. It's possible also that the overcrowding of public maternity hospitals will reach a peak in the coming year. Some public hospitals may actually consider offering homebirth in an effort to ease the congestion in their wards. Am I dreaming? It sounds to me as though mothers and babies will do well out of the Budget.

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