The proportion of women who give birth by caesarean has risen dramatically in the developed world over the past few decades, with rates in Australia almost doubling, from 18% in 1991 to 31% in 2008.
Until recently we’ve been unclear on the reasons why. But research published recently by my colleagues and I in the journal PLoS One shows Australia’s private health insurance policies have played an important role – at least in Western Australia.
There’s no doubt that adequate access to emergency caesaren delivery can save the life of both the mother and infant. But high rates of caesarean section births, particularly rates above 15%, may result in poorer maternal and infant health outcomes. Following a caesarean section, infants are at greater risk of breathing complications and infections; while mothers are at greater risk of injury and complications for the current and subsequent births.
The private sector has played a significant role in the rising caesarean section rates in Australia. [Recent research](http://bmjopen.bmj.com/content/2/5/e001723.full](http://bmjopen.bmj.com/content/2/5/e001723.full) from New South Wales found that the caesarean section rates have risen more rapidly in private hospitals than public hospitals since the mid-1990s, bringing it up to 43% in private hospitals in [2009](http://www.aihw.gov.au/publication-detail/?id=10737420870](http://www.aihw.gov.au/publication-detail/?id=10737420870), compared with 28% in public hospitals.
Researchers have previously put the rising caesarean rates down in the developed world to obestricians’ fear of litigation. Others have found that some women – particularly more educated women – prefer a cesarean section over vaginal birth and ask their private obstetrician for their baby to be delivered surgically.
The rise of private health
After the introduction of universal health care in 1984, rates of private health insurance declined, from 50% in the pre-Medicare era to 31% in 1997.
In an attempt to reverse this trend and relieve pressure on the public hospital system, the Howard government introduced incentives for more Australians to obtain private health insurance (PHI). The most significant aspects of these reforms included a 30% rebate on premiums regardless of income and a penalty on premiums for those who take out PHI after the age of 30.
These policy reforms were introduced over a three year period, but it was the PHI premium penalty (introduced in 2000) that was ultimately successful in increasing the proportion of Australians with PHI by about 50% and reducing the pressure on public hospitals.
However, due to the high cost of the 30% premium rebates, statistics from Institute of Health and Welfare show that, following the policy reforms, the government spent a similar amount on private patients (funded by PHI) and public patients, which was not the case prior to the implementation of the policy.
The PHI policy incentives – particularly the premium penalty – were mainly aimed at people in their 20s and 30s; one of the biggest target groups were therefore young families and women of childbearing age. Our research has shown that the birth rate in the private sector increased by about 50% and the birth rate in the public sector decreased by about 20% immediately following these policy reforms.
Further, the rate of caesarean sections performed before labour (planned surgical delivery) increased by about 10% immediately following the introduction of the policy incentives in 2000.
Greater risk of complications
The private hospital system certainly offers women more continuity of care. In private hospitals, a woman will generally see a private obstetrician throughout her pregnancy, while in a public hospital she will be cared for by a range of midwives and clinicians, even if she has a regular GP.
But giving birth in the private sector comes with a number of risks, most notably greater exposure to obstetric interventions such as induction, episiotomy, epidural anaesthesia and, of course, caesarean section.
With PHI having become easily affordable for many young families following the PHI policy initiatives, more women have been exposed to these interventions in the past decade.
This prompts the question, would government resources spent on the premium rebates in the past decade or so have been better utilised through increased funding towards public hospitals? Public hospitals in Australia have been under significant pressure and face acute shortages of midwives and obstetricians.
And could the resources have enabled public maternity hospitals to set up better systems of continuity of antenatal care for all women in Australia, regardless of their financial means? Increased financial resources would allow public maternity hospitals to hire more midwives and thus set up a system where women can see the same midwife throughout pregnancy as well as during delivery.
It’s time for the commonwealth, states and territories to review the nation’s maternity structures and move towards a system that prioritises the health and well-being of women and their infants.