A call for private obstetricians to publish their intervention rates

What impact would it have if private obstetricians were required to publish their caesarean section rates and other indicators of their professional practice?

It’s an intervention worth testing, suggest the authors of the article below, Hannah Dahlen, Associate Professor of Midwifery at the University of Western Sydney, and Bashi Hazard, a solicitor and mother of three children.

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Can we increase transparency and informed choice in private obstetrics?

Hannah Dahlen and Bashi Hazard write:

A study involving nearly 700, 000 women was published in the British Medical Journal Open earlier this month, and it found low risk women having their first baby in a private hospital in NSW over an eight year period (2000—2008) had a 20% lower normal vaginal birth rate.

Most concerning was that only 15% of low risk, first time mothers had a normal birth without intervention in private hospitals – with 35% experiencing this in public hospitals.

We also compared the findings to a similar study done 10 years earlier in NSW that used the same low risk cohort of women and found the caesarean section rate had gone up by 10% amongst women giving birth in private hospitals and 5% for women giving birth in public hospitals.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) responded with a media release titled ‘women have never been better informed’.

RANZCOG produced all the usual rhetoric about more women today being over the age of 35 and the caesarean section rate being higher in this group. However, we excluded anyone under over the age of 34, anyone with medical and/or obstetric risk factors, small or large babies or preterm or overdue babies to get this low risk cohort.

Perhaps most fascinating was the way RANZCOG passed the responsibility back to women as being a ‘informed’ group of women who were obviously making the choice to have these interventions. Bashi, a mother and solicitor, gave a sobering insight into the pressure she experienced to have two caesareans in a private hospital in an article published in the Sydney Morning Herald the following day.

So are women really lining up and demanding interventions from their obstetricians or is it more complex?

A study just published online in Midwifery found no difference in the numbers of women in Queensland wanting to have a caesarean section in the public or private sector, yet significant differences in actual caesarean section rates.

Perhaps it is time to stop hiding behind the skirts of women and create a more transparent system to really enable women to make informed choices?

The BMJ study made the front page of the Sydney Morning Herald and led to huge media exposure and public interest. During the course of the day journalists started asking what could be done to change these intervention rates or make women aware of them.

One suggestion given by both Bashi and myself was to make better use of the Federal government’s MyHospitals website. Women could access information here on intervention rates in different hospitals and under different private obstetricians. NSW is one of the few States that publishes yearly intervention rates for each hospital in the NSW Mothers and Babies Report, but again there is no data on individual obstetricians’  intervention rates.

There are obstetricians in this country who have very low intervention rates (even better than the public sector!) and there are obstetricians whose caesarean section rate is far higher than their normal vaginal birth rate.

Currently a woman chooses her obstetrician based on her general practitioner’s recommendation or advice from her friends, but she has no idea what philosophy of birth the obstetrician might have or how high their cesarean section rate is. If this was made public then perhaps a more informed choice could be made.

Some of the information we suggest could be on the website for private obstetricians would be the following:

• Caesarean section rate
• Instrumental birth rate
• Episiotomy rate
• Induction of labour rate
• Support for alternative birth positions
• Support for waterbirth
• Support for eating and drinking during labour.

This information could be updated every year. In order not to disadvantage obstetricians with caseloads of higher risk patients, the percentage of twins, breech, hypertension, diabetes etc could be listed and even adjusted for.

This transparency may have a positive impact and help obstetricians make the effort to keep their rates at a reasonable level when they see how they compare to their colleagues. Women could read about the philosophy of their care provider and choose accordingly.

Those women wanting a waterbirth or to give birth in an upright birth position, for example, would not have to discover at 36 weeks or even during the birth that this would not be supported, while those wanting a normal vaginal birth will steer clear of those obstetricians with high caesarean section rates.

In the USA for the first time, insurance companies seeing the added morbidity and cost stemming from caesarean section and induction of labour have urged doctors to scale back on these interventions. The average caesarean in the US costs $24,300 compared to $15,200 for a vaginal birth.

At present there is little accountability in Australia for intervention rates. As one journalist was shocked to discover recently, the Towards Normal Birth in NSW Policy Directive aiming to decrease the caesarean section rate in NSW does not apply to private hospitals.

So unless something is done soon, we will see the gap between public and private hospitals identified by our study only growing wider.

We wonder which obstetrician would be brave enough to put their statistics up first?

• Hannah Dahlen Associate Professor of Midwifery UWS and lead author of the study, Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study. Bashi Hazard is a solicitor and mother of three children – two born in under private obstetric care.