It’s a system where the government pays, the patient pays and the doctor smiles before he or she slaps you with a monstrous bill.

I took notice last year when AAP’s Los Angeles correspondent Peter Mitchell criticised the fees charged by health care providers in the US.

His wife gave birth to a baby boy and the bill come to over $A50,000, but it was completely covered by their $A418 monthly payments for US health insurance.

I have recently confronted a mirror experience as an American journalist living in Australia.

But I calculate that Peter paid less in out-of-pocket costs during his wife’s pregnancy than my wife and I did in Sydney.

We initially decided on the public health system for the birth of our son until we caught sight of our local hospital’s maternity ward: a demountable structure.

… The deal-breaker came when I asked what would be the medical response to an emergency birth.

Answer: a helicopter to transport my wife to a better-equipped facility.

Both of us had private health insurance, which we’d never used, so we thought we’d give it a go.

The out-of-pocket costs for the private hospital were estimated in advance at $500, which turned out to be accurate in the end.

We shopped around for a recommended obstetrician and settled on someone in the CBD who charged $4000, which we thought would be for the delivery, no matter the outcome.

Of that amount, we had to pay $1800 after Medicare.

We heard of prices for obstetricians as low as $3000 in Sydney’s west and as high as $6400 on the north shore.

Our doctor also charged us $100 for every visit to his office, of which we received about $80 back on each bill from Medicare.

So far, we’re in for about $2800, which we thought was about the maximum we wanted to pay in a country that rates its public health care system among the best in the world.

The first anaesthetist charged $700 to stick a needle in my wife for the epidural – a 10-minute procedure.

The second anaesthetist, who was present during the surgery, charged an additional $1386 and did almost nothing.

During my wife’s procedure, a young nurse present made it clear she was there to take photos and asked if I had a camera with me. I did.

The assisting surgeon charged another $420 and to top things off, our obstetrician sent us a bill for another $1539.

Last but certainly not least, a paediatrician making daily rounds at the hospital checked out our son on three separate occasions for less than five minutes a visit.

The cost for that? $700.

You’ve known for days.
The urpy-ness before breakfast (when you can eat breakfast), the swollen bits, the tender bits, all good indications. Even the home-kit was positive but it wasn’t “official” until the doctor said it: you’re pregnant.

But after leaving your first prenatal exam – and after more tests than you’ve had in your lifetime – your mother (overjoyed) read through some information you received and said she never remembered half that stuff when you were born. Grandma (ecstatic) said she wasn’t even awake when your mom was delivered.

Have we come a long way, baby? Yes and no, as you’ll see when you read “Get Me Out” by Randi Hutter Epstein, M.D.

Let’s start in the year 1530. You’re about to become somebody’s mom. Because a sign on the door of your room says “no boys allowed,” you’re surrounded by girlfriends, female relatives and a midwife (if you could afford her). They would have herbs for you, food and drink. Someone might consult a book of pregnancy advice (available for thousands of years). You’d labor with people you knew.
But as an almost-mom in 1530, don’t expect anything for your pain. In 1591, a laboring mother (of twins!) was burned at the stake because she dared to ask for relief.

Fast forward three hundred years.
You’re at a lying-in hospital, so-called because post-delivery recovery takes weeks of bed rest. You might be allowed visitors, but no midwives; male doctors have convinced the general population that midwives are dangerous. Giving birth away from home and family, you’re told, is best for you and the baby.

… Dr. Christopher Dotson had been allowed to help oversee Dr. Andrew Rutland’s probation beginning in 2007. Dotson completed five years of probation in 2005 as part of his settlement of negligence allegations after a woman bled to death following a Caesarean section and a case of a stillborn baby.

A California Medical Board spokeswoman told the Register that probation staff had erred and Dotson has been removed as Rutland’s practice monitor.

… Documents … allege a midwife ignored and turned down the volume of an echocardiogram alarm that sounded for more than three hours …

The documents also claim Mrs Body was diagnosed and treated for deep vein thrombosis and thrombophilia (blood clotting) …

She alleges the hospital ought to have known her medical history and the risks associated and failed to recognise a natural birth “could not be performed safely”.

The documents show Mrs Body was admitted to hospital at 8am on February 26, 2007, and was monitored at half-hour intervals between 9.30am and 3pm.

Her waters were broken by a doctor about 4pm and at 4.30pm an epidural was administered.

… the statistical association between endometriosis and infertility is beyond dispute. One well-cited study found a higher prevalence of endometriosis in infertile women (48 percent) than in fertile women undergoing tubal sterilization (5 percent) … infertile women are 6-8 times more likely to have endometriosis than fertile women.

… a new diagnostic staging tool has been proposed that predicts the chance of spontaneous pregnancy in those with surgically documented endometriosis who are treated without IVF … The EFI score ranges from 0-10, with 0 representing the poorest prognosis and 10 the best … those patients with scores of 0-3 could expect a cumulative pregnancy rate of 11.1 percent at 3 years, increasing to 68.3 percent for those with scores of 9-10.

… workplace problems are preventing Canberra-based obstetricians from doing more public work.

As many as 16 registrars … can be attached to the Canberra Hospital Obstetric and Gynaecology Department at one time.

But RANZCOG spokesman Andrew Foote says five consultant obstetricians have left in just over a year.

“In order to do surgery, you need senior doctors who are seeing the cases and putting the cases on operating lists,” he said.

“That has fallen to a quite significant level.”

… the Canberra Hospital had “the potential to be a leader in the RANZCOG program throughout Australia and New Zealand.”

But in its recommendations it listed “dysfunctional relationships within the Obstetric and Gynaecology Department …

… conflict between senior staff … was having an impact on trainees.

… obstetricians would work at the hospital if the conditions were better.

… many of the doctors and registrars who have left the hospital … complained of a toxic workplace and uncooperative relationships with some midwives.

… they were concerned some midwives raised the alarm too late in emergency situations with potentially disastrous consequences.

“One of the cultural concerns I have is that there’s this ‘I’ve failed if I have to call in a doctor’, both at the patient level and at the midwife level,” …

… “This concept has been built up and perhaps sold to the public that it is possible to have a pregnancy unencumbered by any medical staff,” he said.

Gill Hall from the ACT College of Midwives says most doctors and midwives work well together.

“There’s a lot of people in both professions who are working very hard to change the culture and to make practice much more collaborative,” she said.

Health Minister Katy Gallagher says the Federal Government’s changes to Medicare which will reduce rebates to private obstetricians could be partly behind doctors raising the allegations.

For the past seven months, the state Department of Public Health declined to release a report outlining the trend.

California Watch spoke with investigators who wrote the report and they confirmed the most significant spike in pregnancy-related deaths since the 1930s. Although the number of deaths is relatively small, it’s more dangerous to give birth in California than it is in Kuwait or Bosnia.

“The issue is how rapidly this rate has worsened,” … “That’s what’s shocking.”

… “current trends and evidence suggest that maternal mortality rates may be increasing in the U.S.”

The alert asked doctors to consider morbid obesity, high blood pressure and diabetes, along with hemorrhaging from C-sections, as contributing factors.

… Shabbir Ahmad, a scientist … decided to look closer. He organized … a systematic review of every maternal death in California. It’s the largest state review ever conducted. The group’s initial findings provide the first strong evidence that there is a true increase in deaths – not just the number of reported deaths.

Changes in the population – obese mothers, older mothers and fertility treatments – cannot completely account for the rise in deaths in California …

… scientists have started to ask what doctors are doing differently. And, he added, it’s hard to ignore the fact that C-sections have increased 50 percent in the same decade that maternal mortality increased. The task force has found that changing clinical practice could prevent a significant number of these deaths.

… While the maternal mortality rate among black women is rising, the task force found a more dramatic increase in deaths among white, non-Hispanic mothers …

… In 1996, the maternal death rate in California was 5.6 per 100,000 live births … Between 1998 and 1999, the World Health Organization changed its coding system, which may have increased reporting of deaths. The California rate was 6.7 in 1998 and 7.7 in 1999. Because the number of mothers who die is small, the rate tends to fluctuate from year to year.

In 2003, when California revised its death certificate, the rate jumped to 14.6. And in 2006, the last year for which data is available, the rate stood at 16.9.

… When researchers unveiled their initial findings to a conference of the American College of Obstetricians and Gynecologists in 2007, there were gasps from the audience … The idea that California was moving backward even in an era of high-tech birthing was implausible to some. Confirmation of the trend was noted in the 2008 report …

The state of California has yet to share the report with the public. Researchers say that, after reviewing the report in 2008, officials in the Department of Public Health asked for technical clarifications. Revisions were complete and approved in the first half of 2009 …

… it is important for the public to be aware now that these trends are worsening …

“Even though they tend to be small numbers in terms of maternal mortality, it is important – it’s very important – that these trends be looked at,” she said. “And efforts need to be made to try and reverse them when they are going in the wrong direction.”

Rising C-section birth rate

Nearly one in three babies is now born by C-section. Many scientists have acknowledged that at some point, as the number of surgeries spiral upward, the risks will outweigh the benefits. But the C-section remains a useful tool, and in the middle of labor, doctors say, it’s hard to balance the potential long-term harm against immediate crisis.

Today, doctors face a condition called placenta accreta, where the placenta grows into the scar left by a previous C-section. In surgery, doctors must find and suture a web of twisted placental vessels snaking into the patient’s abdomen, which can hemorrhage alarming amounts of blood. Often, doctors must remove the uterus.

Main said this complication from C-sections has increased eight-to-10 fold in the past decade. Nonetheless, most women survive the ordeal … the rise in deaths is indicative of a larger problem.

“For every maternal death, there are 10 near misses; for every near miss, there are 10 severe morbidity cases (such as hysterectomy, hemorrhage, or infection), and for every severe morbidity case, there is another 10 morbidity cases related to childbirth,” …

Inducing labor before term more common

… Dr. David Lagrew … noticed that a lot of women were having their labor induced before term without a medical reason. And he knew that having an induction doubled the chances of a C-section.

So he set a rule: no elective inductions before 41 weeks of pregnancy, with only a few exceptions. As a result, Lagrew said, the operating room schedules opened up, and the hospital saw fewer babies admitted to the neonatal intensive care unit, fewer hemorrhages and fewer hysterectomies.

All this, however, came at a cost: The hospital had to take a cut in revenue for reducing the procedures it performed. Lagrew doubts that any hospital has increased its C-section rate in pursuit of profit, but he does note that the first hospitals to adopt controls on early elective inductions have been nonprofits.

According to a report issued by the advocacy group Childbirth Connection, “Six of the 10 most common procedures billed to Medicaid and to private insurers in 2005 were maternity related.” On average, a C-section brings in twice the revenue of a vaginal birth. Today, the C-section is the single most common surgical procedure performed in the United States.

“If all these guys were losing money on every C-section, well, what’s the old saying? Whenever they tell you it’s not about the money, it’s about the money,” Lagrew said.