‘A jawdropper’: baby deaths fuel calls to save private maternity
Birth outcomes including stillbirth and neonatal death have been found to differ widely between public and private hospitals, fuelling urgent calls to save private maternity units.
The rate of stillbirth and neonatal deaths in public hospital deliveries is double the rate of newborn fatalities in the private system, with mothers three times more likely to sustain birth trauma and haemorrhage in public care, the largest dataset of Australian births ever examined has revealed.
The shocking figures have lifted the lid on the true state of divergent birth outcomes between public hospital midwifery-led care and obstetric delivery in private hospitals as the data that has long been suppressed by state governments was published on Monday night in a major international journal.
The findings have prompted calls for urgent policy reform to stem the decline of private maternity services in Australia, which are struggling to remain viable and are predicted to become extinct within a decade.
In a peer-reviewed paper published in the prestigious British Journal of Obstetrics and Gynaecology, health economist Emily Callander examined outcomes from more than 368,000 births in NSW, Queensland and Victoria from a larger dataset of 863,700 records which accounted for 78 per cent of all births in Australia between January 2016 and December 2019.
Professor Callander, an expert in Women’s Health Economics at Monash Centre for Health Research and Implementation, datamatched low-risk births across the public and private systems, adjusting for clinical and demographic factors to ensure a like-for-like comparison of birthing mothers, and compared a variety of fetal and neonatal outcomes, as well as maternal complications.
There were higher adverse outcomes in the three-quarters of births that took place in standard public maternity care in Australia, which were characterised in most public services by fragmented antenatal, intrapartum and post-natal care led by midwives.
Overall, there were 778 more stillbirths or neonatal deaths in public hospitals, thousands more low Apgar scores (a measure of a baby’s health at birth), 10,627 additional maternal haemorrhages, and more than 3273 more 3rd and 4th-degree perineal tears.
Neonatal intensive care admissions were three times more likely in public hospitals, and oxygen deprivation in babies was five times higher.
Caesarean section was found to be the safest mode of birth, and occurred at a much higher rate in private hospitals where almost 50 per cent of births were by caesarean section, the majority of them planned, compared with a 31 per cent C-section rate in public hospitals. Rates of induction of labour in private and public hospitals were roughly similar.
Despite the fact that women pay large out-of-pocket costs to give birth privately, mostly for antenatal care, the cost to all funders of births in the private system was significantly lower than public births, with each pregnancy and birth costing on average $5929 more in standard public maternity care. This indicates that the fragmented nature of care in public labour wards, which is characterised in many services by a fractious working relationship between midwives and obstetricians, is inefficient and costly.
The Australian foreshadowed the results of the study in April after headline figures were presented at a scientific forum in Sydney, amid escalating concern regarding the impending collapse of the private maternity system.
Obstetricians who have had long careers in public hospital birthing units say the problems in public labour wards go deeper than fragmented care. Some are describing public maternity care as a “broken system” where women and babies are too often being avoidably harmed.
Although Australia’s birth outcomes are outstanding internationally, birth outcomes have been declining in Australia in recent years. In Queensland, the neonatal death rate now sits at around 1 per cent of all births, a figure recently described by former health minister Greg Hunt as “a jawdropper”.
Professor Hunt remarked at a recent forum of the National Association of Specialist Obstetricians and Gynaecologists that the results of Professor Callander’s study, co-authored by Monash University professor Helena Teede and Monash associate professor Joanne Enticott and others, were so concerning that it was “almost at royal commission level”.
Professor Teede said at the forum that the data in the study was devastating, with an average of four babies dying in Australian hospitals every week, and that policymakers, doctors and women had been “completely blind” to the deteriorating outcomes and paralysed to be able to change it.
“It is quite clear that Australian babies are dying unnecessarily, that women are not receiving appropriate care and, more importantly, that women do not know,” Professor Teede told the NASOG birth forum.
The co-founder and CEO of the Australasian Birth Trauma Association, Amy Dawes, welcomed the publication of the Callander research as critical for transparency in birthing outcomes in circumstances in which at least one in three women experiences birth trauma. “While we continue to ignore these outcomes we continue to live in a system where you have often two ends of the spectrum in birthing choices,” Ms Dawes said.
“On the one hand you’ve got an overmedicalised approach that is perhaps too quick to intervene, and on the other end of the spectrum you have an ideology-driven approach that treats birth as a one size fits all.
“For too long, women have been collectively convinced that pregnancy and birth is a neutral health event, with few risks. This is a tactic used to suppress freedom of choice.”
Perth obstetrician Hannah Sylvester, a WA councillor for NASOG, left the public system three years ago after 12 years of service after being unable to cope with the conditions.
“I felt morally and ethically unable to continue working in an underfunded, understaffed, broken system,” Dr Sylvester said.
Dr Sylvester now works as a private obstetrician in Perth and births between 20 and 30 babies every month, but she has inquiries for up to 100 births a month from across the state and regularly deals with women “crying because they have phoned every private obstetrician in Perth” and they are all at capacity amid rolling private maternity unit shutdowns.
“I am currently in a state of disgust and horror at the current facilities for women’s health in general and the direction in which (governments and insurers) are taking maternity care,” Dr Sylvester said.
Since 2018 in Australia, 18 private maternity units have closed amid severe financial and workforce challenges, 13 of them in the past three years. Tasmania now has only one private birthing unit, and the Northern Territory has none, although private obstetricians have been granted rights to birth babies for private patients in the Royal Darwin Hospital.
Cairns has also been stripped of all of its private maternity units. And rural mothers across the nation mostly have no access to local private birthing.
The reasons for the closures are a combination of high costs of running 24-hour private maternity units and low payments to private hospitals by insurers, low rebates and high out-of-pocket costs for antenatal care, and high insurance costs for women who want maternity cover. There is also a national shortage of anaesthetists and paediatricians willing to attend women giving birth at private hospitals.
“All Australian women and families need urgent policy changes to ensure private maternity services remain viable and accessible,” said Catholic Healthcare Australia’s director of health policy Katharine Bassett.
A recent paper in the Medical Journal of Australia predicted that given the trends, private maternity would be “extinct by 2030” in Australia. Private obstetricians are warning that if the private system falls over, public hospitals will not be able to cope.
“The failure of the public sector to maintain adequate maternity provision has meant the divide between the public and private outcomes is widening and public maternity care is unsuitable for the population,” Dr Sylvester said.
“Currently we have a situation in which it is unethical to not provide women with a choice. The lack of choice is systemic gender discrimination, it is archaic, and it flies in the face of the basic statistics of what pregnant and birthing women want and need.”
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