Outcomes for mothers and babies who receive standard public hospital care are significantly worse than for those who receive private obstetrician-led care, according to a study published in the British Journal of Obstetrics and Gynaecology this week.

Researchers reviewed more than 368,000 matched low-risk births across Queensland, New South Wales and Victoria that occurred between 2016 and 2019.

What they found was concerning.

Stillbirths and neonatal deaths were twice as likely to occur in the public system, and babies were around three times more likely to be admitted to NICU and more likely to be deprived of oxygen in public hospitals. Women who gave birth in public hospitals were about three times more likely to have a third or fourth degree perineal tears, and more than twice as likely to haemorrhage.

In keeping with previous research, the study did find lower rates of caesarean sections in the public system (31.6% of births in public hospitals compared to 47.9% of births in private hospitals.)

How rigorous was the data matching?

A dataset of >863,000K births was reduced down to two matched cohorts of 184,146 low-risk women with similar demographic, clinical and socioeconomic characteristics. Matching was used to control for key baseline differences between the women who gave birth in public hospitals and those who gave birth in private hospitals.

This included age, BMI, socio-economic status, rurality, parity, plurality, non-English speaking country birthplace, use of assisted reproductive technology (ART), pre-existing diabetes, gestational diabetes, hypertension or preeclampsia, smoking after 20-weeks gestation, and Aboriginal or Torres Strait Islander identification. The authors note that ART and BMI were not available for matching for one state, and smoking for another.

Two professors of midwifery who responded in a Conversation article argued that other factors that could impact on outcomes were not included: “There was no controlling for drug and alcohol use, mental health, refugee status and many more significant factors impacting health outcomes for mothers and babies.”

Differences in care

According to the BJOG study authors, “standard public care involved mainly fragmented midwifery, obstetric and General Practitioner provider care, with birth in a public hospital. Private obstetric-led care was led by a personally selected obstetrician, with midwifery involvement and birth in a private hospital.”

More evidence that change is needed

National Association of Specialist Obstetricians and Gynaecologists president Associate Professor Gino Pecoraro called the results “shocking.”

“The take-home message is that what we’re currently doing now in our public hospitals – which is a midwifery model with obstetric rescue – is an unsafe model with bad outcomes and potential for serious harm to women, and it’s more expensive than just sending all women into the private sector,” Associate Professor Pecoraro said. “So to continue doing this would be absolute folly.”

The study found the cost per pregnancy was $5,929 higher in standard public maternity care.

“I think it fairly clearly shows that we need to bring back obstetrician leadership and oversight in our public hospitals,” Associate Professor Pecoraro said, adding that all private health insurance policies should include pregnancy.

By contrast, women giving birth in the public system now will not have care from an obstetrician “until it turns pear-shaped,” which he says is far from ideal.

“It’s not satisfactory for the woman who meets an obstetrician for the first time when everything’s gone bad. Usually, it’s in the middle of the night and we’ve got six minutes to get the baby out before we’ve got irreparable damage done. That’s very scary for her.”

“It’s scary for the midwife. It’s scary for the obstetrician who knows nothing about that woman and would never have met her until this time.”

Getting worse, not better

While the study looked at births between 2016 and 2019, in Associate Professor Pecoraro’s experience, things have not improved.

“If anything, I’m afraid I suspect things will have gotten worse as we’ve gone further down the midwifery-led with obstetric rescue model in our public hospitals,” he said.

“I’ve certainly noticed a huge difference in my 30 years of the practice of public and private obstetrics. When I first started, the systems were parallel and fairly equal. I’m afraid in the last 10 to 15 years, they have become really quite divergent.”

Does the BJOG study tell the whole picture?

Professors of midwifery Hannah Dahlen and Jenny Gamble argue that it doesn’t. They cite some limitations in the matching of cohorts, and note that not all medical complications are controlled for in the paper. They point out that the study didn’t consider rates of episiotomies, which they say are higher in private hospitals. In addition, they note that higher rates of Caesarean sections in private hospitals can increase risks for future pregnancies and births.

Importance of informed choice

However, one thing Associate Professor Pecoraro and the midwifery professors agree on is that women should be able to make an informed choice.

“Women need to be given accurate information that is factual, evidence-based, and not driven by ideology,” Associate Professor Pecoraro said.

“What we need is to just give women the facts and say, look, if you choose to have your baby in the private sector, yep, you’ve got a greater chance of having a Caesarean section. That’s absolutely proven, but you’ve also got half the chance of your baby not making it.”

“You’ve got half the chance of having a PPH, one third of the chance of having the third or fourth degree tear. Nothing’s for nothing, but I think we need to trust our women and our mothers to make the best decisions for them, and they need to know the differences between all the different models,” Associate Professor Pecoraro sums up.

For more information

Read the full paper here.