Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals.

OBJECTIVE: To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies. DESIGN: A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies. SETTING: A large regional public hospital, New South Wales, Australia. PARTICIPANTS: The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997. RESULTS: After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies. IMPLICATIONS FOR PRACTICE: Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.

Episiotomy in NSW hospitals 1993-1996: towards understanding variations between public and private hospitals.

Episiotomy rates for women experiencing childbirth in New South Wales (NSW) hospitals are another indicator that private insurance may be a risk factor for obstetric intervention. A recent comparison of episiotomy rates in NSW public and private hospitals between 1993 and 1996 revealed that episiotomy rates were 12 to 15 percentage points higher in NSW private hospitals than in public hospitals studied. Rates also appear to be declining in NSW public hospitals, yet this trend is not evident in the NSW private hospitals studied. Although private hospital patients were almost twice as likely to experience forceps or vacuum delivery (often associated with episiotomy), this leaves a 6 to 8 percentage point difference unexplained. Given the potential health-related quality of life issues associated with perineal trauma during childbirth, further analysis of the clinical make-up of privately insured women may help determine the extent to which clinical explanations exist to support the differences in this childbirth intervention.

Trial of labour versus elective repeat caesarean section: a cost-effectiveness analysis.

For subsequent births, women who have experienced previous caesarean section face a choice between elective caesarean section and trial of labour. The study reported in this paper utilises Australian hospital data to compare birth outcome and health system costs of these two options. Although trial of labour is more expensive if the result is an emergency caesarean section, high rates of successful vaginal delivery mean that, overall, trial of labour is found to be 30 per cent less expensive than elective caesarean section. It is estimated that trial of labour remains the most cost-effective option as long as less than 68 per cent of women require emergency caesarean section. This study highlights the potential importance of more accurate information about a broader range of costs and outcomes in order for stronger conclusions to be drawn.