"There remains a stated desire to see a higher percentage of māmā giving birth vaginally," Auckland Hospital says. Photo / 123rf
New Zealand’s largest hospital has put stricter conditions on new private obstetricians, amid concerns about high rates of caesarean sections.
The rules have been criticised as “impractical and inappropriate” by the Auckland Association of Private Obstetricians, which says there are valid reasons why women under the care of private specialists are more likely to have a caesarean.
However, Auckland City Hospital management says the new regime “strikes an appropriate balance between public and private care”.
In 2020 the hospital stopped allowing more private obstetricians to access birthing facilities, citing their high caesarean rates.
Hospital leaders were also unhappy that many women paying for such specialist care lived outside its central Auckland catchment, but gave birth at the hospital because it was where their obstetrician was based.
That put more pressure on an understaffed system struggling with demand, the hospital said.
However, emails obtained by the Weekend Herald reveal the “pause” has ended, after hospital leadership reasoned it would be too controversial to continue indefinitely.
“There is no turning back from this situation [of allowing access], for no other reason than I think we would have a community ‘uprising’”, Julie Patterson, the hospital’s women’s health director, wrote in an email to chief executive Ailsa Claire in May last year.
New Zealand lacks private birthing facilities, and for decades women looked after by private obstetricians (at a cost of about $6000) have used Auckland Hospital’s labour and birthing facilities under “access agreements” with individual specialists.
This looked to be in peril when new access agreements were stopped in late 2020. At the time, Claire told a board meeting that caesareans done by private obstetricians weren’t always clinically appropriate and used a lot of public resources.
Most women giving birth at the hospital could not afford a private obstetrician, Claire is recorded as saying in November 2020 minutes, and “that means when the private obstetrician comes in and uses theatre capacity, that theatre becomes unavailable to the rest of the Auckland population”.
Auckland Hospital has focused on improving equity in maternity services after concerns were raised that some mothers and babies – particularly Māori and Pasifika – were not getting the care they needed amid increasing capacity pressure. Reducing the high elective caesarean rate was part of this wider work.
Documents now released under the Official Information Act show that, in May last year, Auckland Hospital was asked to give temporary access to three more private obstetricians, to provide sick cover.
“I am satisfied that they’re not using this as a means of ‘bending the rules’,” Patterson, the hospital’s women’s health director, wrote in her email to Claire.
Ultimately, ending access for private obstetricians was too big an ask for the hospital, Patterson concluded. It would require action from the Ministry of Health and probably a law change.
“In the directorate we’re focusing on making sure the private provision doesn’t continue to contribute to inequities, that our public workforce is strengthened by SMOs [senior medical officers] having small private practices, and that we have protections in place to ensure, at an individual level, publicly paid time is not spent doing private work,” Patterson wrote.
“I know this is obvious and easy to say, but I’ve discovered not easy to ensure.”
New access agreements are now given to private obstetricians, but under conditions (applying only to new agreements, not those already with access): the obstetrician must treat only women living within the hospital catchment; work most of their time in a public role at the hospital; help teach others, and be on-call after hours.
On average, half of mothers at Auckland Hospital give birth vaginally, and 26 per cent by planned caesarean.
Private obstetricians perform about 58 per cent of planned caesareans.
There are currently 27 private obstetricians with access agreements, all of whom belong to three practices: Auckland Obstetric Centre (AOC), Birthright and Origins. Most also work in public roles at the hospital.
In a statement, the Auckland Association of Private Obstetricians strongly rejected the suggestion its members did clinically inappropriate caesareans and said information given to the hospital board on this subject had not come directly from an obstetrician.
“Therefore, it is possible that the board made subsequent management decisions based on misleading and/or incorrect information.”
Women cared for by private obstetricians tended to be older, the association said, with more complicated pregnancies (for example, IVF or a history of previous caesarean birth – the greatest factor determining the likelihood of another caesarean).
“The age of a woman at pregnancy correlates directly with the likelihood of a caesarean section … many women choose a private model for obstetric care because they know they’ll need a caesarean section, and they want to know who is going to perform their surgery.”
Women needing an intervention were always prioritised according to clinical need, the association said, and that included those cared for by private specialists: “They go in the queue for theatre along with everyone else.”
The new conditions rendered access agreements “almost impossible to obtain” and were “impractical and inappropriate”, the association said. Anyone balancing private and public work under them would likely burn out.
Most private obstetricians also worked in a public system in the midst of a workforce crisis, the association said, and being able to do private work helped attract and retain obstetricians who were at risk of opting for better pay and conditions in Australia.
It said reducing their workload would also pile pressure on the public system because, among other things, private obstetricians worked with and paid private midwives.
Auckland Hospital management has been asked to scrap the new conditions, and instead issue access to the three main practices. This would be on the proviso that bookings don’t exceed current levels, but allow each group to decide the number of specialists needed.
Private obstetricians say they understand new access will be given only if an existing holder retires or gives theirs up – a “one in, one out” rule.
However, Dr Mike Shepherd, who leads hospital services for Te Toka Tumai Auckland (formerly Auckland DHB), told the Weekend Herald there was no definitive “one in, one out” rule.
“We believe the current conditions, which were introduced less than 12 months ago following discussion with private specialists, strike an appropriate balance between public and private care. We can confirm that three access agreements have been issued since the updated conditions were introduced.”
He rejected the association’s criticism of the data the women’s health service provided to the board in 2020.
“The related 2020 board meeting included robust discussion around the caesarean section rate at Auckland City Hospital – this is another example of some of the strongly held views among people involved in healthcare services regarding vaginal births and c-section births, and the option to receive care from a private specialist,” Shepherd said.
“While the caesarean section rate at Auckland City Hospital is high in comparison to other hospitals and birthing facilities in New Zealand, we acknowledge the reason for caesarean section births are varied.
“Our priority is for all women birthing at Auckland City Hospital to give birth in the safest way for their individual circumstances, with a good understanding of the benefits and risks.”
Having one-on-one care with the same specialist is the reason Portia O’Kane paid for a private obstetrician for the birth of her three children.
O’Kane’s children are now 7, 4 and 9 months. Her eldest was born in Australia in a “textbook vaginal birth”, but her second was in the breech position so a caesarean at Auckland Hospital was needed.
That history meant she also requested a caesarean for her third child.
Friends who used midwives had done the same, she said, and focusing on caesarean rates was “an old-school way of thinking about obstetricians”.
“They are so much better than just saying, ‘Oh, we will do a c-section, it’s so much easier.’
“I would never push to have a c-section at any time, until it became a medical necessity to do that.”
O’Kane is a co-owner of LuxeCare, a company that offers postnatal packages at the 5-star Sofitel Hotel in Auckland’s Viaduct.
Most of her clients used private obstetricians – “because if they can pay for private obstetrics they can pay to come and stay with us” – and, of that group, she said about 70 per cent birthed vaginally, and 30 per cent by caesarean.
Current demand means all private obstetrician practices in Auckland are almost fully booked for December 2023. If women aren’t booked in by 6 weeks’ gestation they are usually unable to do so.
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