January 3, 2009
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There are wide discrepancies in rates of intervention for births, writes Julie Robotham, smh.
THERE was never any question in Leanne Ortika's mind that she would have an epidural for pain relief when she delivered her first child.
"I decided that from the moment I got pregnant," said Mrs Ortika, 28, whose daughter Abigail is now six months old. "I didn't want to feel any pain."
Luckily for her, she was in the right place. At Sutherland's Kareena Private Hospital, where Abigail was born, only 4 per cent of mothers do without pain relief - one of the lowest rates in NSW, but on a par with most other private hospitals - as doctors adhere to the powerful maxim of patient choice.
At Auburn Hospital, where a state high of 23 per cent of women have no pain relief, Entessar Chami felt her choices were respected, too.
A few puffs of nitrous oxide at the height of her labour got the 27-year-old through the swift birth on December 17 of Shadi, her second child, and she felt relieved and grateful.
Throughout her previous pregnancy, with daughter Layla, now two, a caesarean section had been a possibility because of a low-lying placenta that shifted just in time for a vaginal birth. Mrs Chami had been horrified by "the thought of them cutting my stomach open to deliver a baby when I could just push it out naturally".
A national review of birth services and the roles of doctors and midwives in bringing children into the world has highlighted wide discrepancies in rates of birth intervention across NSW, especially between the public and private systems.
Caesarean births reached 46 per cent at Kareena and exceeded 40 per cent at most other private hospitals, where women are usually assisted by the same private obstetrician they have been seeing throughout their pregnancy, according to 2005 figures - the most recent available.
Between one-quarter and one-third of women in most private hospitals have an episiotomy - a surgical cut to the vagina to widen it for delivery, compared with about 10 per cent in the public sector. Forceps or vacuum deliveries are about 15 per cent of all births in private hospitals, well above the 10 per cent state average.
And while differences in the age and health of pregnant women are behind some of the disparity, experts say this is not enough to explain it all. Even young, healthy women such as Mrs Ortika and Mrs Chami may have very different perspectives on how they wish to give birth, and their demands - and hospitals' willingness to accede to them - are at the heart of the issue.
Ted Weaver, the president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said having an epidural anaesthetic - more widely available in the private than the public system - increased the chance a woman would not be able to push out her baby independently.
If the drug blocked all sensation, so the woman had no urge to push, "there's a pretty high chance - more than 50 per cent - she'll end up with [a vacuum extraction or forceps delivery]", he said.
Then, if forceps were used, "most women would end up with an episiotomy", Dr Weaver said. It was not clear whether women knew about the link between these interventions.
But Dr Weaver said there was "also a cascade of non-intervention - the idea that you leave everything alone and it'll be all right. That model has many flaws in it. You can be criticised for not doing things, too."
In the college's submission to the maternity review, being undertaken by the Commonwealth Chief Nurse and Midwifery Officer, Rosemary Bryant, it said reasons for the high private caesarean rate included the older age of mothers with health insurance, and the lack of emergency caesarean facilities at many private hospitals, which may persuade doctors to schedule the surgery instead of waiting to see how the birth progresses. As well, it said, mothers who chose private care appeared less tolerant of any risk to the foetus.
But the submission conceded there were "particular practitioners in the private sector who have a caesarean section rates in excess of 60 per cent. [The college] views these rates with concern."
In an individual submission, David Ellwood, a professor of obstetrics and gynaecology at the Australian National University Medical School, said caesarean rates were, "inappropriately high" in the private sector, and he was concerned "that once we reach a rate of … 35 to 40 per cent we could reach a tipping point from which the rate will accelerate more rapidly".
Recent research showed caesareans increased risks to both mother and baby in a first pregnancy, and more so in subsequent pregnancies.
Andrew Zuschmann, who delivers babies at Kareena, said there was a high demand there for "maternal choice caesarean section" without medical need.
"I'm a strong advocate of patient choice," he said. "I see my job as a facilitator and provider of information. I think women in this area are highly educated and highly informed."
But despite this, said Dr Zuschmann, "nobody's asked me my personal caesarean section rate, ever."
Indra Wijetunga, director of clinical services at Kareena, declined to comment on the hospital's birth intervention rate, saying, "these are choices between patients and doctors".
Paul Mackey, the director of policy and research at the Australian Private Hospitals Association, said doctors worked as contractors in private hospitals, which typically did not set clinical policies, except to ensure doctors were appropriately qualified. But Mr Mackey said he hoped the maternity review would offer "greater understanding as to why there is this variance".
Fiona Hammond, Auburn Hospital's clinical midwifery specialist, said only women whose pregnancy was judged low-risk were attended there. But the low intervention rate was also attributable to practices within the unit. "We try to encourage labour in an upright position," she said, which helped it to progress faster.
"Midwives do lead the care and consult with obstetricians rather than being told what to do. We try not to invoke a sickness model around us. We try to encourage women that it is a normal part of life."