Letters
Women's health
Volume 190 - Issue 9

Adverse outcomes of labour in public and private hospitals in Australia

Authors:  Lyndsey F Watson, Mary-Ann Davey, Mary A Biro and James F King

Med J Aust 2009; 190 (9): 518-519. || doi: 10.5694/j.1326-5377.2009.tb02542.x
Published online: 4 May 2009
Download PDF (74 KB)
Share: Share on Blue Sky Share on Facebook Share on LinkedIn Share by email

To the Editor: In their recent article, Robson and colleagues conclude that women are at increased risk of adverse perinatal outcomes if they give birth in public rather than private hospitals.1 We are concerned that this interpretation is likely to be false, has caused the public unnecessary alarm, and may be used to support vested interests.

There are several serious limitations in the data, the analyses and the implications.

The authors report that 14.3% of women (about 134 000) giving birth in Australia during the study period were excluded from the analyses. We believe that this exclusion introduces significant bias. Outcomes and sensitivity analyses should have been presented for the excluded groups, enabling the reader to interpret the findings appropriately. Pre- and post-term births and multiple births were appropriately excluded from the analysis. However, perinatal deaths due to congenital anomalies should also have been excluded. In Victoria in 2004, 19% of perinatal deaths at term were caused by congenital anomalies.2 These almost always occur in public hospitals.

The authors adjusted for a number of maternal demographic characteristics in their risk assessment. Other factors known to reflect sociodemographic status, such as education, occupation and income, and low birthweight, were not included; therefore the adjustment is unlikely to be adequate.

The analysis should have been stratified by hospital level of care. Women at high risk of adverse outcomes should be (and are being) cared for in tertiary public hospitals — which, unlike private hospitals, are designed to provide high-level care — as a matter of need and not of choice. The lumping together of all public hospitals in the analysis and provision of summary outcomes necessarily skews the findings. By doing this, the authors are effectively comparing apples with oranges.

The proper analysis of severe perineal laceration would exclude those women who had caesarean sections, because they are not at risk of perineal trauma. Stratification by type of vaginal birth is misleading when women attempting vaginal birth in private hospitals are much more likely to experience instrumental birth than those in public hospitals.

In conclusion, differential exclusion of a significant proportion of the population, inadequate adjustment for confounding factors, lack of stratification by hospital type, and inappropriate analysis of perineal lacerations are likely to lead to faulty inference and cause unnecessary alarm. This is particularly unfortunate at the time of publication of the national Maternity Services Review.3

Authors

  • Lyndsey F Watson1
  • Mary-Ann Davey1
  • Mary A Biro2
  • James F King3
  • 1. Mother and Child Health Research, La Trobe University, Melbourne, VIC.
  • 2. School of Nursing and Midwifery, Monash University, Melbourne, VIC.
  • 3. Department of Perinatal Medicine, Royal Women’s Hospital, Melbourne, VIC.

Correspondence: l.watson@latrobe.edu.au

References

View this article on Wiley Online Library