Episode 161 - That New Research on Private Obstetric Care
Mel
[0:00]Welcome to the Great Birth Rebellion podcast. I'm your host,
[0:07] Introduction to the Great Birth Rebellion
Mel
[0:03]Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:28] Private vs Public Maternity Care Debate
Mel
[0:24]Welcome to today's episode of the Great Birth Rebellion podcast. Today, we are getting on the bandwagon and contributing to the discussion about this new research paper that came out which concluded that if women choose private obstetric care they are significantly less likely to have adverse health outcomes and the overall cost of their care is lower than if they go to a public hospital and I've received hundreds of messages and emails asking me to cover this because, of course, private obstetricians are loving this. They're eating it up and women out there are wondering what to do with it. So, of course, there's more to the story. So to cover this paper, not only did I do a little bit of a call around to the grapevine and have a chat to some other health professionals and academics to add to the conversation today, I've also invited Professor Hannah Dulland from Western Sydney University to have a conversation with me about this article. And Hannah has also already written a response to this research paper in the conversation, which is linked in the show notes below. You can get access to the resource folder for this episode. So it's already in there. You can read what she's written.
Mel
[1:44]And Hannah has also done research papers like this one using similar linked data sets. So She's very familiar with this method of research, and I know that Hannah's been busy all week responding to media requests to talk about this article. Hannah, welcome once again to the Great Birth Rebellion podcast.
Hannah
[2:06]Thanks, Mel. Lovely to be back.
Mel
[2:08]Hannah said to me, I had my week planned, Mel, and then somebody drops a research paper. So let's get into it. This paper is called Maternal and Neonatal Outcomes and Health System Costs in Standard Public Maternity Care Compared to Private Obstetric-Led Care. And it's a population-matched cohort study. Now, we're going to explain exactly what that means.
Mel
[2:33]So I'll give the listeners a very brief introduction to the paper and then we can jump into it. So the aim of the paper was to compare some health outcomes and the cost of standard public maternity care in Australia and compare that with private-led maternity care in Australia. So they meant to compare the public maternity care system as a whole, which is for the most part what we would call fragmented, and they compared that to what would happen if you had a private obstetrician that had some midwives involved potentially. It was an observational study, which means that they didn't design a study and execute it. They just looked back on data that had already been collected and it was administrative data. So it's the type of data that a midwife or doctor would enter into the hospital computer system after a birth, for example. So they looked at standard maternity care, which they reported was largely fragmented. So women don't have a nominated care provider. It's just whoever they get on the day. And they compared the public system to care given by the private obstitution that was chosen by the woman. And we'll say more about this when we critique it and I'm sure those astute listeners at home might already be seeing an issue with this strategy.
Mel
[3:58]But the paper examined outcomes for 368,000 births that were selected out of a bigger data set of about 867,000 women who gave birth in New South Wales, Queensland, and Victoria here in Australia. So only three states. And the data was from 2016 to 2019.
Mel
[4:19]So they looked at the data from the two different models and wanted to see if there was a difference in outcomes for stillbirth, neonatal deaths, neonatal intensive care admission, the condition of the baby at birth. So they had a look at APGAR scores, third and fourth degree perineal tears for women, postpartum hemorrhage, and then the average cost of care per pregnancy.
Mel
[4:42]So we are going to look into the results together, but for now I'll tell you what their conclusion was. So the author said that we have shown significantly lower adverse health outcomes and costs in private obstetric-led care compared to standard public maternity care. So remembering that they only looked at those immediate outcomes for the first four weeks for stillbirth, neonatal death, neonatal intensive care, condition of the baby, third or fourth degree tears, PPH, so postpartum hemorrhage and the average cost of care per pregnancy. Now we all know because you're listening to the Great Birth Rebellion podcast that we can't just read the conclusion and the summary of the paper and take it and run with it. You have to look inside and you have to pick it apart and that's what Hannah and I are going to do today. So Hannah, let's have a comb through the article. I can pick it apart, but at first glance, what would you, what's your response been when people ask you about this article?
[5:50] Critique of the Research Paper
Hannah
[5:51]Look, a couple, well, many things. I had lots of responses when I first saw it because it's in direct opposition to research that we've shown different outcomes for. But I just want to say it's not that this is bad research. It's not that there weren't really important statistical methods used to try and match the population. It isn't that it isn't published in a good journal. And there are some really good researchers on this paper. So this isn't about dismissing it all. Our job, as researchers and as people who want to know what's going on, is to critique it.
Hannah
[6:25]So research is only as good as the question you ask, the data that you have to answer that question, and the way that you analyse it. And then there's a third aspect, which is the way you report it. Do you report it really acknowledging the limitations, or do you report it as, hey, guess what, everyone? This is so much better and so much safer. And then if the media get hold of it, then you end up with a whole narrative that runs out of control. So it is a well-done paper in a good journal. It asks a really important question, which is what is the difference between those models? The problems that we've got, what you really ideally should be trying to do is compare apples and apples. And that's what this study did not do. So for example. We've also done this because previously in the data set before 2016, and it's important for people to know this, the model of care was not available in our collected data. But since 2016, it has been. This research was done on data from 2016 to 19. So they had model of care in there.
Mel
[7:30]What you're saying is in the data set they use, because you've done a similar research project to this, you couldn't compare models of care because previously it wasn't being collected in those data sets.
Hannah
[7:43]There wasn't being notated. We couldn't identify it out of all the big data
[7:49] Issues with Data Collection
Hannah
[7:48]sets. Yes. Which we have now.
Mel
[7:50]Yeah, so we have now. So that data set now will tell you which ones were continuity of care, which ones were fragmented. So the first problem we saw was is that the authors chose not to acknowledge that classification and just compared private obstetrics with public care and they also left out any home births and private midwives.
Hannah
[8:16]So what they did is they took out private midwifery care and they took out home birth. They then clumped all of the public hospital models together and, of course, we know there's fragmented medical-led care, there's fragmented mixed medical midwifery, there's GP-shared care, there's MGP, which is Midwifery Group Practice with Continuity, There's MAPS models, which is antenatal and postnatal. There's so many different types of models, and some of those are continuity and some of them not. So MGP, around 14.5% of models are MGP.
Hannah
[8:52]They then compared that whole pile of models, many which are very fragmented, and we know that does not lead to optimal outcomes, and women fall through the gaps in the system, to a highly continuity autonomous model, which is the private obstetric model. Where women are able to see their obstetrician in their rooms, they go into hospital, they're cared for by midwives all through their labor and birth, the obstetrician comes in to do the last little bit. Then they care for my midwives, then they go back into the community and then they see their obstetrician at six weeks. So there is continuity of that person and that person also has huge authority and, you know, it is a very different scenario to multiple providers providing care. So ideally, they could have compared private obstetrics to private midwifery. That would have been one way of looking at it or continuity model compared to continuity model in the public sector. So that's kind of the first criticism, but that's not the only criticism. The second thing they tried to do, which is what you want to see happen, so this isn't a criticism of the researchers, is they tried to then say, okay, let's try and get these women as similar as possible. So they did really complicated statistics. They did things called bootstrapping and all sorts of things to try and match those populations. And then you ended up with 368,000 women.
Hannah
[10:21]And they tried to match them. And they matched them on things like demographics, on age, on whether they were a first-time mother or a subsequent-time mother. And then they also looked at, you know, managing the risk factors that come with intervention, which is medical risk factors. But the only ones that they looked at were hypertension and diabetes. Now, there are hundreds of those risk factors, and those risk factors are much more in the public sector. In the public sector, we have women that range from just as advantaged as in the private sector to incredible poverty, to drug and alcohol use, to mental health issues, to lack of transport to even get to an appointment, to huge impact on income, and you name it. We have multiple complex issues in the public system and multiple health issues that couldn't be controlled for because they don't have the data. It's not because they weren't doing good research. It just does not exist in our data sets. So as much as you try and match these two groups of people...
Hannah
[11:31]You can't actually match them because they're so different. The only way you could get this identical is to randomise women, which means saying to a woman, okay, you're randomised to having public hospital care. You're randomised to having a private obstetrician. We're never going to get that trial up. So they're doing the best they can with what's on offer, what we've got to work out. But then again, they also try to adjust for things like smoking and reproductive use of reproductive therapy and BMI and that. But then some of the states that they included, which are New South Wales, Victoria and Queensland, don't have some of those items. They don't have them. And so they were missing as well. So you've got these layers of problems with what at surface looks like they match them, something that's absolutely impossible to do. And then your conclusion is it's so much safer to have a baby in the private hospital. Let's not forget that nearly 50% of the women in the private hospital in this group had a cesarean section. Let's not forget we're not following them on into the next birth. Let's not forget that we're only looking at pregnancy birth in the first four weeks. So lots of stuff that we haven't actually captured.
Mel
[12:47]So then the first issue was that the data set they used, although they treated the data appropriately with what they had, in terms of the research methodology, it's what anybody, any researcher would have done. The problem is, is that the database is poor. It's an inaccurate database that has limited information. And so there's confounding factors that could have created this outcome that is completely unrelated to the place in which you gave birth and the person who looked after you. They've assumed that the private obstetrician was the key element in improving outcomes. Whereas there's all these other things in the background that could have just as easily changed the outcomes. And there's not necessarily a correlation between the outcomes and the actual care provider or model of care.
Hannah
[13:39]It's sort of like saying we're going to compare children or, you know, teenagers' scores in a selective high school or a very elite area to people who live out west and go to a school with huge disadvantage. And we're going to say going to a private school or a selective school leads to better results. Well, we all know that's rubbish. We know that the support and the extra infrastructure around those kids are what leads to the outcome. So we've got the same situation going on here. They're using the best they've got, and I do want to reiterate that. There's nothing wrong with the analysis, but you're still not comparing apples and apples. And so as a researcher, you should be saying, you've got to be really cautious about that. We need more research. These are all the gaps. These are the things we haven't covered.
[14:38] The Complexity of Maternity Models
Hannah
[14:34]But my biggest criticism is they had the ability to look at model account. Why didn't they do it? I would die to have this data set. My data set ends at 2016. I would love to have the next lot of data.
Mel
[14:46]Well, and that's one of the issues, actually. We can't really check it. This isn't a public data set. They had access to this that we can't really check. And so the people that I was speaking to when I did a little ring around, because I was like, rightio, let's have a conversation about this article. And other maybe healthcare providers out there could confirm this or not. But one of the obstetricians that I spoke to who works in a hospital said, you've got to remember in terms of the classifications, when we push buttons in the computer, sometimes there's not a button for something and we have to classify it as something else. So he said that things like medically required terminations, for example, for babies who are unwell or women who are very unwell and can't continue their pregnancies, or the stillbirth button gets pushed in a public system. And these kinds of things don't happen as frequently in a privacy.
Hannah
[15:44]And even more than that, anything really complicated comes across to the public system, to our highly expert fetal medicine people. Correct. So we end up with the sickest women, the sickest babies, and the greatest social complexity. And whether or not that is well tracked from I intended to have a baby in a private hospital and these things happen and I still track your outcomes, that is much harder to do because often the button that's pushed is because I ended up in a public hospital, the midwife's filling out the done. She goes, oh, yeah, she's having a baby in a public hospital. I actually started a baby as a private. She's now transferred because of a problem. So there's multiple issues depending on this data, too much for face value.
Mel
[16:27]Yeah. And the other thing that wasn't controlled for is babies who had abnormalities, who regardless of where they were born, would have either been stillborn or been at high risk of dying soon after birth. They were included in the data as well.
Hannah
[16:45]Yeah. And they controlled for them. They did account for them. But in the data analysis we've done, we've always removed congenital abnormalities completely because what we know is even when one thing's identified at birth, that can be linked to other problems that come up later and that impact on baby outcomes. So it's safer to remove congenital abnormalities. We also know those are higher in some populations, which are much more likely to be in the public sector.
Mel
[17:13]Well, and removing them means that you've got more likelihood of answering the question of did private obstetric care improve outcomes? Because a baby with an abnormality was going to have the same outcome regardless of who caught the baby at birth. And so if you take out the babies with abnormalities, then you take out a confounding factor.
Hannah
[17:36]You do, and who knows if the outcome would be different, but you're assuming their outcome on a collective, if you grouped a whole lot of those babies together compared to well babies, it's going to be quite different. Yeah.
[17:47] Analysis of Outcomes
Mel
[17:48]So what they found then, they said that in standard maternity care, so in the public system, there were 778 more stillbirths or neonatal deaths. Did they clump those together?
Hannah
[18:02]So that is more, because they had two groups of women that were equally matched in numbers. So, that number of women that they had equally matched, that 368,000, was equally matched in private and public. So, if you look at a collection of 362,000 women, then there were 700 more stillbirths in the public sector. Right. Because they're the same number. That's why they made it. That's why they stated that way. But it's also quite a scary way to put it without some sort of caveat around that.
Mel
[18:39]Well, they said, so 0.9% of either risk in the public system of either a stillbirth or a neonatal death, 0.9% versus 0.4% in the private sector. Similarly they said that more babies were admitted to neonatal intensive care unit so 3.5 percent in the public sector 1.3 percent in the private sector yeah 2,747 more babies had an APGA less than seven at five minutes so three percent in the public sector 1.5 in the private sector.
Hannah
[19:22]And I've got to say, I think we've got to stop using less than seven at five minutes. I think it's a very, very poor indicator. I think we should be looking at less than four. That's now what a lot of people are moving to because less than seven is a very poor predictor for an adverse outcome, honestly.
Mel
[19:39]So what they said was, is that all clinical outcomes showed in effect favouring private obstetric care. However... Nearly 50% of the women had cesarean sections. They also said that there was a reduced chance of third and fourth degree tears, but then they also didn't tell us that there was an increased chance of episiotomies in private sector.
Hannah
[20:03]Well, they didn't even look at episiotomy because it's always much higher in the private sector, so that wouldn't have been good news.
Mel
[20:08]Right. And I assume that if you're doing more cesarean sections and more episiotomies that you also have less third and fourth degree tears.
Hannah
[20:15]You do, but to be really fair, you should, and again, it's very hard to tell, but I'm assuming they've done what you should do, which is to only look at your third and fourth degree tears out of your vagina births. But if you're doing a lot more caesareans, you're doing potentially you're having less complicated births. So even though they looked at things like, you know, instrumental, they looked at all these things, you potentially, the more times you take a baby out through the sunroof, as we say, The less times that baby comes through the perineum, you're going to inevitably see some change. But my biggest criticism of that, and of course that's a big part of my body of work that I've done research on, my biggest concern about that is we know that the biggest risk factor for third and fourth degree tears, you know, number one, it's forceps. It's bad news, forceps. Number two, it's vacuum extraction. But the highest rates of third and fourth degree tears are within some of our different ethnic groups. So, Asian women, Indian women, we've got very high rates of third and fourth degree tears. Now, while they controlled for country of birth, they didn't control for ethnicity because we don't gather that data. So, my country of birth is Yemen.
Hannah
[21:36]Clearly, I'm not a Yemeni. We've now got second and third generation people from countries that will be recorded as Australian that actually are, you know, ethnically perhaps from some of those higher, those areas of risk. And that's where we have bigger populations where we have higher risk. The third thing that's really important with this is that when we did a study a few years ago and we looked at looking at private and public on third and fourth degree tears, we actually then went in and looked at surgeries to repair things like, you know, significant bowel issues and that that are around us. We looked at the 12 months afterwards and we looked at the surgery. We actually found more women were having repairs and things in the private than in the public sector.
Hannah
[22:25]So when we published that and I started to ask midwives, you know, what could this be, what started to come out is that third and fourth degree tears may be under-recorded in private hospitals because they come with litigation. So the only one that sutures a perineal trauma in a private hospital is the obstetrician. They make the decision. They call it what they want. They write it in the records. Now, I'm not saying that the majority of obstetricians aren't going to do exactly the right thing. And they're going to record it excellently. But there is some concern that maybe because there are multiple people checking and looking and being involved in this, that maybe there is also an under-recording of severe perineal trauma, which is what third and fourth degree tears are collectively recorded as.
Mel
[23:14]This is not the first time I've heard this. So as I was doing the ring-around to other academics in the research process of this, something that one of the private obstetricians said is that there's a general understanding that obstetricians under-report the severity of tears. So it kind of generally makes their stats look a little bit better. And potentially the same with postpartum hemorrhage, because that was another thing they found was a reduction in postpartum hemorrhage that, you know, if there was no major issues for the woman, it's just as easy for them to tick the did not have a hemorrhage box, has had a hemorrhage box to kind of make their stats look a little bit different considering they're private clinicians.
Hannah
[23:59]There's a little bit more to that, which I think is really interesting to unpick as well. So in a public hospital, then we're much more likely to weigh and measure. Now, in a private hospital, the obstetrician does the birth. The obstetrician will probably look at it and go, oh, that looks like about 490 mils, which just manages to get in under the 500 mils. So there's a lot of subjectivity in PPH documentation if you're not doing the measuring and the weighing of drapes and things. We also have women who are much more compromised in the public system with lower hemoglobins, et cetera, et cetera. So, there's a lot more vigilance around the risk that comes with a PPH compared to when you're a well-healthy woman, as you'll see much more of in the private sector. So, I think just looking at PPH 500 mils, look, there are some countries that don't take anything as a postpartum hemorrhage until it reaches 1,000. So, I think that's a soft end. You need to start to look at things like admissions to intensive care, transfusions, big stuff. Yeah. We'll give you an idea of whether or not this is actually a morbidity or is this something that we should be concerned about?
Mel
[25:14]Yeah, and I found it was interesting that the only thing that they really thought about to check for outcomes for the women was the third and fourth degree tears and postpartum hemorrhage.
Mel
[25:26]Because we've skipped over the very real risk factors that exist for women when you use cesarean section at a rate of nearly 50%, which is what happened. And so they've given us this tiny little snapshot into outcomes for the birth and four weeks afterwards without considering the ongoing risk that they've now put that woman and her future children at, having given half of their clientele a cesarean section. And they said, well, look, we've improved the stillbirth rate we have for that particular baby, but you've increased it for that woman's next baby and her next baby after that. And you've also increased her risk factors for every single pregnancy now that she has beyond that first cesarean section. And this is the same argument. Rixa frees from Breach Without Borders, talks about the risk of vaginal breach birth versus the risk of having a cesarean section for a breach. And she talks about how, yep, if you have a vaginal breach birth, about one in 500 of those babies won't survive birth. If you do a cesarean section, one in 1,000 won't survive birth as a breech baby. So when you look at the stats like that, people will say, well,
Mel
[26:46]If you have a cesarean section, you half the risk of stillbirth from breech. However, when you look at the next birth, for women who had a cesarean section for breech, the risk all balances out because you've just reduced the risk of the first
[27:09] Risks of Cesarean Sections
Mel
[27:04]birth, but then increased the risk of the second birth for both the woman and the baby. And so the risk of looking at data in such a small window means that you don't consider the woman's individual risk for her lifetime. It just shines a light on the possibility of good outcomes in that moment with private obstetric care.
Mel
[27:26]And that's something that we actually already know, is that continuity of care models are gold standard. They produce good outcomes on the whole when you compare it to fragmented care models. So it's almost not a fair study to do. Because you're like well of course when you've got women who are advantaged enough to choose a private obstetrician to pay for a private obstetrician to have continuity of care of course we're going to expect an improvement in outcomes when you compare it to all the rest of the stuff but in the same way as you were saying if they compared continuity of care with an obstetrician to continuity of care with a midwife we could be having a whole different conversation because that is a more closely matched research project.
Hannah
[28:19]Yes, yes, no, I agree with you, Mel, but there's so many levels to this. So we did a published study earlier this year where we looked at 172,000 really low-risk women. So we removed everybody out of that as much as we could with the data that we've got, which is similar data to what we're talking about here, but we didn't have a model of care. And we took out anyone who is older than a certain age, younger than a certain age, smoking, congenital, everything, everything that was a risk factor. And we said, okay, let's look at what kind of birth you had. What's your mode of birth for your first baby?
Hannah
[28:57]And then let's track you to the second and the third, if you have a third. And we looked at that. So we found that women who had an initial spontaneous vaginal birth had a 91.3% chance of having subsequent vaginal birth. We found that if they had a cesarean, their probability of having a VBAC was 4.6% after an elective cesarean and 9% after emergency one. Then we looked by public and private and we found that those outcomes were much less for all of that. So if you have a spontaneous vaginal birth, let's just look at this in really broad terms, you've got more than a 91% chance of having another one and another one and another one if you plan to do that. If you have a caesarean, you've got such a high chance of having another caesarean. Now, we all know it's not the first caesarean that's your problem. The first caesarean is the least risk.
Hannah
[29:52]It's maybe number two, but it's probably number three or four. Where you start to see an increase in the placenta growing abnormally through the uterus or low, but also there's a higher rate of stillbirth being shown in some of the big studies in women who've got a scar on their uterus in that subsequent pregnancy. And we haven't even started talking about autoimmune disorders and the increased risk from the microbiome and the lack of seeding that a baby gets when it comes through cesarean section. We also haven't even looked at the fact that there was high rates in the private sector in that paper. We're just discussing where babies were born earlier than their 39 weeks. So... Well, what about education outcomes? What about educational schools? We know that every week counts. It's a major campaign in our country that every week counts. So it's sort of like, again, I'll bring it back to the scenario that we're taking a highly selective private school, comparing it to a school that's in a disadvantaged area and saying, oh, it's so much better to go to the selective school in this private area because they do better and so everyone should have that. Well, no, because it's a heap more complicated than actually doing that. So that's why we have to be so cautious about data. We have to interrogate it. We have to question it. But I also want to come back to the point, and I've just been in Indonesia, amazing country.
Hannah
[31:21]Indonesia has more than 170 maternal deaths per 100,000. Our sits at around between five and seven per 100,000. So they have a huge number of women who are dying, and they're dying from preventable things like PPH, so hemorrhage. They're dying from hemorrhage.
Hannah
[31:37]They're dying from preeclampsia, things that we now hardly ever see in our maternal mortality statistics. Having a baby in Australia, one of the safest countries on earth to have a baby regardless of where you have that baby. And so to put scary headlines in a country like Australia where your chances of having a good outcome are excellent and don't actually get better in Australia Pretty much every country on earth other than Scandinavia, you know, they always get the sweet steak. It's outrageous. It's outrageous to make women frightened because whatever model of care you choose that works for you, and for some women that is a private obstetrician and an elective caesarean. For some women that is wanting continuity of midwifery care and wanting as much as possible to have a normal paginal birth, if that's possible, with this support.
[32:31] The Impact of Care Models
Hannah
[32:32]Everyone's different. Whatever model you choose, your outcomes are safe in our country.
Mel
[32:37]Do you think there has been an intentional campaign to scare women about the public sector in a bid to try and use this paper to leverage women's fear to make them choose private obstetric care?
Hannah
[32:52]So you just asked a really important point and I didn't get in the original thing we submitted to the conversation, got taken out as too political. Cool, but anyway...
Hannah
[33:02]14 private maternity units have shut down in the last year or two, right? That's 14. And the reasons are staffing and the decline in women accessing private sector. So you've got some fairly concerned obstetricians who feel like the private rate is declining. Their hospitals are shutting down. Midwifery has taken off in a big way. More and more women want it, and there's such a lot of positive both research and media around it. There's inevitably going to be some concerns. So you've got no private sector, as far as I know, no private maternity now in the Northern Territory and in Tasmania. I could be wrong on Tasmania. Why, though, has that happened? Two reasons, staffing and declining women wanting to go there. So, staffing. So many midwives go, I don't want to work in this model. I want to work in a model where I can be with women, where I can use my midwifery skills. So there's a real problem in midwives wanting to work in the private sector. Number two, women. Women are realizing that continuity of care with the midwife, where you get her all the way through, or him, all the way through your labor and your birth. And then for four to six weeks afterwards, visiting you at home actually gives you a hell of a lot more.
Mel
[34:26]Yeah.
Hannah
[34:26]And you're not out of pocket as much as well. So women are starting to go, ha-ha, cottoning on, making decisions. Private obstetricians are deeply threatened. So a paper like this coming out with the headlines it did, and let's remember this was published, the media was in right-wing politics. Papers, which had clearly been targeted for this article, the headlines were definitely politically motivated. And the next day, the second headline that came out was obstetricians are paid peanuts. Well, I would love to say, you put an average midwife's pay packet up against an average private OB, and I'll bet my bottom dollar that that is much, much higher. So when they did the cost analysis, I mean, I just looked at this and in the media what came out was how dare the midwife rebate in Medicare now be more for labour and birth than for an obstetrician. Have you ever seen an obstetrician spend 22 hours by a bedside?
Mel
[35:31]No, that's, yeah, the midwives are the one who are putting in the hours. So are you thinking that because of the decline in the use of obstetric care in Australia, and as a result, 14 private hospitals have had to shut down through kind of lack of interest, that the obstetricians are looking for fodder to try and drum up some more business to continue their model of care. And this was an ideal opportunity.
Hannah
[36:01]I want to be careful with that because there were some really good people on this paper, including some really respected midwives as well. So let's not say that this paper set out to be a political statement. What I am saying is when some people heard about this paper, perhaps they went to the media and the media they knew would give them the most sensational headlines in order to get the political message out. So I'm not saying the authors intended this. Yeah. I'm saying that the move of this paper into the media and those scary headlines, And then the subsequent day, which was Obstetricians Paid Peanuts, which is a ludicrous statement, absolutely ludicrous, smacks to me of politically motivated spin. But I'm not saying that the author set out for a politically motivated paper. I want to make that really clear because there's some extremely expert clinicians and researchers who know what they're doing on this paper. Everyone can misuse a paper.
Mel
[37:04]Correct. And I was thinking that as I was reading this, I was like, if this was about home birth, 100%, you can guarantee that my bias would be to pick it up and run with it and wave it about as like further proof that the model of care that I believe in is superior. No doubt about it. And that's why I wanted to talk about this. And I really combed through it. I wanted to look at this as if I was looking at as a home birth paper and trying to, you know, I wanted them to convince me that yes, they were right. And part of me is like, well, yeah, actually, maybe this is actually an indictment potentially on the standard of care that we have because of the fragmentation. We all, that's no new news. Fragmented care does not have as good outcomes as continuity of care. We know that. We know that the researchers in their methodology did a good job. They're obviously incredibly good academics because a lot of them are professors, actually. When I had a look into each of them, I thought, okay, the problem's not with the authors. The problem's not with the methodology. But there were some issues with the data set and how it was potentially used. And then now with how it's been picked up as a political piece...
Mel
[38:29]But this isn't a new strategy. You know, 100 or 200 or so years ago when obstetrics kind of thought about to medicalize childbirth and bring childbirth into the obstetric realm, this was the similar strategy is if we can make women scared and then offer them the answer in our services, then we could perpetuate our work.
[38:55] Political Influences on Maternity Care
Mel
[38:56]But yeah it's it's a tricky one because I know the number of people who sent me the article wanted us to pick it apart and show that it was and discredit it as information but part of me is going maybe maybe there's something to it but obviously all the little issues that I think
Hannah
[39:17]You're spot on Mel. I think our system is broken. Yeah. And I think that what we should get out of this is not private obstetric care is better because we sure know they have a lot more intervention. What we should get out of this is let us fix up the sector where 75% of women get birth and let's look at the models of care that work. Now I remember an obstetrician saying to me once when I was saying about the Cochrane Systematic Review and I said, look, we have.
Hannah
[39:52]High-level evidence. We've just had the WHO come out with a toolkit on how to roll out MGP. There's no other model that's being promoted nationally and internationally as MGP. Why? Because we have a Cochrane systematic review that shows when you compare continuity to all the other kinds of models, the outcomes are better, the cost is less, women are more satisfied, women are more likely to breastfeed. So I just said to this obstetrician, I said, I've got a Cochrane systematic review here. Show me yours. And they can't. There is no high-level evidence. I'm talking about randomized control trials because we have to prove ourselves as midwives. The reason we have all of those randomized control trials from countries all over the world is because we fought and fought and fought to have midwifery care acknowledged, where the assumption was always medical is better. So we have to prove this model against medical care all the time, against all the other models of care. Private obstetrics has never, ever had to prove itself. And the comeuppance has come up where they decline in their revenue, they decline in their access to private hospital care, where they are being challenged now by midwives who do have level one evidence.
Hannah
[41:11]If I were an obstetrician right now, I would be nervous And I can understand feeling threatened and wanting to hunker down and kind of shore everything up and prove your point. And all of us, when we publish a paper, are going to put the spin on it that we are most aligned with in a cognitive and philosophical way. The job of. Good researchers and media, good media, may I say, that take more than just the message they're sent and clinicians and government is to critique and get to the bottom. And so what we're doing here is doing that critique. We're not saying this is bad research, but we are saying this is very low level of evidence. This is not a randomized control trial. It's this, what we're talking about here sits at about level four.
Mel
[42:03]Sure.
Hannah
[42:04]Very low down in the levels of evidence of which you would have confidence to make recommendations that what was spread across the headlines in the paper was irresponsible because we couldn't have the confidence and it was scare tactics with the headlines.
Mel
[42:22]And it was trying to frighten women away from the public system and into private obstetric care. But what women need to know is if they do opt for private obstetric care at the surface level you may improve outcomes for your baby but and you've done research papers on this before and I've actually I've put them in the resource folder for everybody to read you significantly increase your risk of high level interventions like cesarean section when you compare it to the public system and then as a result of that increase your risk for subsequent births. So I don't think we should look at this at a microscopic level of this first individual birth. Think about it across your lifetime and also how you can avoid the shortfalls of the maternity care system, the public maternity care system that exists because certainly most women can't afford private obstetric care. But there's things that you can do in a public system to improve your individual outcomes like seek out continuity of midwifery care in the system.
Hannah
[43:35]And get in early because they're booked out, because they're popular. Yes. A lot of women don't know to get in early.
Mel
[43:42]That's right. You could demand that the hospital that you're at actually look into MDP programs if they don't exist in their midwifery care programs. I had a woman say to me the other day that she's been put immediately into the obstetric clinic because she's got twins, but she wants to see a midwife too. And I said to her, why don't you ask them if you can double up? Tell them I'll see the obstetrician and the midwife. She said, oh, maybe just ask. You could talk to somebody.
Hannah
[44:10]And just on that, Mel, we hugely disadvantage women with risk factors. Totally. The best survey that Hazel and I led, the most unhappy group, The ones that felt the least cared for and respected were the high-risk women because they didn't ever have the same person. They didn't have any. It was literally they became their disease. They were not a woman with all the complexities, social and psychological needs. So we have to do better with women with risk factors. We're really about it.
Mel
[44:45]I agree. And I tell people all the time that anyone, a GP, an obstetrician, a midwife, a nurse midwife can give you maternity care, but only a midwife can give you midwifery care. And midwifery care is a unique type of maternity care that you can't get from anybody else. So midwifery is like step one of care. And then you start adding clinicians as needed to provide additional maternity care, but you're never going to replace midwifery care by hiring a private obstetrician or even having a public obstetrician.
Hannah
[45:21]And let's also, just while you're saying that, Mel, which is such a good point, so many obstetricians have now got midwives in their rooms.
Mel
[45:29]Which is great. I mean, I think they know that. They know.
Hannah
[45:33]Locking the care better.
Mel
[45:34]Exactly. It's making it so much better. I think it's a great idea that obstetricians get midwives in because they're like, whoa, there's something lacking here. Just like if I as a midwife had a client who had some risk factors and I thought, well, I can't give you care for that particular thing. We're going to need to include an obstetrician here. I love that some private obstetricians are starting to invite midwives in and the women are seeing the midwives as much as they're seeing their obstetrician. And in fact, I was in a workshop the other day and the obstetrician was talking about the model that they were using and how they've got midwives in there and how great it is that when the obstetrician is at a birth, they know that most of the time the midwives can take over the clinic and care for quite a large majority of the client base in the absence of the obstetrician, and they thought that was great. But I agree.
Hannah
[46:29]I mean, but can I just make a point on that? Because I totally agree with you, Mel. I think that the more women are exposed to midwifery care, the better it is, and I think it enhances obstetric care. And many midwives work in obstetric practices, but my shout out to my obstetric colleagues is let it come back this way. Don't just collaborate with us when you're in charge. Collaborate with us when we are also the lead care maternity provider. That ain't happening. And so there needs to be some generosity of spirit and there needs to be some true collegiality. and let's have it come back. Because imagine if every midwife who had continuity of care practice had a warm, collaborative and respectful relationship with a great obstetrician. So much easier. Wow. We've solved this problem, but we've still got this big divide and this big resistance to obstetricians working with us if they're not the ones leading the maternity camp.
Mel
[47:31]This is shown again the age-old battle, the age-old battleground of who owns maternity care and who gets which piece of the pie. And, you know, historically, as obstetrics came in, they've just been historically perpetually trying to take more of the pie than perhaps they're entitled to. You know, it makes a point of, yeah, the current ongoing battle that's happening in the maternity guest system and it doesn't serve women to be having this. It's not having this conversation or it doesn't improve outcomes in the public system.
Hannah
[48:10]We want us to work together. Women want to see us using the best of our skills
[48:17] The Cost of Maternity Care
Hannah
[48:15]to work for them and with them. It does not help any of us when we work against each other.
Mel
[48:21]Yeah.
Hannah
[48:22]I think it's important we address the cost stuff because that was the bit that blew me out of the water more than anything. Because of course, Sally Tracy's done some fantastic research where she compared MGP.
Mel
[48:32]She had a trial with obstetrics,
Hannah
[48:34]And it was cheaper to have the care through MGP, midwifery group practice. When they did this analysis, they looked at all of the costs of the PBS and the MBS, which are the pharmaceutical benefit scheme and the Medicare, and they looked at the costs for the episodes of care and all, and I had no criticism with how they did that. They had a very good economist on this. So they came out saying that to have a baby in the public sector was nearly $6,000 more than the private sector. Well, as soon as I saw that, I choked on my Weedabix. And then I started to look into the elements that were measured. What we do know is when you are private and you're more socially economically advantaged, there's a lot you pay out of pocket for that is not captured in all that data. So then I went to look at patient out-of-pocket item. And I looked at what are you out-of-pocket in this study? this study for under public care, $472. What are you out of pocket for if you have private care, $4,285. So don't just put up the headlines that one costs more than another because the cost is to the women. The women are paying that cost.
Mel
[49:47]So you're saying the government saves $5,929 if a woman chooses obstetric care because the woman's picking up the bill instead of the government.
Hannah
[49:59]Because, no, because in the private sector, the woman pays, there's a certain amount covered by Medicare, and then there is usually the gap, the excess the woman pays. Well, that is being paid for by the woman. So it's not affecting the government resources. It's not affecting the government. Yes, because she's paying it herself out of her own account.
Mel
[50:19]That's what I mean. So because the government's footing the entire bill for women who are giving birth in the public system, whereas in the private system, there's a little bit of Medicare, there's a little bit of private health insurance and there's a little bit of the woman's money. And so this paper said, oh, it's heaps cheaper if you give birth in the private hospital, but it's only heaps cheaper for the government. It's not actually heaps cheaper.
Hannah
[50:42]For the maternity care episode. Yeah. But what really struck me was the out of patient, out of pocket. So if I'm a woman thinking what's best for me and I look at it's cheaper to have a baby in the private hospital. But the reality is, if you have a baby in a public hospital, it's $472 out of pocket compared to average, remember, average, $4,285 out of pocket. Then I feel like we're not getting the whole story when the headline is that it's, you know, more cost effective to have your baby in a private hospital. For who?
Mel
[51:15]For who? But also, it's impossible. You know, what enraged me is that you can't do a 50% cesarean section rate and tell me that your costs are less than vaginal births in public system because vaginal births are way cheaper, theoretically.
Hannah
[51:32]However, no, cesareans, there's a bigger amount of money put as a rebate against cesarean section, but it's not just that number. Right. A vaginal birth may be 17 hours of multiple staff and midwifery care and lots of things that are involved in getting that woman to having that baby vaginally. Cesarean section, schedule you in. Half an hour later, bang, you're in recovery. You've got a baby in your arms. There's a multiple level of complex health costs that go with that mode of birth. So, you know, if I'm an obstetrician and I'm, And I've got 300 women a year that I've booked in because I need that to pay my private rooms, my insurance, all the other things that I feel should be part of my package. There's no way I can be on call 265 days a year, you know, in the year and get any sleep and keep my marriage and have any sanity. Why would I not have the incentive to encourage, support, or be less likely to promote vaginal birth? When I go in for half an hour, I do a list scheduled and I can get through six or seven women in a list. Why? We've got a system that rewards problematic practice. Now, I want to raise one more thing.
Mel
[53:01]Yes.
Hannah
[53:02]And it's in the paper in a little bit and I thought, ooh, I read flags here. There's constant referral back to the UK and their inquisition.
Mel
[53:10]Yes. Why are they doing that? Because I looked at that. I was like, don't talk about the UK. This is all Australian data.
Hannah
[53:17]So that's when I went, aha, there's politics involved. So the paragraph that grabbed me was there are flawed approaches to maternity care, such as at the United Kingdom, Shrewsbury National Health Service Trust, East Kent, And then they put in an Australian one, the Mackay Hospital, for service failures, poor pregnancy outcomes, independent inquiries, highlighting a failure to investigate, learn and improve.
Hannah
[53:46]Improvements include continuity of midwifery care, and I'm sure probably the midwife on the paper got that thrown in, which compared to standard care could improve outcomes and cost effectiveness, yet is challenging to scale up. So what I'm seeing increasingly come up in obstetric discourse, and I think it's really important we address it, which is the ideology of normal birth. That for too long, this is what I'm reading, is that midwives have been here promoting normal birth, but meanwhile, the complexity of women has gotten higher and higher and high. We've got older women, we've got more complex women, we've got women with more, you know, they're large, as I always say, the mantra, they're larger, they're sicker, they're asking for it. That seems to be the kind of discourse. And yes, I agree. I agree. Women are older. I do agree. There is more complexity. I think women are getting pregnant. They never would have got pregnant. That adds to a whole lot more maternity complexity. But my answer has always been, why is it that when you take the two models with the highest age group and also they have different levels of complexity in them? So let's take private midwives and private obstetricians. They have the oldest women, right?
Hannah
[55:02]You look at it and you go, yes, yes, maybe there's a little bit difference in some of the medical complications, et cetera. But the outcomes are so vastly different amongst the population that still is not without its complexity. So we know when we did the big study on pace of birth and we compared low-risk women in hospital birth center and home birth, we saw when you take the same women and you then look at the different outcomes, vastly different levels of intervention. Happening in those different sectors. So I guess the point I want to make is I'm sick and tired of hearing everything being blamed on those women that are apparently the problem. And I think it's time for us to take responsibility on how we contribute and we do contribute to what we're currently seeing. And let's fix a fragmented system. Let's make our system safer physically and psychologically. And let's not scare women. and let's all work together. That, I think, is the way forward.
[56:06] Moving Towards Better Care
Mel
[56:06]Yes.
Hannah
[56:06]We've kind of just shot ourselves in the foot and that's why we are where we are. Now, how do we untangle that? How do we come back? How do we make a system that actually gives women the best option wherever they give birth?
Mel
[56:20]Yeah.
Hannah
[56:20]That they give birth with. That's not our call. Our call is to make whatever system the best option.
Mel
[56:28]I mean, what we do know is that continuity of care is better than fragmented care. At the very least, we should work towards a model where women can choose their care provider and that that care provider is with them for the duration of their pregnancy, birth and postpartum. That would be step number one, I think. And then let's look at it after that.
Hannah
[56:46]Yeah, because we know that the outcomes for the baby and the mother are as good or better. You know, it costs less when you look at those models. and we know most importantly that the psychological outcomes, the birth trauma, all of those things that ripple from it are better. So, yeah, I totally agree. I don't think we should even be having the debate about continuity of care.
Mel
[57:10]No, neither do I. That's why I was like, what is this paper even doing? We know continuity of care is better, but then what they did with it, what the media did with it and went, well, see, now everybody should have a private obstetrician. That's not what you should be saying. We should be saying, hey, fragmented care doesn't really work. We know that already. This is not brand new.
[57:33] Conclusion: The Future of Maternity Care
Mel
[57:31]And continuity of care is the way forward.
Hannah
[57:34]And if you were to truly compare the time a midwife spends with you in those models, the time they spend with you in hours, compared to the time a private obstetrician spends with a woman counting antenatal birth and the almost zero postnatal. Yeah. My goodness, it's time we did that study.
Mel
[57:54]Can we do a study? I think instead of time, I reckon we've got to compare private midwifery to private obstetrics. We could match. You could match them. I mean, that would be a study.
Hannah
[58:09]Yeah, well, the average being seven minutes antenatal visit to an hour for a private midwife. I think very clearly we'd know what the outcome was.
Mel
[58:18]Yeah, I mean, across, obviously, satisfaction scores. Anyway, we digressing.
Hannah
[58:23]Hannah- I was so cranky about the costing. Because when they said, why should midwives get paid more for birth? Well, come on. We're coming for, what, half an hour at the end and we're there for the entire thing? Like, it's just scurrilous. And this is not to criticize our obstetric colleague. But we are in a system where there's huge advantage and support to obstetrics. And for the very first time, for a long time, it's getting tough up there. Well, welcome to our world.
Mel
[58:54]But also, this is great. It's kind of like, hey, midwifery is making a job better. I know, but hey, good on everybody. Like, it's happening. We're tipping the scales. Like, maybe this is a glimpse into some more balance.
Hannah
[59:11]And that's what we want. We want balance. We want humanity. We want accessibility. We want fairness.
Mel
[59:19]Amazing. I feel like we have 100% picked apart so many elements of this paper. Were we doing
Hannah
[59:25]An interview or were we just having a cup of tea together? We were both.
Mel
[59:28]We were doing both. I forgot we were recording. We were just having a conversation.
Hannah
[59:34]A chat with Mel.
Mel
[59:35]A chat with Mel. But I think probably what the take-home message of this paper is, don't take this as private obstetric care is better than public care. That's what they would like to sell this paper as. And certainly the conclusion seems to inch towards that. The media inched towards, hey, you could have safer birth outcomes if you choose private obstetric care. But there's so much more involved in this conversation. as you've just heard. So it can't be taken at face value based on this particular paper.
Hannah
[1:00:13]Absolutely. Yeah. And it is low level evidence. And there's a lot of other evidence out there that you need to look at when you are making your considered decisions around where you have a baby. But whatever you choose, having a baby in Australia is a very safe thing to do.
Mel
[1:00:30]Correct. And we know that because Hannah and her colleagues did the birthplace in Australia study, which I will link in the resource folder,
Hannah
[1:00:38]Led by my wonderful colleague, Vanessa Scarf. I need to acknowledge her. It wasn't Hannah led it.
Mel
[1:00:44]No, Hannah, sorry. I was on a board. Just because, you know, I'm your cheerleader. Hannah did all this stuff, but obviously, yes, there are people around Hannah that do a lot of other stuff. Australia is a very safe place to have a baby. Very safe. And there are other things you can do to improve outcomes, not just.
Hannah
[1:01:05]But when I say that, when I say safe, we, again, we're all slipping into the physical safety. It's not always a safe place to have a baby psychologically. So we haven't finished our job until we've got both of that ready. You know, physical safety is the flaw. That's the basic. Emotional, psychological, social, cultural safety is the ceiling. You don't have a house without a floor and a ceiling.
Mel
[1:01:32]I often say that we should all expect to come out of our births alive. That's like the bottom rung of the ladder. That's step one of maternity care. Expect to survive. And then we want to climb the rest of the ladder in Australia. And then to climb the rest of the ladder to actually reach peak experience of physical, social, emotional, psychological, cultural safety, then we're talking. We're not ending the conversation at, hey, but your baby's alive. You're like, yeah, we all expect that. Sometimes it doesn't happen, but we all expect that as the minimum standard of maternity care. That's not the maximum standard. So yeah, let's up our standards on our outcome expectations. Thank you, Hannah, again for being here at the Great Birth Rebellion podcast, and we will see you in the next episode.
Hannah
[1:02:28]Thanks, Mel.
Mel
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