Atlas investigation reveals caesarean concerns

An increasing number of healthy pregnant women are having caesarean sections before reaching full term, potentially causing adverse health risks for their baby.

This is according to a major report, The Third Australian Atlas of Healthcare Variation, being launched this week by Minister for Health the Hon Greg Hunt. 

The Atlas investigation into the timing of caesarean sections found that in some locations, as many as one in five planned births were before 37 weeks.

“We have known for some time that planned caesarean sections before 39 weeks increase short-term risks for the baby, but emerging evidence also links early births to an increased risk of long-term developmental problems such as poorer school performance and attention deficit hyperactivity disorder,” said Jonathan Morris, Professor of Obstetrics and Gynaecology at Sydney Medical School.

“If a woman has a healthy pregnancy and there is no clinical need for earlier delivery, waiting until approximately 39 weeks is best for baby. This is in line with recommendations from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.”

To understand if these recommendations are being implemented, the Atlas investigated the timing of planned births without a medical or obstetric indication. It found that in 2015, between 42% and 60% of planned births by caesarean section before 39 weeks had no indication, among the four states and territories that reported these data.

New Atlas findings

The Atlas, produced by the Australian Commission on Safety and Quality in Health Care in partnership with the Australian Institute of Health and Welfare, investigates healthcare use in four clinical areas: paediatric and neonatal health, cardiac tests, thyroid investigations and treatments, and gastrointestinal investigations and treatments.

It also examines national patterns in medicines use over time for four common groups of medicines: antipsychotics, opioids, antimicrobials, and medications for attention deficit hyperactivity disorder (ADHD). A more detailed exploration of these data will be published in 2019.

“While some variation in healthcare use by area is expected, given the needs of different populations, wide variations can be a sign that some people are getting health care that they don’t need while others may be missing out on the health care that they do need,” said the Commission’s Clinical Director, Professor Anne Duggan.

“Previous Atlases have identified unwarranted variations in care, prompting changes to the delivery of common medical procedures including knee surgery and colonoscopy. The data and recommendations in this Atlas will be used by clinicians, consumers, policymakers and researchers across Australia to deliver equally important improvements in health care.”

Overuse of antibiotics in children

In addition to the findings on caesareans, another area of concern is the overuse of antibiotics among Australian children — potentially putting many at risk of serious long-term adverse effects.

The very high rates of antibiotic dispensing in Australian children suggest that antibiotics are frequently prescribed inappropriately — such as to treat viral infections where they have no benefit. Research links antibiotic use to changes in a child’s normal gut bacteria and an increased risk of a number of conditions in later years, including asthma, Crohn’s disease and weight gain.

The Atlas found high rates of antibiotic dispensing for children aged 0 to 9 years — equivalent to one antibiotic prescription annually for every child. Rates were highest for children aged 0 to 4 years. Overall dispensing rates are triple those in some similar countries.

As with antibiotics, proton pump inhibitor (PPI) medicines can also adversely affect the gut bacteria. These changes have been linked to increased risk of infections such as gastroenteritis and pneumonia and to food allergies. For infants 12 months and under, the Atlas found a four-fold difference between the lowest and highest rates in PBS dispensing of PPIs.

“PPI medicines are being used to treat general symptoms such as irritability, crying and colic, despite evidence that they are usually not effective in these situations,” said Professor Duggan.

“Much more research still needs to be done into the medium- to long-term effects of these medications, and so any inappropriate use of these medications is concerning.”

Inappropriate use of gastroscopy

The Atlas also detected wide variations in two of the most common medical procedures performed in Australia — gastroscopy and colonoscopy. Gastroscopy is used to investigate upper gastrointestinal symptoms such as heartburn. It is also used to detect oesophageal and stomach cancers. These cancers are relatively rare, yet gastroscopy numbers continue to rise and it is now the sixth most common same-day procedure in Australian hospitals.

The Atlas found a clear anomaly between cancer burden and use of investigations for gastrointestinal diseases in Australia. The national rate for colonoscopy hospitalisations is about 1.5 times that for gastroscopy hospitalisations, yet the incidence of colorectal cancer is about seven times that of stomach cancer and about 11 times that of oesophageal cancer — indicating that gastroscopy may be substantially overused.

Professor Duggan explained: “Both these procedures are often performed by the same doctor, so gastroscopies that are of limited benefit should be minimised, and that theatre time allocated to people with a greater need for a timely colonoscopy, who might otherwise miss out on a potentially life-saving cancer diagnosis.

“As a doctor I am always concerned when it seems that there is underuse of important investigations or treatments by people who could benefit greatly from their use. For Aboriginal and Torres Strait Islander peoples, and people in regional and rural Australia, this is unfortunately true for many of the procedures investigated in this year’s Atlas. These communities continue to require a stronger focus.”

Antipsychotics in older Australians

A repeat analysis of the prescribing of antipsychotic medicines to Australians aged 65 and over indicates that this continues to be a problem. The 2015 Atlas identified overuse of these medicines, with concerns they were being used for behavioural symptoms such as dementia or delirium. The 2018 Atlas recommends changes to regulations that could improve the use of these medications.

The Atlas is available online at https://www.safetyandquality.gov.au/Atlas. National, state and territory summaries with local areas are also available.

Image credit: ©stock.adobe.com/au/Steve Lovegrove