The obstetricians are out in full force, suggesting that mooted changes to the Safety Net will “punish women and their families because they chose to seek help with their pregnancy and births from doctors in the private sector rather than the overwhelmed public hospitals system”.
For another perspective, have a read of this Crikey article in which three academics (with midwifery backgrounds) outline how Federal Government policies, including the Safety Net, have had the unintended side effect of driving up obstetricians’ incomes (at huge cost to the public purse), and promoting a problematic model of care.
For those cynics who might wish to dismiss these concerns on the grounds they were put forward by representatives of a discipline known for contesting the obstetricians’ view of the world, here is an extract from a submission to the Federal Government’s recent maternity services review.
It is by David Ellwood, professor of obstetrics and gynaecology at the ANU. I hope he doesn’t mind but I’m quoting it at length because it is so pertinent to the current debate.
Extract of letter:
1. The current rate of intervention in childbirth
The inexorable rise in the caesarean section rate is something which needs to be addressed as a matter of some urgency. We don’t know the current rate in 2008, although the last figures published by AIHW (2005) show that the caesarean section rate has risen to above 30%. I suspect when the latest issue of Australia’s Mothers and Babies for 2006 comes out next month the rate will have climbed again. I’ve been concerned for a number of years that once we reach a rate of somewhere between 35% – 40% we could reach a tipping point from which the rate will accelerate more rapidly.
Indeed this has been the experience in some overseas countries and there are some notable examples where the caesarean section rnotable examples where the caesarean section rates have rapidly accelerated to 70% or 80%.
There is now a body of scientific evidence in the literature, much of which has been published over the last few years, to suggest that caesarean section does increase the risks to both mother and baby in the index pregnancy, and also increases significantly the risks in subsequent pregnancies. Although the absolute risks are still relatively low, the relative risk when compared to vaginal birth is significant for a number of adverse outcomes.
I believe that there are a number of strategies that could be used to reverse this undesirable trend, but there are two which are worth bringing to the attention of the Review. Firstly, there is a significantly higher rate of caesarean section in the private sector than in the public sector. Whilst some of this is to do with differences in the population of birthing women who use the private sector there is ample evidence that the rates are inappropriately high, even when corrected for some degree of selection bias. It does seem to be an odd situation, (as was pointed out during one of the workshops) that a women can choose to have an elective caesarean section in the private sector and be financially supported to make this choice, whilst an indigenous women is unable to choose to birth naturally ‘on country’. The second area in which I believe there could be a major impact is to increase the midwifery input into natural childbirth. There is a lot of low risk obstetrics which is practiced in the private sector with minimal midwifery input during the ante-natal period. A move to midwifery models of care, either in the public sector, or encouraging the use of midwives in the private sector should have a significant impact on reducing the rate of inappropriate caesarean sections.
2. The unexpected impact on the public sector of supporting private obstetrics
About seven or eight years ago it would be fair to say that private obstetrics in this country was under significant threat. The medico-legal and indemnity insurance crisis at that time was leading to a significant number of obstetricians choosing not to practice
private obstetrics. Indeed, in 2001 the future looked bleak. There have been three significant policy initiatives which have gone a long way to reversing this trend. These have been, in no particular order, subsidies for medical indemnity insurance premiums, tax benefits for those who take out private health insurance (as well as the 30% rebate), and most recently the use of the Medicare safety net to support private obstetric fees. Whilst this has lead to a very positive change in the number of obstetricians choosing to work in the private sector, I believe this has had an unexpected adverse impact on the public sector. As you would be aware, a lot of high risk obstetrics is practiced in the public sector and this is where there is perhaps the greatest potential for skilled obstetricians to make a significant difference.
The current climate is so favourable that it is now possible for newly graduating obstetricians to choose to work exclusively in the private sector. The incomes which are possible, as well as the fact that it may be easier to obtain a degree of work / life balance from this choice, has meant that many new graduates choose to work exclusively in the private sector. It is possible to work effectively part time and limit the number of births to ensure a reasonable income without putting in the long hours which are often required in the public system. As someone who has worked in the public system for all of his professional life, it now appears that the competition between the two sectors is such that it’s becoming almost non-competitive for the public sector. It has always been difficult to recruit to full time salaried positions within the public sector but it is now becoming almost impossible.
I have major concerns for my own sub- speciality of maternal/fetal medicine as we are now seeing a significant drift to the private sector, even from those who have chosen to work full time in tertiary high risk obstetrics. I believe that something has to be done to reverse this trend and to put some balance back into this situation so that full time employment in the public system is much more competitive with the kinds of incomes which are now possible in the private sector.
This trend is also having an impact on academic O & G. The increasingly small pool of full-time salaried specialists, who often have an academic role as well, are becoming the ‘work-horses’ for the public system. Thus, their ability to carve out an academic career is very limited. If this continues, we can predict the demise of academic O & G in a short time.
You can read the rest of the letter here.