Academic journal article Australian Health Review

Factors Associated with Changes into Public or Private Maternity Care for a Second Pregnancy

Academic journal article Australian Health Review

Factors Associated with Changes into Public or Private Maternity Care for a Second Pregnancy

Article excerpt

Introduction

In Australia, approximately one-third of women receive private obstetric care for pregnancy and childbirth and overall 30% of births occur in private hospitals.1 Private care usually involves antenatal, birth and postpartum care by a single carer, an obste- trician, whereas public maternity care often includes a range of carers including residents, registrars, midwives and staff specia- lists and may occur through a range of models of care including team care and shared care.2 Although there have been numerous federal incentives to take up private care, including the private health insurance rebate (introduced in 1999, means tested from 2012), lifetime health cover (introduced in 2000) and the Medi- care levy surcharge (introduced in 1997), since 2004 the propor- tion of women giving birth as private patients has not changed.1,3 However, there have been changes in where the private care is provided with an increase in the proportion of births in private hospitals (from 22.9% to 24.5%) consistent with a small increase in the availability of private hospital beds.4,5 Following the introduction of the baby bonus in 2004 and the associated birth boom, private hospital births did not increase as quickly as public hospital births probably because maternity beds in private hos- pitals are capped.6

For women who have previously given birth, the choice of public or private care in a subsequent pregnancy and birth is likely to be affected by numerous factors, including satisfaction with previous care,7,8 continuity of previous care,7 proximity to services and personal circumstances related to income, partner and childcare. There is evidence to suggest that interventions and outcomes of one pregnancy are associated with changes in the type of delivery,9,10 timing of delivery9 and outcomes of subsequent births.11 Bahl et al. sent postal questionnaires to women 3 years after they experienced an operative delivery in theatre and found that the women were more likely to aim for vaginal delivery after a prior instrumental compared with a Caesarean birth, and were more likely to have had a further birth within 3 years following instrumental birth.9 Chen et al. used population-level data on over 100 000 women who had a first vaginal birth and examined the impact of adverse outcomes in a first birth on subsequent mode of delivery. Obstetric interven- tions and adverse pregnancy outcomes in the first birth were associated with increased risk of operative delivery in the second birth.10 Taylor et al. demonstrated using population data that Caesarean section in a first pregnancy (compared with first vaginal birth) conferred additional risks on the second pregnancy, including increased risks of uterine rupture, hyster- ectomy, postpartum haemorrhage following vaginal delivery, manual removal of placenta, infection and intensive care unit admission.11 These studies highlight that first-birth interven- tions and outcomes can affect subsequent birth preferences and birth outcomes.

Extending this previous research, we hypothesised that ob- stetric interventions and adverse outcomes in a first birth might influence a change in the type of maternity care. Specifically, it is possible that interventions such as epidural analgesia or Caesar- ean section, or adverse outcomes for the mother (excessive bleeding) or baby (fetal death) may prompt a change from or to a public hospital. Understanding some of the factors prompting women to change care type is important in a context where maternity care frameworks focus on woman-centred care. If adverse outcomes are associated with changing care type, this may indicate groups of women with whom care providers may want to have postpartum discussions about subsequent place of birth. Royal Australian and New Zealand College of Obstetricians and Gynaecologists policy statements indicate that presentation for care at a subsequent birth where there is a history of, for example, perinatal death is a trigger for discussion about appropriate type of care. …

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