Time to stop dismissing obstetric care as ‘intervention’ when it is saving lives of mums and babies

Obstetricians are too often forced to defend ‘interventions’ when they are actually treatments reducing mortality for both mothers and their babies, a leading practitioner says.

Delivering a baby in a private hospital with an obstetrician is safer, new research has demonstrated. Picture: Getty Images.

Obstetricians delivering in private hospitals have always known that having your baby under the care of a private obstetrician in a private hospital is significantly safer than the frequently fragmented care afforded in our public maternity units.

New research, led by Monash University health economics professor Emily Callander and published in the prestigious British Journal of Obstetrics & Gynaecology, tells the same story.

This should not read as a criticism of public units. The private obstetricians who contributed data to the BJOG paper were all trained in public maternity units. Many of us continue to contribute to public hospitals through direct part-time employment, appointment as visiting medical officers, or through teaching, mentoring and/or research. What distresses many of us is the fact that we cannot deliver the same care to patients in public hospitals that we do in private hospitals.

Unfamiliar and uncomfortable to far too many care providers and decision-makers is that there is a dividend in the higher rates of induction of labour, the higher rates of caesarean section, and other factors intimately related to the higher level of direct involvement of specialist obstetricians, paediatricians and anaesthetists in the care of Australian women in private hospitals. Collectively, they deliver greater levels of safety for those women and their babies.

I have zero interest in demeaning the capability and professionalism of my midwife colleagues, nor my obstetric colleagues who work full-time in public hospitals.

However, in my 25-year career working as a resident, registrar, senior registrar and consultant in maternity units in Australia, Ireland and Britain, I have no doubt that the thoughtful and deliberate use of all that medicine has to offer mothers and their babies should be celebrated and not so consistently questioned, devalued and demeaned.

The work of obstetricians is too often described as ‘interventions’ when they are providing the safest and most appropriate care for mothers and babies, Michael Gannon says. Picture: iStock.

Too often obstetricians are asked to defend “interventions” without any consideration of the fact that they are “treatments”, designed to reduce morbidity and mortality in both mothers and their babies. The fallacy that midwives should be the lead clinicians in so-called normal births, only involving obstetricians and their medical colleagues when problems emerge – what I call “flying squad” maternity care – is at the heart of the compelling data set that shows the stark gap in safety between public and private maternity hospitals.

Obstetrician/gynaecologists are the only healthcare workers who can deliver true continuity of care. As gynaecologists we help women conceive, for example through treatment of endometriosis or polycystic ovarian syndrome, or using assisted reproduction techniques. We have the medical training to understand the impact of chronic medical conditions on pregnancy, and pregnancy on those conditions. After the baby is born, we have the expertise to manage any complications from the birth, family planning and contraception.

How we deliver care in private hospitals cannot be completely replicated in public hospitals. Public maternity units are funded by a much more generous case-mix system than how private care is funded. They are typically better at managing patients with severe drug and alcohol problems or mental health disorders. Managing the smallest and sickest newborns in tertiary-level neonatal intensive care units also makes sense. Scale is important. Maternal-fetal medicine units are better placed in larger hospitals providing expertise after referral in specific cases.

Dr Michael Gannon is a consultant obstetrician and gynaecologist with 18 years’ experience as a specialist. He has delivered over 5000 babies. Picture: supplied

However, it is time for the public system to start accounting for its results, especially as Callander et al have carefully accounted for potentially confounding variables such as socio-economic status.

It is incumbent on individual midwives and obstetricians to explain the reasons for various treatments in the antenatal period, in labour and beyond.

It is equally incumbent on decision-makers within our hospitals and health services to consider ways in which we can improve treatment and reduce the gap in outcomes between mothers and their babies in public and private hospitals.

We can no longer continue to pretend there is not the potential for major long-term harm in long labours, in prolonged second stages of labour (the time frame after the cervix is fully dilated), lower rates of epidural analgesia, and extended periods of time waiting for spontaneous onset of labour beyond the due date.

Reform is needed to offer Australian women a choice about where they have their babies. We cannot continue to ignore the evidence before us and continue to fail to invest in women’s health and child health by supporting private maternity care.

Reform to the healthcare system is required to give women a choice about whether to have their baby in the public or private system, Gannon says. Picture: iStock.

The current financial arrangements between private health insurers, private hospital groups, doctors and patients are no longer fit for purpose. The closure of multiple private maternity units in Australia in recent years is testament to some failed and outdated financial metrics. We should not be in a position where hospital groups decide they can no longer afford to lose money on maternity, prioritising other more profitable areas of healthcare. We should no longer tolerate the situation where Australian women are forced to pay for gold-level insurance and yet still face significant out-of-pocket costs for their anaesthetic care. The current situation discriminates against reproductive-age women.

The moral argument to act to deliver Australian families a choice of how they are cared for should be strong enough on its own. But beyond choice, the BJOG paper reveals private obstetric care in Australia to be safer for mothers and babies.

We should also respond to the evidence by finding ways to increase the involvement of obstetricians in the care of patients in our public hospitals. Long overdue investment in the third and fourth trimester of pregnancy can be an investment in the future of our country.

Dr Michael Gannon is an obstetrician and gynaecologist in private practice. He is also chair of the Perinatal & Infant Mortality Committee of Western Australia, the group that measures stillbirths and neonatal deaths in that state.

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This column is published for information purposes only. It is not intended to be used as medical advice and should not be relied on as a substitute for independent professional advice about your personal health or a medical condition from your doctor or other qualified health professional.