Response: public and private intervention rates in obstetric practice

Abstract

TO THE EDITORS: Dodd and Robinson (2004) present a commentary on our recently published work (Shorten B & Shorten A 2004) which examines the trends in obstetric interventions within New South Wales (NSW) public and private hospitals from 1997-2001. We welcome discussion on this important issue which has both clinical and economic implications. They acknowledge that our emphasis on recent changes in subsidies for private health insurance adds a concerning new dimension to what is a well established debate regarding obstetric intervention rates in Australian private and public hospitals. Rather than being primarily a concern for the 'health funders', it has implications for all Australian taxpayers, who bear the opportunity costs associated with subsidising potentially ineffective, or even harmful, health care interventions or models of care at the expense of other worthy health care programs.In acknowledging that risks and benefits exist for all health care choices we must be cautious in recommending that as long as consumers are fully informed of the risks and benefits then it is acceptable to provide funding, ignoring the broader societal implications of such resource consumption. Therefore the need for transparency and accountability (Dodd & Robinson 2004, p. 11) within the private obstetric sector is both an economic and ethical imperative.One of the interesting contradictions in contemporary obstetrics is the use of the argument that consumer demand is a contributing factor behind the growing rate of birth intervention. However, practitioners simultaneously recommend funding of high quality research with the purpose of gaining better evidence upon which to base clinical practice. It is important for high quality evidence to be produced and disseminated, but the existence of that evidence alone will not address the current trend in obstetric interventions. Those who support the principles of evidence based practice will be aware of the challenges faced by those attempting to 'get evidence into practice'. The presence of evidence does not equate to evidence-based practice, and consumers are not necessarily aware of this. Further, the presumption that consumers are not well informed about the vitally important consequences of their health care choices is a central pillar underpinning extensive public regulation of, in particular, the health care professions. This provides further reason to be cautious in evaluating arguments relating to consumer choice as a factor in observed interventions and outcomes.If it is the case that most private obstetncians are also gynaecologists, and work in several settings; and ... non-clinical factors may have a greater impact on interventions than evidence from systematic reviews (Dodd & Robinson 2004, p. …