This chapter examines variation in three women’s healthcare interventions and two maternity care items. Analysis by Statistical Area Level 3 (SA3) showed marked rate differences across Australia in hysterectomy, endometrial ablation, cervical loop excision and cervical laser ablation, and third- and fourth-degree perineal tears.
Hysterectomy (surgical removal of the uterus – womb) and endometrial ablation (surgical removal of the inner lining of the uterus) are commonly used to treat heavy menstrual bleeding. The hysterectomy rate in Australia is one of the highest reported in the Organisation for Economic Co-operation and Development (OECD), and there is concern that hysterectomy may be overused to treat benign conditions.1-3
This Atlas observed a seven-fold difference between the lowest and highest rates of hysterectomy and a 21-fold difference in rates of endometrial ablation. The finding extends understanding of variation from the first Atlas4, and confirms there is marked variation in use of each procedure across Australia. Higher rates of hysterectomy in some areas could be due, in part, to lower use of less invasive treatments for heavy menstrual bleeding. Although hysterectomy stops menstrual bleeding in all women, it is a major surgical procedure.5 Pharmaceutical treatment is recommended as the first-line treatment for heavy menstrual bleeding, and endometrial ablation as the first surgical option, if appropriate and the woman prefers it.5-7 Improving access to these effective treatments may help some women avoid the need for hysterectomy.8
This Atlas observed an 18-fold variation in rates of cervical loop excision or cervical laser ablation. Expanding availability of these precancer treatments in outpatient settings and ensuring use consistent with guidelines may reduce this variation.
In selected women aged 20–34 years, the Atlas observed a three-fold variation in caesarean section rates. Australia has a higher rate of caesarean section than the OECD reported average.9 Ensuring that young women with uncomplicated pregnancies have information and access to services that support their choices for first birth will help ensure the appropriate use of caesarean section.
In all women giving birth vaginally, the Atlas observed a 12-fold variation in rates of third- and fourth-degree perineal tears. Developing an agreed national standard of care to minimise the risk of perineal trauma in childbirth is a priority.
Hysterectomy and endometrial ablation
3a. The Medicare Benefits Schedule (MBS) Review Taskforce to ensure that MBS item descriptors relating to treatments for heavy menstrual bleeding are aligned with the care described in the Heavy Menstrual Bleeding Clinical Care Standard.
3b. State and territory health departments to ensure that women who have heavy menstrual bleeding have been offered clinically appropriate treatment options, as described in the Heavy Menstrual Bleeding Clinical Care Standard, before they are placed on a waiting list for hysterectomy.
3c. Relevant professional colleges to include intrauterine device insertion within their advanced training programs. They should also review incentives for clinicians to participate in continuing professional development training programs on intrauterine device insertion, and access to such programs, to increase the number of clinicians skilled in insertion of the levonorgestrel intrauterine system.
Cervical loop excision and cervical laser ablation
3d. State and territory health departments to implement outpatient models of care for cervical loop excision and cervical laser ablation to ensure that, if clinically appropriate, patients can be offered treatment in outpatient settings.
3e. The Commission to work with relevant colleges and specialist societies to develop decision support tools on birth options for pregnant women aged 34 years and under without complications for birth.
3f. Maternity health services to ensure regular clinical review of perinatal data (National Core Maternity Indicators and additional data from perinatal datasets) by a multidisciplinary team that includes neonatologists.
3g. The Australian Institute of Health and Welfare, in collaboration with data providers and other stakeholders, to investigate ways of improving reporting of caesarean section rates according to obstetric and neonatal risk factors, such as use of the Robson classification.
3h. The Commission to refer the Atlas findings to the Community Care and Population Health Principal Committee of the Australian Health Ministers’ Advisory Council for consideration in relation to the inclusion of caesarean section <39 weeks (273 days) without obstetric or medical indication as a National Core Maternity Indicator (as described in the AIHW report National Core Maternity Indicators 2010–2013, released in 2016).
Third- and fourth-degree perineal tears
3i. Relevant medical and midwifery professional colleges to develop, agree on and disseminate an agreed model of care for the second stage of labour to minimise the risk of severe perineal trauma. 3j. The Commission to work with Women’s Healthcare Australasia, and relevant colleges and specialist societies to develop a clinical care standard on perineal care during vaginal birth, to improve national consistency of best practice for the prevention, recognition and management of severe perineal trauma.
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Time Series Data