Why private obstetrics is facing a crisis in Australia.

Arianne, is 13 weeks into her second pregnancy. She gave birth to her first child, a boy, in the maternity unit of Cairns Private Hospital back in 2022 after undergoing assisted fertility treatment and she tells Mamamia that she was incredibly grateful for the quality of care that she received. 

Arianne, who previously lived in Sydney, had undiagnosed endometriosis for most of her life, until she moved to Cairns and started the IVF process. The private specialists she saw in Cairns made the initial diagnosis and ensured that she received attentive care through her fertility journey, from egg removal to implantation and eventually, the delivery of her first baby.

"I have to say, if I had known that there were specialists in Cairns that had experience treating these reproductive issues, I would have flown out of my way from Sydney and sought treatment in Cairns many, many years ago," she says. 

Now pregnant with her second, Arianne is feeling stressed. There have been rumours swirling for months that the maternity unit at Cairns Private Hospital could close its doors this year. The hospital, which is the only private birthing facility north of Townsville in Queensland, delivers more than 300 babies every year. Unsurprisingly, the ongoing uncertainty about its rumoured closure is causing a significant amount of stress amongst patients and practitioners in the region. 

A review of the unit announced by the hospital, which is owned by Ramsay Health Care, was confirmed earlier this year and will take place in October, allegedly guaranteeing that the unit will remain open until at least September. However, this doesn't give much assurance to Arianne, who is due after the review begins. 

"It's so insane that we have such high quality specialists here and it's quite sad that we're hamstringing them and their patients and the public by discussing possible closure of the unit," Arianne says.

If Cairns Private Hospital's maternity ward closes, Arianne would have to travel four and a half hours away to the only other hospital where her private obstetrician has clinical privileges to practice. 

"If I want her, who knows all my history, who I'm comfortable with to give me my treatment or deliver my baby, we would have to organise to go down to Townsville and have it at the hospital down in Townsville that she has privileges at."

Listen to Hello Bump discuss the benefits of the public vs. private system for giving birth below. Article continues after podcast. 

Narelle is a midwife working at the Birds of Paradise Women's Health Clinic in Cairns and she agrees that women should have the option to access private care. Narelle says that Birds of Paradise currently has about 150 women on the books within the clinic who are due to give birth at the end of the year (including Arianne), and many of those women are reporting feelings of anxiety about the private hospital closure to their practitioners. 

Birds of Paradise services the top 1,000 kilometres of Queensland, with many pregnant women travelling for private care – but if the private hospital closes, their services will be limited to antenatal and postnatal care and their patients will face uncertainty about where they can give birth. 

Narelle says she believes in the public model of care, which can offer excellent midwifery programs that see strong continuity of care, but she also sees a huge amount of value in private obstetrics for some patients. 

"A lot of our women have had quite long fertility journeys, they might have had previous birth trauma and we work really closely within our clinic but with GPs, their psychologist, and other care providers to give them continuity of care and the best outcomes... I get a bit emotional because some of these women that are coming back to see us, they are having that third, fourth, fifth baby with our clinic." 

Dr Gino Pecoraro, president of the National Association of Specialist Obstetricians and Gynaecologists, tells Mamamia he believes Cairns could see a disaster in their maternity care on par with what happened in the coastal city of Gladstone in Queensland, where the closure of a private obstetrics unit led to an influx of patients into a public maternity unit that was not equipped to deal with those numbers and led to the loss of specialist doctors. The maternity unit was placed on bypass in July, 2022 meaning all patients were diverted. 

The complete collapse of those services in Gladstone forced hundreds of women to travel over 100km to Rockhampton to give birth and maternity services for 'low-risk' births only resumed last month at Gladstone Hospital. 

"We've got heaps of stories of women who have delivered by the side of the road while they're travelling from Gladstone to Rockhampton... It's just awful. You can't suddenly tell a woman at 36 weeks to pack up and move hundreds of kilometres away," Dr Pecoraro says. 

The threat to the maternity unit at Cairns Private Hospital and what happened in Gladstone aren't isolated incidents, in fact, they represent a wider trend unfolding across the country of the closure of private maternity units. 

In March of this year, the maternity ward at Geelong's Epworth hospital closed its doors, impacting about 100 expectant mums. The hospital said that extreme workforce shortages, particularly of midwives, as the reason for closing but it was also criticised by the Australian Nursing and Midwifery Federation for displaying "little initiative in investing in its midwifery workforce". 

In 2021, the only private hospital in Geraldton, Western Australia, closed its doors to maternity patients, citing the same lack of midwives as the reason for its closure. 

So, why is private obstetrics being threatened in Australia? 

The use of private obstetrics in Australia has been, in general, on a downward trend in recent years. Data from the Australian Institute of Health and Welfare shows that private hospital births fell from 28 per cent of all births in 2006-7 to 24.5 per cent in 2015-16. 

Ramsay Health Care previously reported a 12 per cent reduction in births in their private maternity units over the course of one month back in 2018. At the time, Ramsay's managing director blamed the lack of affordability of private health insurance. 

Dr Pecoraro agrees with the assessment that there is an ongoing crisis in private health insurance that sees women forced to pay huge amounts to access reproductive health cover. 

"The health funds are allowed by the federal government to engage in gender-based discrimination and make women pay double the price for health insurance that men have to pay. If you want reproductive health cover, it's only in 'gold' policies, whereas prostate cover is in 'bronze' policies... But even then, if you do get the insurance policy, all that covers is for the hospital bed, the rebates as set by the Medicare and the health funds are woeful. So, even if you've got the top private health insurance, you're out of pocket five grand, on average, to have a baby," he says. 

Then there are the staffing shortages that have led to the collapse of private units, like the one at Epworth hospital and in Geraldton. 

Speaking to The Guardian, Christine Catling, who is an associate professor in midwifery at the University of Technology, Sydney, said that maternity services are seeing an ageing workforce and early-degree midwives are quickly disillusioned by patchy systems that interrupt continuity of care. 

Dr Bronwyn Hamilton, a private obstetrician based in Melbourne tells Mamamia that staffing shortages have intensified since the beginning of the pandemic because more people are looking to work remotely and not take up in-person positions. 

Listen to the Mamamia Out Loud team discuss extended maternity leave below. Article continues after video. 

Dr Hamilton also notes that the closure of these private maternity units can place a huge amount of pressure on the public system, as was seen in Gladstone. 

"As less options are available, there is a flooding into the public system and more of a burden on the public system and they really don't have the ability to take on anymore. They're all very busy already... the safety might be less in an already-overrun public system. 

Sometimes there can be say, 10 women in labour and one doctor on for the whole labour ward, it's pretty hectic in the public hospital system," she says. 

The closure of private maternity units also leads to questions about the quality of work for obstetricians themselves. 

What are the effects on the obstetricians? 

Dr Hamilton, who has worked in both the public and private system, says that "not every obstetrician wants to work in the public system" and the job satisfaction of specialists needs to be taken into account. She believes that there needs to be a balance between work available in the public and private system to make sure that specialists have a work-life balance, as well as ensuring that skills are kept up in the workforce. 

Dr Pecoraro agrees with this sentiment, saying that part of the attraction of 20 years of training is that doctors can eventually get a job in the private sector. "Doctors like to be their own boss," he says. Dr Pecoraro also notes that obstetricians can face harsh treatment in the public system under midwifery models, beyond the demanding working conditions. 

"You're the enemy in the room because you're going to tell this woman that we need to perform something like forceps or a vacuum or, God forbid, a caesar. And you know, they blame you for everything. And when things go wrong, of course they're going to try to get legal compensation – and the people they sue are not the people who have been by their side the whole time but the people who they call in – and that's called an obstetrician," he says. 

Dr Pecoraro points to these extreme workplace pressures as the reason that obstetricians have extremely high rates of suicide. One study published in March this year found that obstetricians and gynecologists are more likely than any other medical specialists to report having thoughts of suicide.

As for Arianne, for the moment, she is just forced to consider her options if (or when) the maternity unit at Cairns Private Hospital does close. It's stressful to think about, Arianne says, and hardly an ideal position to be in during pregnancy. 

She is uncertain about the proposition of having a doctor at a public hospital deliver her baby – not because she wouldn't trust the quality of care but because she values the continuity of care with a private obstetrician who understands her medical history thoroughly. 

"I believe all women should have the agency to choose and have access to [private care] but if the closure of the maternity unit at Cairns goes ahead, then that choice will be removed and you leave all these brilliant obstetricians and patients scrambling to find alternative methods."

Elfy Scott is an executive editor at Mamamia. 

Image: Canva.