03 Aug 2010

Private obstetricians – not so evil after all!

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I don’t exactly run to the mailbox when the Medical Journal of Australia arrives early each month and so it was today. Anyway while thumbing through today’s edition I came across an article and an accompanying editorial examining outcomes for women and babies in Australia.

Of course you will have noticed many articles in the press recently decrying the bad habits of private obstetricians – most particularly our high obstetric intervention rates. The Sydney Morning Heraldin particular seems only too happy to devote front page real estate to any story illustrating the evils of caesareans and obstetricians (and of course the two go together) notwithstanding the more than occasional flimsiness of the science involved.

Anyhow today Dr Steve Robson and colleagues examined nearly 800,000 full term (37 to 41 weeks gestation) that occurred in Australia between 2001 and 2004. As well as being up to date the study took account of risk factors for adverse outcomes like smoking, increased maternal age, indigeneity, medical complications and remoteness from medical services. The babies most at risk of adverse outcomes – the premature and the very overdue – were not studied so this study examined typical Australian women giving birth and their babies.

The bottom line is that if you give birth in a Private Hospital your chance of your baby dying is half that if you do so publicly. The same statistic applies to the chance of your baby having requiring a significant degree of resuscitation after birth. To be fair of course the absolute risk of an adverse event in this day and age is low and Robson again confirmed the high intervention rates of obstetricians.

Now whenever clinicians see research we don’t like we shoot the messenger and criticise the scientific methodology that led to the conclusion we disagree with. God knows I do it myself. Many individuals and organisations (including the Federal Government) are unlikely to receive this study joyfully as it does not fit with a number of agendas in play at the moment (have I mentioned how paranoid I can be?). Criticism of this study will appear shortly.

But, there’s a problem.

The Robson study is consistent with a number of other pieces of Australian research conducted over the last decade or so.

  • Dr Fiona Stanley’s group in Perth have demonstrated that elective caesarean (as opposed to planning to give birth vaginally) is associated with a significant reduction in the risk of a significant brain injury for the baby.
  • The Victorian Department of Health’s Maternity Indicators (found on the Victorian DOH’s website) have consistently shown that the – risk adjusted – likelihood of death of a baby is lower in the private sector than in most public hospitals
  • A recent study from Newcastle in the Australian and New Zealand Journal of Obstetrics and Gynaecology showed that patients of private obstetricians had lower stillbirth rates than public patients.

So where does the truth lie?

As usual, it lies in the middle ground. Firstly in this day and age with the high quality of training of all practitioners involved in maternity and the tools available to us (ultrasound, fetal monitors, epidurals and ready access to operating rooms and paediatricians) the absolute risk of your baby dying or coming to serious harm around the time of its birth is very low – probably below half a percent. However it also seems that an assiduous approach to fetal welfare both before and during labour – along with a low threshold for performing a caesarean – appears to be associated with optimal outcomes.

Women pay a price for the welfare of their babies in the form of high intervention rates and we probably do as many as 500 caesareans to save one baby. Also despite our best efforts tragedies still occur. So we are not so good at deciding exactly which babies are likely to come to severe harm during their births.

Accordingly we – well private obstetricians at least – err on the side of caution.

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