[ozmidwifery] Interesting article

[Mary Murphy]

British Journal oi Obstetrics and Gynaecology April 1993, Vol. 100, pp. 303-306 COMMENTARIES In Australia, approximately 50% of women carry some form of private health insurance for childbirth, with some variation between States. This gives them access to an obstetrician of their choice and to either private hospital accommodation or to a private bed in a public hospital as an intermediate patient. The obstetrician (or in a rural setting, a general practitioner/obstetrician) is remunerated on a fee-for-service basis by the Federal Government, receiving a global schedule fee for obstetric care regardless of complications of pregnancy or the type of delivery. The obstetric specialist’s fee currently amounts to $AU600. The patient is responsible for meeting any difference between the private obstetrician’s fee and the schedule fee. This extra fee varies between obstetricians and may be as high as an extra $AU600 but on average is an extra $AU110 (Deeble 1991). The average fee-forservice payment to private obstetricians and gynaecologists in Australia in 1991 was $AU291 600 which does not include income from extra billing (O’Reilly 1992). The other 50% of Australian women who do not carry private health insurance have their medical and hospital charges covered by a compulsory levy applied to all income earning Australians (1.25% of gross salary); there are no direct charges for public health services. This gives obst‘etric patients access to a public hospital where care is provided by salaried doctors and midwives. Almost no private obstetric hospitals in Australia produce annual clinical reports and most mixed hospitals produce information in which public and private data are combined. However, in those hospitals from which data are available an approximate doubling of caesarean section and instrumental delivery rates is seen for private births compared to public births with caesarean section rates for private patients often in the range of 30 to 35%. A similar doubling of intervention rates for private patients has been observed in the United Kingdom with 10.4% caesarean section rates for NHS patients compared to 22.5% for patients in pay beds (Macfarlane 1988). It is probable that these higher intervention rates are not due to the biological or medical differences between private and public obstetric patients. If anything, private patients are, in general, better nourished, better educated and better prepared for birth; they might be expected to require (and wish for) less intervention in childbirth. Not surprisingly, there is no evidence to show that these higher intervention rates confer any improvement in outcome for the mother or her baby (Cary 1990). When testing the strength of an association between two variables, a doselresponse relationship increases the likelihood of a causal effect. The data from Australia and the USA indicate such a dose/response relationship in the association of private insurance and high intervention Obstetric intervention and the economic imperative