Private Obstetric Care Research Articles

Dietary supplements, guideline alignment and biochemical nutrient status in pregnancy: Findings from the Queensland Family Cohort pilot study.

In high-income nations, multiple micronutrient (MMN) supplementation during pregnancy is a common practice. We aimed to describe maternal characteristics associated with supplement use and daily dose of supplemental nutrients consumed in pregnancy, and whether guideline alignment and nutrient status are related to supplement use. The Queensland Family Cohort is a prospective, Australian observational longitudinal study. Maternal characteristics, nutrient intake from food and supplements, and biochemical nutrient status were assessed in the second trimester (n = 127). Supplement use was reported by 89% of participants, of whom 91% reported taking an MMN supplement. Participants who received private obstetric care, had private health insurance and had greater alignment to meat/vegetarian alternatives recommendations were more likely to report MMN supplement use. Private obstetric care and general practitioner shared care were associated with higher daily dose of supplemental nutrients consumed compared with midwifery group practice. There was high reliance on supplements to meet nutrient reference values for folate, iodine and iron, but only plasma folate concentrations were higher in MMN supplement versus nonsupplement users. Exceeding the upper level of intake for folic acid and iron was more likely among combined MMN and individual supplement/s users, and associated with higher plasma concentrations of the respective nutrients. Given the low alignment with food group recommendations and potential risks associated with high MMN supplement use, whole food diets should be emphasized. This study confirms the need to define effective strategies for optimizing nutrient intake in pregnancy, especially among those most vulnerable where MMN supplement use may be appropriate.

Vaccine intention and hesitancy among Australian women who are currently pregnant or have recently given birth: the Birth in the Time of COVID-19 (BITTOC) national online survey

ObjectiveTo examine the prevalence of COVID-19 vaccination, and factors associated with vaccination intention and hesitancy in pregnant and postnatal women in Australia.Design and settingA national online survey was conducted over...

O36 - Labouring Together: Women’s Experiences of “Getting the Care that I Want and Need” in Maternity Care

Poor collaboration has been identified as detrimental to the safety and experience of maternity care. The Labouring Together study was conducted to explore women's and clinicians' perceptions and experiences of collaboration in maternity care in Victoria, Australia. Underpinned by well-established conceptual theories of collaboration and shared decision-making (SDM), a sequential, mixed-methods, multi-site case study approach was used to explore women’s perceptions and experiences of maternity care in four diverse case studies of public and private hospitals. Women's preferred and experienced role for SDM were quantified using the Control Preferences Scale (CPS) and analysed using chi-square analyses by case and socio-demographic characteristics. In depth interviews were conducted to explore preferences and experiences reported by women. Most women indicated that they preferred an autonomous or collaborative role for SDM, however 24.4% of women reported experiencing a passive decision-making role during their maternity care. Statistically significant differences were identified between the preferences and experiences of decision-making among women who chose private obstetric care compared to public maternity care. The conceptual framework of Getting the Care that I Want and Need emerged from inductive analysis of qualitative data. Impacts upon women’s autonomy over decision-making in maternity care included: access to midwifery models of care, access to relational continuity of care; understanding of the rights of the woman; and models information sharing for risks and benefits of all options and proposed interventions. Bureaucratic style decision-making based upon a dominant discourse of risk avoidance was identified as a major barrier, with power to ultimately veto the woman’s choice The Labouring Together study findings provide evidence to support women to use SDM processes to enable decision-making in maternity care. However, fundamental barriers were identified to hinder collaboration; and shared decision-making with women is not routine practice in Victoria, Australia.

A direct comparison of patient-reported outcomes and experiences in alternative models of maternity care in Queensland, Australia.

We aimed to directly compare women's pregnancy to postpartum outcomes and experiences across the major maternity models of care offered in Queensland, Australia. We conducted secondary analyses of self-reported data collected in 2012 from a state-wide sample of women who had recently given birth in Queensland (response rate = 30.4%). Logistic regression was used to estimate the odds of outcomes and experiences associated with three models (GP Shared Care, Public Midwifery Continuity Care, Private Obstetric Care) compared with Standard Public Care, adjusting for relevant maternal characteristics and clinical covariates. Of 2,802 women, 18.2% received Standard Public Care, 21.7% received GP Shared Care, 12.9% received Public Midwifery Continuity Care, and 47.1% received Private Obstetric Care. There were minimal differences for women in GP Shared Care. Women in Public Midwifery Continuity Care were less likely to have a scheduled caesarean and more likely to have an unassisted vaginal birth, experience freedom of mobility during labour and informed consent processes for inducing labour, vaginal examinations, fetal monitoring and receiving Syntocinon to birth their placenta, and report highest quality interpersonal care. They had fewer vaginal examinations, lower odds of perineal trauma requiring sutures and anxiety after birth, shorter postpartum hospital stays, and higher odds of a home postpartum care visit. Women in Private Obstetric Care were more likely to have their labour induced, a scheduled caesarean birth, experience informed consent processes for caesarean, and report highest quality interpersonal care, but less likely to experience unassisted vaginal birth and informed consent for Syntocinon to birth their placenta. There is an urgent need to communicate variations between maternity models across the range of outcome and experiential measures that are important to women; build more rigorous comparative evidence for Private Midwifery Care; and prioritise experiential and out-of-pocket cost comparisons in further research to enable woman-centred informed decision-making.

Private provider incentives in health care: The case of caesarean births

Private doctors and hospitals face incentives to intervene in the process of childbirth because they are employed and paid differently from their public counterparts. While private obstetric care has been associated with higher rates of caesarean birth, it is unclear to what extent this is attributable to unobserved selection effects related to clinical need or patient preferences. Using administrative birth data on over 280,000 births in Australia between 2007 and 2012, we implement an instrumental variables framework to account for the endogeneity of choice of care. We also exploit Australia's institutional framework to examine the differences in doctor-level and hospital-level incentives. We find that giving birth in a private hospital leads to a 4 percentage point increase in the probability of having an unplanned caesarean birth. Over our study period, this equates to an additional 3241 caesarean births.

The benefit of prophylactic cervical cerclage in twin pregnancies

Background: Despite the progress in modern obstetric practice, preterm labor is second leading cause of death in the 1st month of life and the main cause of perinatal morbidity and mortality; it remains a difficult problem to prevent, delay or even stop. It occurs in 5%–13% of all pregnancies before 37 weeks' gestation but its incidence in twin pregnancies is about 25%. Objectives: This study aimed to determine the effect of prophylactic cervical cerclage (CC) in comparison to others methods: vaginal progesterone and bed rest in prolongation of gestational age in twin pregnancies to prevent preterm labor. Materials and Methods: A retrospective descriptive study was conducted between January 2012 and September 2018, in a private obstetric antenatal care clinic in Duhok/Kurdistan Region/Iraq. It involved 150 women with twin pregnancies attending this clinic for follow-up, they divided into: Group 1 (N-86): women who received prophylactic CC; Group 2 (N-44): those who got the vaginal progesterone supplementation of 100 mg from 20 to 34 weeks of gestation; and Group 3 (N-20): those who asked for advisement of bed rest and restriction of physical activity. Results: Most of the total sample 95.3% had dichorionic placenta, the majority of them 84.7% were the result of assisted reproductive techniques. There was no statistically significant difference between the three groups in relation to maternal age, gravid, and previous preterm delivery, but there was in relation to the gestational age at delivery. In Group 1, 93% who delivered >37 weeks, whereas 16% and 10% in Group 2 and Group 3 who delivered at this gestational age, respectively. The overall perinatal survival was 91.3% and 26.6% who admitted to Neonatal Intensive Care Unit. Conclusions: The current study found that the prophylactic CC was an effective method to prolong pregnancy among women with twin pregnancies.

Cost-effectiveness analysis of natural birth and elective C-section in supplemental health

ABSTRACTOBJECTIVE To conduct a cost-effectiveness analysis of natural childbirth and elective C-section for normal risk pregnant women.METHODS The study was conducted from the perspective of supplemental health, a health subsystem that finances private obstetric care, represented in Brazil by health plan operators. The reference populations were normal risk pregnant women, who could undergo natural childbirth or elective C-section, subdivided into primiparous and multiparous women with previous uterine scar. A decision analysis model was constructed including choice of delivery types and health consequences for mother and newborn, from admission for delivery to maternity hospital discharge. Effectiveness measures were identified from the scientific literature, and cost data obtained by consultation with health professionals, health plan operators’ pricing tables, and pricing reference publications of health resources.RESULTS Natural childbirth was dominant compared with elective C-section for primiparous normal risk pregnant women, presenting lower cost (R$5,210.96 versus R$5,753.54) and better or equal effectiveness for all evaluated outcomes. For multiparous women with previous uterine scar, C-section presented lower cost (R$5,364.07) than natural childbirth (R$5,632.24), and better or equal effectiveness; therefore, C-section is more efficient for this population.CONCLUSIONS It is necessary to control and audit C-sections without clinical indication, especially with regard to primiparous women, contributing to the management of perinatal care.

Factors promoting or inhibiting normal birth

BackgroundIn response to rising rates of medical intervention in birth, there has been increased international interest in promoting normal birth (without induction of labour, epidural/spinal/general anaesthesia, episiotomy, forceps/vacuum, or caesarean section). However, there is limited evidence for how best to achieve increased rates of normal birth. In this study we examined the role of modifiable and non-modifiable factors in experiencing a normal birth using retrospective, self-reported data.MethodsWomen who gave birth over a four-month period in Queensland, Australia, were invited to complete a questionnaire about their preferences for and experiences of pregnancy, labour, birth, and postnatal care. Responses (N = 5840) were analysed using multiple logistic regression models to identify associations with four aspects of normal birth: onset of labour, use of anaesthesia, mode of birth, and use of episiotomy. The probability of normal birth was then estimated by combining these models.ResultsOverall, 28.7% of women experienced a normal birth. Probability of a normal birth was reduced for women who were primiparous, had a history of caesarean, had a multiple pregnancy, were older, had a more advanced gestational age, experienced pregnancy-related health conditions (gestational diabetes, low-lying placenta, high blood pressure), had continuous electronic fetal monitoring during labour, and knew only some of their care providers for labour and birth. Women had a higher probability of normal birth if they lived outside major metropolitan areas, did not receive private obstetric care, had freedom of movement throughout labour, received continuity of care in labour and birth, did not have an augmented labour, or gave birth in a non-supine position.ConclusionsOur findings highlight several relevant modifiable factors including mobility, monitoring, and care provision during labour and birth, for increasing normal birth opportunity. An important step forward in promoting normal birth is increasing awareness of such relationships through patient involvement in informed decision-making and implementation of this evidence in care guidelines.

Barriers to antenatal psychosocial assessment and depression screening in private hospital settings.

The evidence of benefit for antenatal psychosocial assessment and depression screening has been sufficient to lead the implementation of screening in public hospitals in all states of Australia. Details of the implementation of perinatal screening in private obstetric settings is less well known. As any successful implementation relies on the identification of local barriers, we aimed to determine what perceived or actual barriers may exist for the implementation of evidence-based perinatal screening interventions in private obstetric care, and specifically within small private hospitals. The integrative literature review method offers a structured systematic approach to organise, synthesize and critique research from a range of sources. This method was used to determine what barriers have been identified in implementing psychosocial assessment and depression screening with women receiving obstetric care in private hospital settings. The integrative review findings suggest that barriers to implementing psychosocial screening in the private sector are similar to those experienced in the public sector but may also be influenced by the corporate focus of private services. Barriers were identified among health professionals, within the personal and psychosocial context of women and their families, and at provider or system level. Once identified, barriers can be systematically addressed to enhance the success of implementing psychosocial and depression screening in the private sector. Screening is likely to be influenced by the business models and operating systems of private service providers. Health professionals working within this environment need more support to conduct perinatal assessment within this context.

Bereaved parents' experience of care and follow-up after stillbirth in Sydney hospitals.

Despite stillbirth being identified as one of the most traumatic events a woman can experience, there is a lack of evidence on which to inform best practice in hospital and follow-up care. The aim of this study was to identify which strategies are most valued by parents regarding care following stillbirth in order to improve the support and management of grieving families. Mixed methods questionnaires were sent to bereaved participants of the Sydney Stillbirth Study. Questionnaires included a combination of fixed and open-ended responses regarding two critical areas: the participant's hospital stay and their follow-up care. We analysed the qualitative data using thematic analysis. Of the 103 women who experienced a stillbirth, 36 responded to the questionnaire. Responders were more likely to have private obstetric care (odds ratio (OR) 4.7, 95% CI 1.7-12.7) and be tertiary educated (OR 6.2, 95% CI 2.3-16.8). Three key themes relating to hospital management of stillbirth were identified: the emotional response to grief, the educational importance of being guided through the grief process, and the environmental aspects of adequate time and appropriate physical space. Families preferred not to be seen in an antenatal setting for follow-up. Simple key components of care including a sensitive and respectful approach, offering guidance as to creating memories, and arranging follow-up care in a quiet and private environment are valued by families experiencing a stillbirth. Incorporating these into practice is achievable and could benefit both families and caregivers.

Antenatal psychosocial assessment and depression screening in a private hospital.

It has been recommended that psychosocial assessment (including depression screening) be integrated into routine antenatal care across Australia, but implementation in the private sector has lagged. This study aimed to report preliminary outcomes associated with an antenatal psychosocial assessment and depression screening program implemented at an Australian private obstetric hospital setting and to report characteristics and correlates of elevated depression symptoms in this sample. A total of 993 pregnant women (mean ± SD gestational age 27.9 ± 6.7 weeks) participated in a structured psychosocial assessment interview and completed the Edinburgh Postnatal Depression Scale (EPDS). Six per cent of participants scored ≥13 on the EPDS. Psychosocial correlates of antenatal depressive symptoms included low income, history of pregnancy termination, poor practical support, lack of confidence and history of depression. Almost 1 in 10 of the total sample was referred for further assessment and clinical support. The prevalence of clinically significant antenatal depressive symptoms in this sample highlights the importance of antenatal depression screening for all women, including those who choose to access private obstetric care.

International caesarean section rates: the rising tide.

International caesarean section rates: the rising tide.

Can private obstetric care be saved in South Africa?

This article examines the question of whether private obstetric care in South Africa (SA) can be saved in view of the escalation in medical and legal costs brought about by a dramatic increase in medical negligence litigation. This question is assessed with reference to applicable medical and legal approaches. The crux of the matter is essentially a question of affordability. From a medical perspective, it seems that the English system (as articulated by the Royal College of Obstetricians and Gynaecologists) as well as American perspectives may be well suited to the SA situation. Legal approaches are assessed in the context of the applicable medicolegal framework in SA, the present nature of damages and compensation with reference to obstetric negligence liability, as well as alternative options (no-fault and capping of damages) to the present system based on fault. It is argued, depending on constitutional considerations, that a system of damages caps for noneconomic damages seems to be the most appropriate and legally less invasive system in conjunction with the establishment of a state excess insurance fund.

What are pregnant women told about models of maternity care in Australia? A retrospective study of women's reports

ObjectiveTo describe women's reports of the model of care options General Practitioners (GPs) discussed with them at the first pregnancy consultation and women's self-reported role in decision-making about model of care. MethodsWomen who had recently given birth responded to survey items about the models of care GPs discussed, their role in final decision-making, and socio-demographic, obstetric history, and early pregnancy characteristics. ResultsThe proportion of women with whom each model of care was discussed varied between 8.2% (for private midwifery care with home birth) and 64.4% (GP shared care). Only 7.7% of women reported that all seven models were discussed. Exclusive discussion about private obstetric care and about all public models was common, and women's health insurance status was the strongest predictor of the presence of discussions about each model. Most women (82.6%) reported active involvement in final decision-making about model of care. ConclusionAlthough most women report involvement in maternity model of care decisions, they remain largely uninformed about the breadth of available model of care options. Practical implicationsStrategies that facilitate women's access to information on the differentiating features and outcomes for all models of care should be prioritized to better ensure equitable and quality decisions.

Change in smoking status during two consecutive pregnancies: a population-based cohort study.

To investigate changes in tobacco smoking in two consecutive pregnancies and factors associated with the change. Population-based cohort study. New South Wales, Australia, 2000-10. A total of 183,385 women having first and second singleton pregnancies. Descriptive and multivariable logistic regression analyses of perinatal data linked to hospital admission data. Proportion of women smoking during their first pregnancy who quit by their second, and of women not smoking in their first pregnancy who did smoke during their second. Among 22,761 smokers in the first pregnancy, 33.5% had quit by their second. Among 160,624 non-smokers in their first pregnancy, 3.6% smoked during their second. Women who were aged ≥25 years, were married, born in a non-English speaking country, used private obstetric care, and lived in a socio-economically advantaged area were more likely to quit or less likely to start smoking in the second pregnancy. Smokers who had gestational hypertension (adjusted odds ratio [OR] 1.36, 95% confidence interval [95% CI] 1.23-1.51), a large-for-gestational-age infant (OR 1.66, 95% CI, 1.46-1.89), and a stillbirth (OR 1.44, 95% CI 1.06-1.94) were more likely to quit, whereas smokers whose infant was small-for-gestational-age (OR 0.65, 95% CI 0.60-0.70) or admitted to special care nursery (OR 0.87, 95% CI 0.81-0.94) were less likely to quit. Among non-smokers in the first pregnancy, the risk of smoking in the second pregnancy increased with late antenatal attendance (e.g. ≥26 weeks, OR 1.30, 95% CI 1.14-1.48), gestational diabetes (OR 1.25, 95% CI 1.07-1.45), preterm birth (e.g. spontaneous, OR 1.25, 95% CI 1.10-1.43), caesarean section (e.g. prelabour, OR 1.13, 95% CI 1.01-1.26), and infant small-for-gestational-age (OR 1.37, 95% CI 1.26-1.48) or required special care nursery (OR 1.14, 95% CI 1.06-1.23). Inter-pregnancy interval of ≥3 years was associated with either change in smoking status. Most smokers continue to smoke in their next pregnancy, even among those who experienced poor outcomes. Intensive interventions should be explored and offered to women at the highest risk.

Catastrophizing mediates the relationship between fear of pain and preference for elective caesarean section

Fear of childbirth is associated with preference for an elective caesarean section (ECS); however, the role of fear of pain and pain catastrophizing (the tendency to predict the worst case scenario) have not been investigated. The aim of current study was to investigate whether fear of pain and catastrophizing were independent predictors of preference for ECS. We hypothesized that pain catastrophizing and negative affectivity would mediate the relationship between fear of pain and preference for ECS. Three hundred pregnant women between 4 and 36 weeks of gestation were asked to indicate whether they would prefer to deliver their baby through an ECS or a vaginal delivery. They were also asked to complete a battery of questionnaires assessing demographic details, mood, fear of childbirth, fear of pain and catastrophizing. Consistent with cultural norms, more than half of the women preferred an ECS (58%). Women who chose ECS were more likely to seek private obstetric care, have had a previous caesarean section and have higher levels of fear of childbirth, fear of pain, more catastrophic cognitions and lower mood. Catastrophizing, but not negative affectivity, mediated the relationship between fear of pain and preference for ECS, as predicted. Fear of both childbirth and pain were both independent predictors of preference for ECS. Catastrophizing mediated the relationship between fear of pain and preference for ECS. Interventions that target these factors may reduce the trend towards increasing numbers of ECS internationally.

The threat of litigation: Private obstetric care – quo vadis?

Because of changes in litigation frequency and estimated claims value, indemnity costs for South African obstetricians have increased sharply and may soon become virtually unaffordable. There is the real possibility of very serious public health consequences and it is important that the matter is addressed as a matter of urgency. Resolution is by no means limited to obstetric care, but it is important that obstetricians become actively involved in the debate. While the alternatives suggested may be considered unpalatable they are raised to open and stimulate debate – they are by no means prescriptive. Clearly the debate has to extend beyond the obstetric or indeed the medical community and urgent and serious consideration will have to be given to tort reform.

Commentary: public and private intervention rates in obstetric practice

Dr Jodie Dodd is a maternal fetal medicine fellow, and Professor Jeffrey Robinson is head of Department of Obstetrics & Gynaecology, University of Adelaide.The paper by Shorten and Shorten published in the last edition of Australian Health Review highlights differences in intervention rates (induction of labour, caesarean section, use of epidural analgesia) between women receiving private obstetric care and those receiving public obstetric care (Shorten & Shorten 2004).Similarly, the authors highlight the more frequent occurrence of "less favourable birth outcomes such as emergency CS, instrumental birth, episiotomy and (perineal) tear requiring suturing" in women giving birth in private hospital settings. These differences persisted after controlling for the risk profile of the woman or development of complications during birth (Shorten & Shorten 2004). These findings are not new in Australia, having been reported previously by King (1993 and 2000), and Roberts and colleagues (2000 and 2002). However, Shorten and Shorten's link to subsidies for private insurance raises a new concern.The global interest in obstetric intervention rates and in particular rates of caesarean section has been underpinned by the assumption that there is in fact an "ideal" rate of intervention, where benefits outweigh risks. Much of this discussion developed after the World Health Organization published a statement to the effect that a caesarean section rate of 15% was appropriate (WHO 1985). However there has been little critique of the derivation of this figure and there is a lack of evidence in the scientific literature supporting it. The rate of any particular intervention should not be considered in isolation - what is important is how the intervention relates to increasing or decreasing maternal and infant mortality and morbidity.

Costing the cascade: estimating the cost of increased obstetric intervention in childbirth using population data

To estimate the cost of "the cascade" of obstetric interventions introduced during labour for low risk women. A cost formula derived from population data. New South Wales, Australia. All 171,157 women having a live baby during 1996 and 1997. Four groups of interventions that occur during labour were identified. A cost model was constructed using the known age-adjusted rates for low risk women having one of three birth outcomes following these pre-specified interventions. Costs were based on statewide averages for the cost of labour and birth in hospital. The outcome measure is an "average cost unit per woman" for low risk women, predicted by the level of intervention during labour. Obstetric care is classified as either private obstetric care in a private or public hospital, or routine public hospital care. The relative cost of birth increased by up to 50% for low risk primiparous women and up to 36% for low risk multiparous women as labour interventions accumulated. An epidural was associated with a sharp increase in cost of up to 32% for some primiparous low risk women, and up to 36% for some multiparous low risk women. Private obstetric care increased the overall relative cost by 9% for primiparous low risk women and 4% for multiparous low risk women. The initiation of a cascade of obstetric interventions during labour for low risk women is costly to the health system. Private obstetric care adds further to the cost of care for low risk women.

Costing the cascade: estimating the cost of increased obstetric intervention in childbirth using population data

Objective To estimate the cost of ‘the cascade’ of obstetric interventions introduced during labour for low risk women. Design A cost formula derived from population data. Setting New South Wales, Australia. Population All 171,157 women having a live baby during 1996 and 1997. Methods Four groups of interventions that occur during labour were identified. A cost model was constructed using the known age-adjusted rates for low risk women having one of three birth outcomes following these pre-specified interventions. Costs were based on statewide averages for the cost of labour and birth in hospital. Main outcome measures The outcome measure is an ‘average cost unit per woman’ for low risk women, predicted by the level of intervention during labour. Obstetric care is classified as either private obstetric care in a private or public hospital, or routine public hospital care. Results The relative cost of birth increased by up to 50% for low risk primiparous women and up to 36% for low risk multiparous women as labour interventions accumulated. An epidural was associated with a sharp increase in cost of up to 32% for some primiparous low risk women, and up to 36% for some multiparous low risk women. Private obstetric care increased the overall relative cost by 9% for primiparous low risk women and 4% for multiparous low risk women. Conclusions The initiation of a cascade of obstetric interventions during labour for low risk women is costly to the health system. Private obstetric care adds further to the cost of care for low risk women.