Australians are fortunate in having a universal health service that provides care for everyone based on taxation. Naturally the health system needs regular “tweaking” to keep it working well for those who use it. However some of the adjustments of recent years are producing consequences in maternity care that are not only unplanned, they are very costly and producing unacceptable levels of morbidity in Australia’s healthy and wealthiest women.

In a bid to raise the uptake of private health insurance which had reached an all time low in 1999, the Commonwealth government introduced an uncapped 30% private health insurance rebate. This encouraged any woman who could afford it to take out private health insurance.

The intention was sound; that is young people use services less therefore their demand against funds would be lower than older and aging groups. However, childbirth is the most common cause of hospitalisation in Australia and subsequent claims have resulted in ever escalating direct and indirect costs.

The beneficiaries of this funding adjustment are private hospitals and privately practicing obstetricians. They have by default become the chosen providers of maternity care, despite the fact that midwives provide a similar and safe service that is less costly.

Paradoxically, private hospital care in association with private obstetric care in childbirth is associated with horrendously high rates of operative birth amongst low risk first time mothers.

Research undertaken ten years ago, even before the government incentive to encourage women to take up private health insurance, showed that among low risk private patients under private obstetric care with an epidural, the most likely birth outcome was an instrumental delivery with an episiotomy. Among similar public patients, the most likely outcome was a non­instrumental vaginal birth without episiotomy.

The second major adjustment to the health system which has had unintended consequences was introduced in 2004 in the form of the new Safety Net. This covers 80 per cent of out of hospital medical expenses for families once their out of pocket, out of hospital, expenses exceed $700 in a calendar year.

Sadly this attempt to improve access has resulted in maternity services not currently providing value for money — either to consumers or to funding bodies. This is a particular issue for rural women.

The advent of the Medicare Safety Net resulted in a rise of more than 250% in the earnings of private specialist obstetricians reported in the media in 2007 since the safety net was introduced. This increases pressure and costs on the health system as a whole. Some privately practicing obstetricians are charging $20,000 dollars for a normal birth and our health system pays the gap insurance to allow them to do so.

Exacerbating these cost blow outs, operating rooms in both public and private hospitals are now so busy with operative birth that other necessary surgery is delayed or cancelled.

In addition to this, large population based studies show increases of avoidable death and injury of mothers and infants associated with the trend to operative birth, especially caesarean sections. The injury again adds costs as babies spend avoidable time in hospital nurseries or women experience infections from abdominal wounds.

This then is the paradox. Tweaks designed to improve our system have resulted in out of control costs, increased suffering and injury to women and infants, and obstetricians now expecting to earn a million dollars a year — most of which is coming from Government money (our taxes) via normal healthy women who do not need their care.

These are important issues that deserve a thoughtful response from the Federal Government’s maternity services review.

Professor Lesley Barclay, Associate Professor Sally Tracy and Associate Professor Sue Kildea are from Charles Darwin University, Darwin

Peter Fray

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