For further information, contact Melissa Maimann at Essential Birth Consulting.
Link to article
30% of births end up in caesareans … two of the influencing factors in this practice: social class and the maternity service utilized (public or private) …
The study, published in the magazine Journal of Epidemiology and Community Health, analyzes the data of female residents in Barcelona who gave birth between 1994 and 2003, and reveals that a relevant factor in the percentage of caesareans is birth care in private clinics, since they double public clinics in the number of surgeries.
The research project’s authors confirm to SINC that, in Spain, the number of interventions carried out through caesareans is ¨excessive¨. ¨More caesareans are being done than should be done. All medical literature interprets that it should be done, at a maximum, in 15% of cases, although in many rich countries this figure is being doubled¨, …
The results show that when public healthcare and private healthcare are compared, more caesareans are carried out in the latter case. ¨When women from disadvantaged social classes give birth in private clinics, the percentage of caesareans is equal to that of more advantaged classes¨.
… Age appears as another factor in these interventions. According to Salvador’s specifications to SINC, ¨With more age, more caesareans. And in the same fashion, with more age, more possibilities of enjoying a more accommodated social class, which means there may be older women who go to give birth at private clinics … ¨.
… Besides the reasons derived from the complications which may present themselves at childbirth, … there are other non-medical reasons for performing caesareans: the ease that planning childbirth can mean for the doctor, the mother, and the family, as well as the economic factor …
Although this is an American article, the stats and findings are just as relevant here in Australia.
The article shows again that the biggest determinant of birth outcome is choice of care provider and choice of location for birth.
Caesarean, induction and epidural rates are all lower when women have access to primary midwife care.
Melissa Maimann, Essential Birth Consulting 0400 418 448
I was wondering about your take on induction leading to cesarean for questionable reasons such as failure to progress. I have been made aware that there is a medicare charge which kicks in after 12 hours labor of about $1300, which is for a difficult or prolonged labor.
A woman goes in for an elective induction, and gets an epidural, and is not told that she’s running a risk of having a prolonged labor. She then is sectioned after a prolonged labor where the extra medicare charge is picked up like the $200 pass go Monopoly treat.
So there an industrial incentive to induce, and then section women after at least 12 hours, without any other indication than non-progression, and what role does the epidural, which drastically limits maternal mobility and uterine function play in this scenario?
The institution gets to charge for induction procedures and drugs, epidural procedures and drugs, staff, monitoring, and then “emergency” cesarean. Is it just me, or could this be intentional?
Dear Marge,
I completely agree with your comments. I have seen the Medicare benefits for births. The onlt point I’d add is that benefit to the Anaesthetist (especially in a private hospital). One hospital I worked in (a large private hospital) had 2 Anaesthetists working there. They used to have input at antenatal classes, encouraging women to have epidurals. In 2006, their epi rate was 87%. The CS rate was 45% (but 30% were elective).
I think there’s a valid place for section after failure to progress or slow progress – eg if the baby is distressed, if there’s simply no progress over many hours (not 1 or 2 …) etc. But it does seem that in some cases, if you’ve progressed less than 4cm in 4 hours, you have your waters broken (if not already done), and then are re-examined in say 2 hours. If you’re not another 2cm dilated, you have a drip. Re-examine in 2 hours, and if you’re not another 2cm dilated, you go for section. As you point out, since epidurals do limit mobility and uterine contractions, you’re almost doomed to travel this path. Most women being induced are advised to have an epi because it’s so much more painful than natural birth.
There is a strong culture in maternity to collaborate and cooperate. The system works so much better when the doctor runs the show and everyone falls in to line. So the doctor orders the induction, the midwives recommend the epi … etc. But who’s really thinking of the woman, who is told she “needs” the induction and that really, an epi would be best?
Yes, there could be an industrial incentive to induce, and then section women after 12 hours (with an advantage to the anaesthetist for this too – s/he comes in at least once for the epi, and then again for the surgery. One of those times is most likely out of hours). However, some babies are distressed before 12 hours, so they’re sectioned before then.
“Is it just me, or could this be intentional?” Private health care is run like a business in many respects. Hospitals generate revenue from “bums in beds”, and throughput of bums in beds. But they want profitable bums, not just any old bum. It’s possible that the scenario you’ve described makes a bum more profitable. More claims can be made when it’s an induction, epi, CS, anaesthetist, bloods, CTG, possible day or two in the nursery for the baby etc. One hospital used to charge $1,040 per night for nursery stay, as opposed to $870 per night if the baby is in the ward. So if baby is in SCN, the charge would be $1,910.
PHI won’t pay for extended hospital stays where there’s no reason for the patient to stay (so you can’t stay in because you like the food, if there’s no medical reason to stay). So there may be an incentive for the hospital to maximise claims for the standard length of stay, but not to create morbidity that will increase the average length of stay, because that would possibly cause reason for the PHI fund to ask questions. The cascade of intervention that you described allows the hospital to increase its claims without increasing length of stay.
But of course, morbidity does increase longer term: the more subtle (and not-so-subtle) consequences of the cascade of intervention: more PND, impaired bonding, possible behaviour problems in the baby as a result of poor bonding, increased asthma and diabetes in the baby, impaired breastfeeding, delayed milk coming in, increased blood loss resulting in anaemia and exhaustion in the mother, increased pain – sometimes for months after the CS, mother feeling like she has failed, and so on. Unfortunately, there is little recognition of these factors in the medical community.
So then elective inductions predictively increase the cesarean rate for all factors, especially in the absence of true medical indications. And then institutions and their associates are able to accurately guesstimate capital gains from interventions and the cascade of interventions, not to mention staff accordingly.
What equates fetal distress? Is it a suspicious tracing or does it have to be pathological?
Research shows that inductions don’t increase the caesarean rate directly. So if you have an induction, no epidural, no fetal distress etc, then the caesarean rate is supposedly not increased. The increase in the CS rate is attributed to the cascade that often (but not always) follows induction – gas / pethidine / epidural / continuous monitoring, immobility etc.
No doubt there would be some sort of Excel program that could predict the chance of induction + epidural leading to ceasarean for fetal distress, failure to progress, failed induction, or the baby remaining posterior at the end of the first stage etc. And yes, institutions could estimate capital gains from interventions etc.
Epidurals that are done early in labour (or even before labour) carry a higher CS rate than epidurals done later in labour, and those who critique research that shows that epis increase the CS rate will argue that the reason for the epi predicts the need for CS, rather than the epi “causing” the CS. So they argue association, not causation. However, this argument does not hold true because we have such a huge variation in CS rates and induction rates. Some hospitals have higher CS rates and high epi rates, ehile a neighbouring hospital (similar clientele) will have lower rates of both. Association (not causation) may be the case, but I wonder if the association is merely private OB / private hosp = high CS, induction and epi rate.
Fetal distress could be a suspicious or pathological trace. Larger public hospitals generally have the facilities to take a fetal blood sample and analyse that to diagnose distress (along with looking at the trace). Smaller public hospitals and privat hospitals don’t have this equipment (or the staff at hand to do the test), so they may do more unnecessary caesareans for “fetal distress” that reveal babies with apgars of 9 and 9, born pink, crying, vigorous etc.