Letters
Women's health Child health
Volume 191 - Issue 10

Adverse outcomes of labour in public and private hospitals in Australia

Authors:  Sally K Tracy, Alec W Welsh, Hannah G Dahlen and Mark B Tracy

Med J Aust 2009; 191 (10): 578-580. || doi: 10.5694/j.1326-5377.2009.tb03329.x
Published online: 16 November 2009
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To the Editor: The study by Robson and colleagues1 predictably produced alarming media headlines. However, we feel the study contains potential inaccuracies that seriously undermine the conclusion that the baby toll is lower in private hospitals.

Did the authors ascertain the true impact of fetal abnormality or conditions requiring transfer to tertiary care? Women with threatened preterm labour often transfer to the public system and subsequently remain under the care of public high-risk teams. Babies with a known congenital anomaly detected antenatally by private obstetricians may be similarly transferred. This highest level of care is only available in public hospitals, usually those with dedicated subspecialist services in maternal–fetal medicine, neonatology or neonatal surgery. When babies who have been transferred from private hospitals to the public neonatal intensive care system subsequently die within 28 days of birth, this may be recorded as a public hospital death.

The authors stated that the “major adverse outcome associated with social disadvantage is low birthweight” but that assessment of the effect of social disadvantage was beyond the scope of their study. Not accounting for the effect of low birthweight is unacceptable. The National Perinatal Data Collection records birthweight accurately and is easily used to remove the bias of low birthweight.

An internationally accepted indicator of optimal perineal outcome is the rate of intact perineum. This is known to be lower in private hospitals but was curiously not reported. Further, a prospective data audit in a tertiary hospital revealed that where episiotomy extends to third- or fourth-degree tear, this is only reported as episiotomy.2 Thus, with twice the rate of episiotomy in private hospitals,3 and its association with severe perineal trauma, this outcome could be seriously under-reported in Robson et al’s study.

The authors identify the significantly higher rate of caesarean sections in private hospitals as one of the measurable benefits of this model of care and dismiss any concerns as “orthodoxy”. They have overlooked the significant morbidity and mortality among term neonates associated with the rise in caesarean rates, both elective and following labour. Research using detailed Australian and New Zealand Neonatal Network data to ascertain admission rates of babies of ‘‘low-risk’’ women to neonatal intensive care units and special care nurseries not only found higher rates of admission across each gestational age group after elective caesarean section but also reported the death of two infants.4 Such morbidity and mortality is arguably the most important differential of care experienced by women who give birth in private or public hospitals.

Authors

  • Sally K Tracy1,2
  • Alec W Welsh1,3
  • Hannah G Dahlen4
  • Mark B Tracy2,5
  • 1. Royal Hospital for Women, Sydney, NSW.
  • 2. University of Sydney, Sydney, NSW.
  • 3. University of New South Wales, Sydney, NSW.
  • 4. University of Western Sydney, Sydney, NSW.
  • 5. Sydney West Area Health Service, Sydney, NSW.

Correspondence: sallytracy@usyd.edu.au

References

View this article on Wiley Online Library