Women in Australia are more likely to have an unplanned caesarean birth if they give birth in a private hospital rather than a public hospital – independent of their health status during pregnancy or their birth plans. Our recent study showed an unplanned caesarean birth was 4.2% more likely in a private hospital compared with a public hospital. For first-time mums, it was 7.7% more likely.
Many studies have pointed to a link between private obstetric care and higher rates of caesarean births. But it’s been difficult to tease out the effects of women who may need or want a caesarean birth. We can’t look to the gold standard of evidence in the form of a randomised trial, because it would be unfeasible and unethical to randomly assign women to public and private care.
Instead, in this study we focused on a large data set of over 289,000 births in NSW between 2007 and 2012, and used a method developed to approximate a randomised trial. Two-thirds of women received public care, while 27% gave birth in a private hospital (7% had a private obstetrician in a public hospital). Women in our study had low risk pregnancies right up to the start of labour and did not plan to have a caesarean. This approach took out the effect of maternal choice and health needs, leaving only the impact of care received: private or public.
Two different health systems
Caesarean birth is a necessary and life-saving surgery when a clinical need exists. However, caesarean birth has also been linked with a range of short and long term adverse child health outcomes, such as respiratory infection, eczema and metabolic disorder. So unnecessary caesarean births may involve increased risk without clear benefit.
In Australia, 35% of all babies were born via caesarean birth in 2017. Of the surgeries performed before the pregnancy was full term, over 40% were without a medical reason. Some of this is due to maternal choice, but international studies have shown that convenience and payment to the doctor or hospital also matter.
In Australia, the way hospitals and providers are paid could be an important factor in birth outcomes. Private doctors and hospitals are employed and paid differently from their public counterparts, so they face different incentives to intervene during labour and childbirth.
Private obstetricians are paid on a fee-for-service basis to attend the birth. By contrast, publicly appointed obstetric and midwifery staff are paid on a salary basis for agreed hours. This means private obstetricians receive more income, the more births they can attend. In some cases, caesarean birth may also be seen as a method of risk management given the uncertainty of prolonged labour.
Hospitals also receive different payment based on whether a birth was caesarean or vaginal, reflecting the relative complexity of caesarean birth. Caesarean birth is a high-cost procedure: an average A$11,782 charge for caesarean birth, compared to A$8,388 for a vaginal birth in a private hospital. In our study, there were more than 3,200 “extra” caesarean births in private hospitals, that is, births that would have been vaginal births in the public system.
Private choices, caesarean outcomes
In Australia, women who give birth in a public hospital have care provided by appointed midwives and obstetricians. If they have the resources, some women may decide to pay for care from a private obstetrician of their choice, either at a private or a public hospital (with reimbursement from their private health insurer). For women who wish to schedule a caesarean birth without health reasons – as a matter of convenience or because they are nervous about vaginal birth – private care is often the only option.
Our research is the first to measure the impact on the type of birth of having a private obstetrician in a public hospital, as well as the impact of giving birth in a private hospital.
We found a smaller effect of having a private obstetrician in a public hospital, which raised the probability of caesarean birth by 2.1%. This could be due to the influence of both the culture in a less-interventionist birth unit led by midwives, as well as the dominance of appointed staff, in public hospitals.
By contrast, we found a larger increase of 4.2% for women who gave birth in private hospitals. Aside from possible payment and convenience incentives, this could also be due to the more interventionist culture in private hospitals. Again, these increases in the likelihood of a caesarean birth were independent of health need at the onset of labour or prior birthing intention. While many caesarean births may occur due to complications during labour, there is no evidence to suggest these complications are more common in private hospitals.
Our results have meaningful implications for women choosing their antenatal and birth care, as well as the health system supporting them. Women value their autonomy and participation in the decision-making process when it comes to labour and childbirth.
Women may choose a private obstetrician for reasons of continuity of care or because of a recommendation. They may prefer the amenities in a private hospital. Our study adds to a body of evidence about the likelihood of surgical intervention in different settings. Women should seek information about their care choices and advocate for their preferences around intervention with their midwife or doctor.
Unnecessary caesarean births mean we are not using scarce health system resources in the best way. This research calls for a rethink of the Australian private health insurance system, which supports this diversion of funding and specialists towards unnecessary care that could carry increased risks for birthing mother and child.