Public or private – What is the difference?

It is not uncommon for my secretary to be asked on the phone by a pregnant womanfork in road 1 who is shopping around trying to decide about pregnancy care: “What is the difference between private and public pregnancy care?”

This is very understandable question. A newly pregnant woman is exploring options for her pregnancy care often with consideration of limited finances. For most pregnant women the only information sources that she can access about this topic are the views of people who she knows (including  family), what she reads on-line and if she went public last time her personal experiences.

The views of others and the opinions read on-line reflect personal experiences and a personal bias of that person or what they have been told by others. As well their opinions may reflect a personal ‘political’ bias about health care (public vs. private). They may not be objective. I would be surprised if the person giving the opinion would have a full and comprehensive understanding of the differences between being a public or private patient for pregnancy care. Being a very busy obstetrician who has worked in both the public and private sectors and having delivered many thousands of babies I am in a very good position to make such a comparison. Yes, I have a personal bias in favour of private care. Hopefully what you read below will help you understand why.

Who is this information for?

This article has been written exclusively for the benefit of pregnant women who are considering to book with me for private pregnancy care and are confused or curious as to how private pregnancy care with me will differ from what they will receive if they went through the public system.

The basic differences

While you will not have any financial cost if you elect to go through the public system to have your baby the main trade-off will be you give up your right to choose your own doctor and you do not get to choose who provides your health care if you choose to be a public patient. While you can often (but not always) choose the hospital you will attend this public hospital has the right to choose who will manage you. If that hospital is a teaching hospital with doctors training to become obstetricians and nurses training to become midwives then you can expect the ‘apprentice’ i.e. trainee obstetrician or trainee midwife will be primarily involved in your care. This is so they can improve their knowledge base and skill set. This training system is how all specialists and midwives have been trained.

A key reason why many people choose private health care is they don’t want a trainee providing their care. The lack of clinical expertise and knowledge of trainees who are primarily involved in your care can have significant impact on the quality of care you receive and there is the greater likelihood of management errors that could potentially endanger the wellbeing of your baby and you. How much training the trainee has had, how much supervision the trainee gets, how accessible the supervising consultant is will vary considerably.  Comparisons that will help you understand the trainee/apprentice concept are for you to agree to have an apprentice hairdresser do your hair, to have an apprentice mechanic repair your car, to have an apprentice builder build your house or to have an apprentice pilot fly the plane you are on.

A chief concern

While there are certain obstetric high risk pregnancy markers which if identified mean a pregnancy is designated ‘high risk’ (of complications), a ‘low risk’ pregnancy is not a ‘no risk’ pregnancy. I tell a patient I have no idea how her pregnancy is going to turn out, whether or not all will be straight forward. There can be sudden dramatic complications, especially with labour and delivery, which are life threatening for mother and/or baby that can happen with minimum or no warning.

It can be said that childbirth is one of the most dangerous times in someone’s life. If the care provider does not have sufficient expertise to deal promptly and appropriately with a complication then the pregnant woman’s life and/or her baby’s life and wellbeing is at increased risk. Sadly over the years I have seen many times when an adverse outcome could have been avoided if the care provider had had adequate training, experience and clinical acumen. Patients tell me of times in a previous pregnancy (when they went public) when there is a crisis and they realise those looking after them don’t know what they are doing. It is frightening experience that they never want to repeat. Hence they go private next pregnancy. I have been personally told by a very senior person in the College that trains obstetricians in Australia (RANZCOG) that a chief concern of the College is the lack of clinical exposure and so experience received by trainee obstetricians now compared to what was the case in the past.

 The main differences in detail

I worked in both the public and private sectors over many years in the past. In more recent years I have chosen not to work in the public sector because of personal concern about the quality of care sometimes received by patients.  From chatting with obstetrician colleagues who do work in the public sector today I am abreast of what is happening in the public sector currently. As well I have had many patients over the years who ‘went public’ with their first pregnancy and have chosen to see me for private care in their subsequent pregnancy. I have some who change from public to my private care during their pregnancy. Chatting with these patients about their public care experiences also provides helpful background information for this article.

If you elect to go public for your pregnancy you will have your own experience which may be different to what is stated below. As well not all public hospitals are the same and two patients managed in the same hospital will not necessarily have the same experience because of pregnancy differences and different staff managing them.

As well there are considerable differences in care provided by private obstetricians. My comments are based on what I do in my practice and how I manage my patients.

Pregnancy care

Where do I attend?

Public: You will attend the hospital antenatal clinic and possibly your GP doctor.

  • Midwives clinic. If you are deemed ‘a low risk pregnancy’ and the hospital has a ‘midwives clinic’ then you will most likely attend the hospital’s midwives clinic for most of your visits.
  • Shared care with your GP, where you will be seen by your GP, is an option if you are deemed ‘a low risk pregnancy’. Whether this service is available to you depends on both the hospital and your GP.
  • Doctor’s clinic.
    • If you are deemed ‘a low risk pregnancy’ and there is no midwives clinic or shared care with GP program at the hospital where you are booked
    • Some of your antenatal visits if you attend a midwives clinic or your GP. This is to check that no pregnancy high risk issues that have been overlooked.
    • If you are deemed a ‘high risk pregnancy’. Some hospitals have special high risk clinics for pregnant women with specific higOffice_2h risk issues.

Private: No differentiation re risk. All visits are at my rooms at Suite 2-06, 12 Century Circuit, Baulkham Hills.

Who will see you for me for my antenatal visits?

Public:

  • Midwives clinic. A nursing sister who has had training/or is in training to become a midwife. Some public hospitals now offer midwifery continuity-of-care programs. A midwifery continuity-of-care program implies a particular midwife or midwives team will look after you through your pregnancy, labour and birth and the postnatal period.
  • Shared care with your GP. Your GP.
  • Doctors clinic.

Trainee obstetrician. You will usually be seen by a doctor who is training to be a specialist obstetrician (like an apprentice). This trainee obstetrician is learning their skills through managing public patients. The amount of experience and clinical acumen varies considerably. If the trainee obstetrician doctor who sees you is concerned about an aspect of your pregnancy he or she will ask advice from a more senior trainee obstetrician or a specialist (fully trained) obstetrician who works at that hospital.

Medical student (if a university teaching hospital) will sometimes accompany the doctor. These students will be hoping to ask you questions and to examine you.

Other doctor. Some doctors working in clinics are not in the specialist obstetrician training programme.

Specialist obstetrician doctor. Sometimes you may be assessed by this specialist doctor in response to a junior doctor’s concern. Sometimes you will be seen by a specialist obstetrician doctor who is working in that clinic even if there is no concern. If you are attending a special high risk clinic you are more likely to be seen by a specialist obstetrician doctor.

Private: I will personally see you at each antenatal visit. I am a fully accredited specialist obstetrician who has managed many thousands of pregnancies over many years. When I worked in the public sector I was asked advice by trainee obstetricians about patients. I would see high risk patients at the public hospital antenatal clinic.

I have had special training and have a special interest in managing high risk pregnancies (conditions such as diabetes in pregnancy, hypertension in pregnancy, etc.).

By seeing me privately not only do you have continuity of care and opportunity for relationship but I provide far more clinical experience and clinical acumen than would usually be the case in the public sector.

Waiting time to be seen for antenatal visits

Public: Often there will be a long wait to be seen. Patients tell me it can be for hours. You are likely to waste a lot of time sitting in the antenatal clinic waiting room.

Private:  I endeavour to keep your waiting time down to a minimum and to be as punctual as possible. If I am called to the hospital urgently and your appointment time to see me is when I will not be in the office then my staff will phone you and rebook your appointment rather than you attending and having a long wait waiting for me to return.

Baby ultrasound scans at my visits

Public: While there will be scans such as the nuchal translucency scan and the foetal morphology scan, ultrasound scans are not done at each antenatal visit to assess baby’s growth, position and wellbeing. Assessment of baby’s growth and position is done by abdominal palpation and a tape measure (to measure the distance between the top of your uterus and your pubic bone). Baby’s heart rate will be checking by a small Doppler ultrasound machine. If there is concern an ultrasound scan will be antenatal carerequested. You can expect to have more ultrasound scans if you attend a high risk clinic.

Private: I will do an ultrasound scan of your baby at each visit. There is no extra fee for you to pay for this service. This is the most accurate way of checking your baby’s growth, position and wellbeing. I include 3D and 4D scanning (3D with movement) and give you a free USB to store your baby photos.

What if I have a question or concern?

Public: While on occasions you may be able to speak with a clinic midwife if you phone the hospital, usually you will need to defer asking your question until your next antenatal visit. Otherwise you need to see your GP, phone the Birth Unit or do your own research.

Private: You can contact me by phone social mediaand by the internet – using the ‘contact us’ option on my web site, by email or by private messaging on social media (Facebook, Twitter, Google+, LinkedIn). I encourage my patients to contact me rather than doing their own research. This is so I know what is happening and to make sure they get correct and relevant advice. As well I have written lot of material on the most common pregnancy questions and concerns and included this information on my web site for you to access.

What if I have a special request about my delivery?

Public: Special request such as induction of labour or Caesarean section without any of the usual obstetric indications is not likely to be agreed to.

I recently had an uninsured patient book with me at 36 weeks pregnancy. She had been attending a clinic in a public hospital. As the pregnancy advanced she developed severe sciatica pain. Her only relief was with strict bed rest and very strong painkiller drugs. She was desperate for induction of labour but this was not agreed to at the public hospital because of her gestation. I assessed her and booked her induction the next week, when she was 37 weeks pregnant. All went well, a healthy baby and the sciatica went.

I had another patient who saw me eight months after a VBAC attempt that went horribly wrong when she was managed at a public hospital. The patient had requested an elective Caesarean section but was denied that request1.

Private: I am happy to agree to your special request as long as there are no obstetric or hospital reasons why the special request cannot be accommodated. I work with you to endeavour to give you the delivery experience you want.

Relationship

Public: Unless you are in a midwifery continuity-of-care program a different hospital staff member may see you at your successive antenatal visits rather than the same staff member seeing you throughout your entire pregnancy. You may have discussed a concern with one staff member only to find that some different staff member is seeing you at your next visit who has no insight into your previous visit discussion and who may have a different point of view.

As well when you are in labour there will most likely be a different staff member that you have never met managing you and who are not privy to any special request or fears and concerns you raised antenatally.

Private: I will personally be providing your care both in your pregnancy and in your 8478_10153376319304021_4551343531378649471_nlabour. I find this gives patients confidence and reassurance in labour and if having a Caesarean section. I endeavour to get to know and build relationships with patients, being well aware of how incredibly exciting and important the pregnancy and childbirth journey is for both you and your husband/partner. I tell patients I want them not only to have a good outcome, but also a good experience throughout their pregnancy and delivery. I will endeavour not to rush you at your antenatal visits and give you enough time to answer your questions and address your concerns. If there are questions or concerns between visits then feel free to contact me at any time.  Facebook messaging is the most popular way of doing this. Sometimes a patient will need extra visits because of pregnancy issues that crop up.

Labour and delivery

Who will manage me in labour?

Public:  A midwife will be assigned to manage you in labour and deliver your baby. Midwives work in shifts so it is possible because of the duration of your labour that there may be a number of midwives primarily responsible for your care.

If you are part of that hospital’s midwifery continuity-of-care program the midwife or midwives who looked after you through your pregnancy should also manage you in your labour, delivery and postnatal stay. If your assigned midwife is not available then another midwife will be assigned when you are admitted in labour.

The experience and so expertise of the midwives vary considerably and so will their clinical acumen. If the public hospital is a teaching hospital it is likely that a student midwife will be assigned to assist in your management and possibly deliver your baby.

If the midwife is concerned about developments in labour then she will ask the trainee obstetrician on duty for the Birth Unit for advice. There are two challenges with this approach. The first is the midwife may not recognise that there is a problem and help is needed. The second is the midwife may be reluctant to involve a doctor despite recognising there being a problem that should be brought to the doctor’s attention. Both not realising there is a problem and a reluctance to ‘hand over control’ to the doctor despite indications can be very dangerous for the patient and her baby.

If the trainee obstetrician is concerned then the senior trainee obstetrician or specialist obstetrician should be consulted. A more junior doctor may not recognise that there is a problem and help is needed.  The response of the senior trainee obstetrician or specialist obstetrician to the situation will vary. A specialist obstetrician’s availability may be coloured by you being a public patient and not a private patient.

If you are a high risk patient then the trainee obstetrician and the specialist obstetrician will be more involved in your care. You will still have a midwife primarily providing care.

Medical students (if a university teaching hospital) will sometimes accompany the doctor and will be hoping to ask you questions and examine you.

Unless you are part of a midwifery continuity-of-care program and the midwife you have seen antenatally is available when you are admitted in labour the midwives looking after you are likely to be midwives who you have not met before. They will not be the same midwives who attended to you in the antenatal clinic. A doctor who you have met in the antenatal visits may be involved in your labour and delivery care.

Private:  A midwife will be assigned to manage you in labour. Midwives work in shifts so it is possible because of the duration of your labour that there may be a number of midwives looking after you.CTG

I am the person responsible for your care in labour. The midwife will keep me informed as to you progress and any adverse developments. I can ‘log-in’ via my office or home computer to the Birth Unit monitor to check on your baby’s and your well-being while in labour.

Who will deliver my baby?

Public: The midwife assigned to manage you in labour will deliver your baby. She may suggest the student midwife does the delivery. Practicing on you will help the student midwife develop her midwifery skills.

If an operative vaginal delivery or Caesarean section is needed the trainee 5 forcepsobstetrician will most likely do the delivery. Sometimes there will be supervision by a more senior trainee doctor or the specialist obstetrician on duty and sometimes there won’t be. By doing your operative vaginal delivery or Caesarean section the trainee will be improving their practical skills. To do an operative vaginal delivery or Caesarean section delivery ‘well’ requires considerable skill which comes with good training and considerable experience. There is more likelihood of complications that could endanger your life and/or your baby’s life because of a trainee’s inexperience. You could be the very first patient the junior trainee obstetrician doctor has ever delivered using a vacuum cup, forceps or by Caesarean section. There will often be other staff members in the delivery room observing your delivery.

If a more difficult delivery is anticipated then a more senior trainee doctor or the specialist obstetrician may do an operative vaginal delivery or Caesarean section.

The patient who saw me eight months after a VBAC attempt that went horribly wrong when she was managed at a public hospital and was denied an elective Caesarean section had signs of uterine rupture in labour that were not recognised by the midwife and trainee obstetrician staff1.

Private: I will delivery your baby in all situations, whether normal vaginal delivery, operative vaginal delivery or Caesarean section delivery. I have done many thousands of deliveries and so I have considerably more skills, wisdom and discernment than you can expect to receive in the public sector. There is increased safety for you and your baby and much less likelihood of avoidable complications.

Raya du PlooySo many patients breathe a sigh of relief when I walk into their delivery room. Even though I know what is happening in their labour when I was not there, my physical presence gives them confidence.

Patients often say how calm I am even when there are complications. I put that down to my considerable experience. It is highly unlikely I will be confronted with something new that I have never seen before. That is not to deny the gravity of the situation. My more relaxed manner is because of my experience and confidence in dealing with the situation.

Birth plan

Public: It is a good idea to work out your preferences and write them down and show them to the midwife when you arrive in labour. The main reason is often the staff that will be looking after you in labour will not know you from the antenatal clinic and their only background will be what is written in the hospital notes. There is often lack of continuity of care and there may be no one in the delivery room who is your advocate.

Private: There is no need for a birth plan. As I will be personally seeing you at every antenatal visit there many opportunities to discuss concerns and preferences before you are admitted in labour. I will be supervising your labour and delivering your baby so there is a relationship and continuity of care.

Postnatal ward

Public: You will be sharing your room with other patients. There could be four beds in the same room. The public hospitals suggest you do not bring valuable items or money to hospital. That is because of the high risk of them being stolen. If you bring your mobile phone or computer keep it with you to avoid theft. Radio and music are usually available on patient handsets, and usually a television is provided in patient lounges. Bedside TV sets are available in some hospitals for rent. Personal radios and tablets should only be used with an earphone. That is because of other women sleeping in the same room as you.

There will be no privacy except a curtain around your bed. There will be a shared bathroom.

Your stay will be kept to a minimum number of days. You will be advised to leave soon after the delivery day and often before breast feeding issues have been sorted out and you have made adequate recovery from the delivery.

Your husband can’t room-in with you.

Patients have told me in their experience meals are left on trays on a food delivery trolley in the corridor of the ward.  It is up to the patient to go to the food trolley, get the tray with her name on it and take that tray back to her bed table to eat the meal.

nwp room

Private: You will have a single postnatal room with your own personal ensuite bathroom, bar fridge, TV, room safe for valuables.

Your husband can stay with you.

Meals are served to you in your room by the hospitality staff. You eat your meal in privacy.

You can stay for the maximum stay allowed by your health fund (usually four nights) or longer in some situations.

 What if my baby delivers prematurely?

7.7% of babies in Australia born in 2012 were preterm with most being late preterm births (34 weeks gestation on)2. This Australian Government report states ‘a small proportion of mothers gave birth at 20–27 weeks (0.8%) and 28–31 weeks (0.7%), while 6.2% gave birth at 32–36 weeks’.

Public: If you are attending a teaching hospital it is likely that the hospital has a neonatal intensive care unit (NICU or Level 3 Nursery). So if you do deliver prematurely your baby will usually be admitted to the NICU at the hospital where you attend.

This cannot be guaranteed when you book and is not always the case. If the NICU in the hospital where you attend is full when your baby needs delivery you will be transferred to another hospital with a Level 3 Nursery that can take your baby. I was once organising the transfer of a patient who was going to give birth prematurely to Nepean Hospital only to be told their last spot had just been taken by a woman from the John Hunter Hospital Newcastle. The John Hunter Hospital has a NICU but it was full.

Private: While private hospitals do not have Level 3 nurseries Norwest Private and the San do have Level 2 nurseries. That means if you go into labour at 34 weeks on (a ‘late preterm’ delivery) you can be delivered at the hospital here you are booked.  This is the case for most preterm deliveries. Your baby would be managed in the Level 2 Nursery of the private hospital where you are booked.

The incidence of delivery before 34 weeks is about 3% of all deliveries. If you did labour before 34 weeks you will need to be transferred to a hospital that has a Level 3 Nursery. The closest teaching hospital is tried first. If that hospital can’t take you then another hospital is requested.  Your baby would be transferred back to the Level 2 Nursery of the hospital where you are booked as soon as suitable.

Cost

Public: There are usually no costs to you if you have your baby through the public system. If you choose shared care with your GP and they do not bulk-bill, you will be charged a consultation fee each visit. Ultrasounds, blood tests and pathology costs are covered by the hospital.

Private: There will be out of pocket expenses. These will be less if you have appropriate cover with a health fund. There is more information about costs on my website.

Is private worth the cost? I definitely say yes. While there are many benefits IMG_6139of being a private patient for pregnancy care the most important is quality of care. Remember it is about you and your precious baby. If you went public and had a catastrophically bad outcome that was due to the lack of expertise of the junior staff looking you would be very, very upset.

I have seen babies develop cerebral palsy as a  result of junior staff mismanagement and the huge tragic impact this has. There are ongoing financial costs that are far greater than what it would have been cost to go private. There is the guilt, as you made the decision to go public and your baby is now paying the price. There are the huge and ongoing emotions costs. I have seen marriages break up as the husband cannot cope with having a handicapped child.  While scenario very uncommon it can happen and I have seen it happen in the public sector a number of times. It is much more likely if junior an inexperienced staff are providing your care. The main reason why I opted out of the public sector and now only manage private patients is I was too upset by adverse aspects of quality of care received by some patients in the public sector.

Final comment

As mentioned above this article has been written exclusively for the benefit of pregnant women who are considering to book with me for private pregnancy care. It has no bearing on pregnancy care provided by other obstetricians. The style of care, personality of the obstetrician, the quality of care, the training, the amount of clinical experience, clinical acumen, management of pregnancy and delivery and complications, and fees charged will be different for different obstetricians. This should not be surprising and would the case for different service providers in any industry.

There is information about what you can expect with your pregnancy care when you book with us  on our website at Highlights of your care with us.

1 http://www.obstetricexcellence.com.au/vbac-attempt-went-horribly-wrong/

2 http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129550054

 

 

Posted by Dr Gary Sykes on -

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