To allow the landmark BJOG article to fade into the background would be a mistake. Let it be a conversation starter, not a flashpoint.
The recently published article in BJOG represents the biggest independent study of its kind ever published in Australian perinatal literature.
It offers a robust and transparent analysis of outcomes and costs across models of care using one of the most statistically rigorous methodologies ever applied to the question of public versus private maternity care in this country.
The strength of this study lies not only in its immense scale—analysing data from over 830,000 births between 2016 and 2019 in three states—but in its sophisticated methodology.
Using bootstrapping across 50 independently rematched datasets, the researchers achieved consistent and statistically reliable results, an uncommon accomplishment in Australian maternity research. The final matched cohorts comprised approximately 160,000 women in each arm, underscoring both the statistical power and the challenge of balancing such large groups. Matching included more than a dozen variables—starting with congenital anomalies, and extending to parity, BMI, country of birth, use of ART, diabetes, and hypertension.
Notably, the study adopted an intention-to-treat approach, ensuring that women who commenced care in the private sector but transferred to the public system remained classified in the private cohort. The authors calculated an error rate of just 0.01%, further reinforcing the precision of their cohort construction.
Far from fuelling division, the study offers an opportunity to unify a specialty increasingly pulled by ideological and economic forces. It challenges us to move beyond rhetoric and instead face what the data reveal.
Key findings and their significance
The findings are both confronting and clarifying.
Unexplained stillbirth or neonatal death was twice as likely in the standard public care model. Low Apgar scores at five minutes were significantly more common, as were third- or fourth-degree perineal tears and postpartum haemorrhage.
Interestingly, the private cohort had a higher rate of planned caesarean sections, a lower rate of unplanned caesarean sections and a higher proportion of births between 34 and 39 weeks.
In contrast, gestational age at birth in the public sector was more frequently either less than 34 weeks or beyond 40 weeks. Induction of labour was higher in the standard public care group.
Economic implications and system considerations
Importantly, the study was an economic analysis.
Private maternity care was found to cost nearly $6000 less per birth than standard public care. However, it should be noted that the financial data analysed in the study do not incorporate liability or indemnity costs borne by the public sector, while the private sector has these costs included in service delivery.
In Australia, public indemnity costs are typically carried by state treasury departments under publicly funded indemnity schemes.
In the UK, these costs are now so significant that the total liability for maternity-related compensation claims exceeds the cost of providing all NHS maternity services annually. This underscores the long-term economic importance of safety and quality in care delivery models.
Contextualising the data: the AIHW report and selection bias
The 2023 Australia’s Mothers and Babies report from the Australian Institute of Health and Welfare was the first to report outcomes by model of care.
It showed that midwifery group practice (MGP) programs are more commonly accessed by women with fewer risk factors—those with normal BMI and lower rates of diabetes, hypertension, or obesity.
Women born in Australia and the UK used MGP services far more frequently than those born in India, Vietnam or Pakistan.
Despite serving a lower-risk population, MGP outcomes showed no consistent advantage over standard public care in key areas.
These findings highlight the need to account for selection bias and clinical complexity when comparing models of care. The rigorous cohort matching of the independent BJOG study, on the other hand, did compare this.
Related
Learning from the UK: a word of caution
Australia is not immune to the repercussions of system-wide policy shifts seen abroad.
In the UK, the pursuit of midwifery-led continuity of care was implemented at scale, but without sufficient structural safeguards. The outcomes have been severe: the Ockenden Review has prompted widespread scrutiny of maternity practices, while Nottingham University Hospitals Trust is now subject to a corporate manslaughter investigation.
The situation has escalated to the point that the UK may face up to £23 billion in class action claims related to maternity care failings, further reinforcing the need for rigorous safeguards and system accountability.
These developments underscore the risks of implementing care models that prioritise ideology over flexible, risk-responsive practice and highlight the dangers of excluding multidisciplinary perspectives, particularly that of obstetricians.
A blended model worth preserving
Australia’s maternity system is unique. It is neither a vertically integrated managed care system, nor a welfare-state model.
It is titled the “blended model”: a complex, often delicate interplay between public and private, state and federal, hospital and outpatient, specialist and generalist. This model has historically produced world-class outcomes, but it is under threat.
The decline of private maternity units, the stagnation of Medicare rebates, the low insurance rebates to hospitals and patients, and the steady dismantling of GP shared care maternity models all signal a slow erosion of this equilibrium.
Without alignment across funding mechanisms and shared investment in workforce sustainability, we risk not only poorer outcomes but a fractured system.
The role of the specialist: familiarity, not fragmentation
Every private specialist has trained and worked in the public system. But how often does the inverse occur?
True system literacy requires bidirectional experience. Yet increasingly, policy and funding streams are diverging. As we fragment, we risk losing the shared clinical language that once united us.
To hold sacred the role of the obstetrician is not to dismiss other models of care. It is to affirm that complexity deserves clinical leadership; that urgent situations demand immediate, experienced hands.
A call to unity
This is not a call to arms. It is a call to community.
We are one system. We must challenge dogma—whether institutional or ideological—and hold each other to the highest standards. We must advocate not just for safety or choice in isolation, but for both together. And we must demand transparency: of outcomes, of costs, and of models of care.
That transparency must not arrive years after the fact. We cannot afford multi-year data lags in a sector undergoing rapid policy and service delivery shifts.
Independent, real-time, accessible, deidentified birth data, readily available for research without the approvals of government to publish, is essential. A clinical quality birth registry is essential infrastructure to inform evidence-based policy, protect patient choice, and support safe, sustainable maternity systems.
To allow this BJOG article to fade into the background would be a mistake. Let it be a conversation starter, not a flashpoint. Let it mark a return to evidence, to shared purpose, and to respect across our diverse and deeply interdependent profession.
Dr Elizabeth Jackson is the vice-president of the National Association of Specialist Obstetricians and Gynaecologists.