The experiences of learner drivers, provisional drivers and supervisors with graduated driver licensing in two Australian jurisdictions

Newly licensed drivers on a provisional or intermediate licence have the highest crash risk when compared with any other group of drivers. In comparison, learner drivers have the lowest crash risk. Graduated driver licensing is one countermeasure that has been demonstrated to effectively reduce the crashes of novice drivers. This thesis examined the graduated driver licensing systems in two Australian states in order to better understand the behaviour of learner drivers, provisional drivers and the supervisors of learner drivers. By doing this, the thesis investigated the personal, social and environmental influences on novice driver behaviour as well as providing effective baseline data against which to measure subsequent changes to the licensing systems. In the first study, conducted prior to the changes to the graduated driver licensing system introduced in mid-2007, drivers who had recently obtained their provisional licence in Queensland and New South Wales were interviewed by telephone regarding their experiences while driving on their learner licence. Of the 687 eligible people approached to participate at driver licensing centres, 392 completed the study representing a response rate of 57.1 per cent. At the time the data was collected, New South Wales represented a more extensive graduated driver licensing system when compared with Queensland. The results suggested that requiring learners to complete a mandated number of hours of supervised practice impacts on the amount of hours that learners report completing. While most learners from New South Wales reported meeting the requirement to complete 50 hours of practice, it appears that many stopped practising soon after this goal was achieved. In contrast, learners from Queensland, who were not required to complete a specific number of hours at the time of the survey, tended to fall into three groups. The first group appeared to complete the minimum number of hours required to pass the test (less than 26 hours), the second group completed 26 to 50 hours of supervised practice while the third group completed significantly more practice than the first two groups (over 100 hours of supervised practice). Learner drivers in both states reported generally complying with the road laws and were unlikely to report that they had been caught breaking the road rules. They also indicated that they planned to obey the road laws once they obtained their provisional licence. However, they were less likely to intend to comply with recommended actions to reduce crash risk such as limiting their driving at night. This study also identified that there were relatively low levels of unaccompanied driving (approximately 15 per cent of the sample), very few driving offences committed (five per cent of the sample) and that learner drivers tended to use a mix of private and professional supervisors (although the majority of practice is undertaken with private supervisors). Consistent with the international literature, this study identified that very few learner drivers had experienced a crash (six per cent) while on their learner licence. The second study was also conducted prior to changes to the graduated driver licensing system and involved follow up interviews with the participants of the first study after they had approximately 21 months driving experience on their provisional licence. Of the 392 participants that completed the first study, 233 participants completed the second interview (representing a response rate of 59.4 per cent). As with the first study, at the time the data was collected, New South Wales had a more extensive graduated driver licensing system than Queensland. For instance, novice drivers from New South Wales were required to progress through two provisional licence phases (P1 and P2) while there was only one provisional licence phase in Queensland. Among the participants in this second study, almost all provisional drivers (97.9 per cent) owned or had access to a vehicle for regular driving. They reported that they were unlikely to break road rules, such as driving after a couple of drinks, but were also unlikely to comply with recommended actions, such as limiting their driving at night. When their provisional driving behaviour was compared to the stated intentions from the first study, the results suggested that their intentions were not a strong predictor of their subsequent behaviour. Their perception of risk associated with driving declined from when they first obtained their learner licence to when they had acquired provisional driving experience. Just over 25 per cent of participants in study two reported that they had been caught committing driving offences while on their provisional licence. Nearly one-third of participants had crashed while driving on a provisional licence, although few of these crashes resulted in injuries or hospitalisations. To complement the first two studies, the third study examined the experiences of supervisors of learner drivers, as well as their perceptions of their learner’s experiences. This study was undertaken after the introduction of the new graduated driver licensing systems in Queensland and New South Wales in mid- 2007, providing insights into the impacts of these changes from the perspective of supervisors. The third study involved an internet survey of 552 supervisors of learner drivers. Within the sample, approximately 50 per cent of participants supervised their own child. Other supervisors of the learner drivers included other parents or stepparents, professional driving instructors and siblings. For two-thirds of the sample, this was the first learner driver that they had supervised. Participants had provided an average of 54.82 hours (sd = 67.19) of supervision. Seventy-three per cent of participants indicated that their learners’ logbooks were accurate or very accurate in most cases, although parents were more likely than non-parents to report that their learners’ logbook was accurate (F (1,546) = 7.74, p = .006). There was no difference between parents and non-parents regarding whether they believed the log book system was effective (F (1,546) = .01, p = .913). The majority of the sample reported that their learner driver had had some professional driving lessons. Notwithstanding this, a significant proportion (72.5 per cent) believed that parents should be either very involved or involved in teaching their child to drive, with parents being more likely than non-parents to hold this belief. In the post mid-2007 graduated driver licensing system, Queensland learner drivers are able to record three hours of supervised practice in their log book for every hour that is completed with a professional driving instructor, up to a total of ten hours. Despite this, there was no difference identified between Queensland and New South Wales participants regarding the amount of time that they reported their learners spent with professional driving instructors (X2(1) = 2.56, p = .110). Supervisors from New South Wales were more likely to ensure that their learner driver complied with the road laws. Additionally, with the exception of drug driving laws, New South Wales supervisors believed it was more important to teach safety-related behaviours such as remaining within the speed limit, car control and hazard perception than those from Queensland. This may be indicative of more intensive road safety educational efforts in New South Wales or the longer time that graduated driver licensing has operated in that jurisdiction. However, other factors may have contributed to these findings and further research is required to explore the issue. In addition, supervisors reported that their learner driver was involved in very few crashes (3.4 per cent) and offences (2.7 per cent). This relatively low reported crash rate is similar to that identified in the first study. Most of the graduated driver licensing research to date has been applied in nature and lacked a strong theoretical foundation. These studies used Akers’ social learning theory to explore the self-reported behaviour of novice drivers and their supervisors. This theory was selected as it has previously been found to provide a relatively comprehensive framework for explaining a range of driver behaviours including novice driver behaviour. Sensation seeking was also used in the first two studies to complement the non-social rewards component of Akers’ social learning theory. This program of research identified that both Akers’ social learning theory and sensation seeking were useful in predicting the behaviour of learner and provisional drivers over and above socio-demographic factors. Within the first study, Akers’ social learning theory accounted for an additional 22 per cent of the variance in learner driver compliance with the law, over and above a range of socio-demographic factors such as age, gender and income. The two constructs within Akers’ theory which were significant predictors of learner driver compliance were the behavioural dimension of differential association relating to friends, and anticipated rewards. Sensation seeking predicted an additional six per cent of the variance in learner driver compliance with the law. When considering a learner driver’s intention to comply with the law while driving on a provisional licence, Akers’ social learning theory accounted for an additional 10 per cent of the variance above socio-demographic factors with anticipated rewards being a significant predictor. Sensation seeking predicted an additional four per cent of the variance. The results suggest that the more rewards individuals anticipate for complying with the law, the more likely they are to obey the road rules. Further research is needed to identify which specific rewards are most likely to encourage novice drivers’ compliance with the law. In the second study, Akers’ social learning theory predicted an additional 40 per cent of the variance in self-reported compliance with road rules over and above socio-demographic factors while sensation seeking accounted for an additional five per cent of the variance. A number of Aker’s social learning theory constructs significantly predicted provisional driver compliance with the law, including the behavioural dimension of differential association for friends, the normative dimension of differential association, personal attitudes and anticipated punishments. The consistent prediction of additional variance by sensation seeking over and above the variables within Akers’ social learning theory in both studies one and two suggests that sensation seeking is not fully captured within the non social rewards dimension of Akers’ social learning theory, at least for novice drivers. It appears that novice drivers are strongly influenced by the desire to engage in new and intense experiences. While socio-demographic factors and the perception of risk associated with driving had an important role in predicting the behaviour of the supervisors of learner drivers, Akers’ social learning theory provided further levels of prediction over and above these factors. The Akers’ social learning theory variables predicted an additional 14 per cent of the variance in the extent to which supervisors ensured that their learners complied with the law and an additional eight per cent of the variance in the supervisors’ provision of a range of practice experiences. The normative dimension of differential association, personal attitudes towards the use of professional driving instructors and anticipated rewards were significant predictors for supervisors ensuring that their learner complied with the road laws, while the normative dimension was important for range of practice. This suggests that supervisors who engage with other supervisors who ensure their learner complies with the road laws and provide a range of practice to their own learners are more likely to also engage in these behaviours. Within this program of research, there were several limitations including the method of recruitment of participants within the first study, the lower participation rate in the second study, an inability to calculate a response rate for study three and the use of self-report data for all three studies. Within the first study, participants were only recruited from larger driver licensing centres to ensure that there was a sufficient throughput of drivers to approach. This may have biased the results due to the possible differences in learners that obtain their licences in locations with smaller licensing centres. Only 59.4 per cent of the sample in the first study completed the second study. This may be a limitation if there was a common reason why those not participating were unable to complete the interview leading to a systematic impact on the results. The third study used a combination of a convenience and snowball sampling which meant that it was not possible to calculate a response rate. All three studies used self-report data which, in many cases, is considered a limitation. However, self-report data may be the only method that can be used to obtain some information. This program of research has a number of implications for countermeasures in both the learner licence phase and the provisional licence phase. During the learner phase, licensing authorities need to carefully consider the number of hours that they mandate learner drivers must complete before they obtain their provisional driving licence. If they mandate an insufficient number of hours, there may be inadvertent negative effects as a result of setting too low a limit. This research suggests that logbooks may be a useful tool for learners and their supervisors in recording and structuring their supervised practice. However, it would appear that the usage rates for logbooks will remain low if they remain voluntary. One strategy for achieving larger amounts of supervised practice is for learner drivers and their supervisors to make supervised practice part of their everyday activities. As well as assisting the learner driver to accumulate the required number of hours of supervised practice, it would ensure that they gain experience in the types of environments that they will probably encounter when driving unaccompanied in the future, such as to and from education or work commitments. There is also a need for policy processes to ensure that parents and professional driving instructors communicate effectively regarding the learner driver’s progress. This is required as most learners spend at least some time with a professional instructor despite receiving significant amounts of practice with a private supervisor. However, many supervisors did not discuss their learner’s progress with the driving instructor. During the provisional phase, there is a need to strengthen countermeasures to address the high crash risk of these drivers. Although many of these crashes are minor, most involve at least one other vehicle. Therefore, there are social and economic benefits to reducing these crashes. If the new, post-2007 graduated driver licensing systems do not significantly reduce crash risk, there may be a need to introduce further provisional licence restrictions such as separate night driving and peer passenger restrictions (as opposed to the hybrid version of these two restrictions operating in both Queensland and New South Wales). Provisional drivers appear to be more likely to obey some provisional licence laws, such as lower blood alcohol content limits, than others such as speed limits. Therefore, there may be a need to introduce countermeasures to encourage provisional drivers to comply with specific restrictions. When combined, these studies provided significant information regarding graduated driver licensing programs. This program of research has investigated graduated driver licensing utilising a cross-sectional and longitudinal design in order to develop our understanding of the experiences of novice drivers that progress through the system in order to help reduce crash risk once novice drivers commence driving by themselves.

Ethnic differences in body fat distribution among Asian pre-pubertal children: A cross-sectional multicenter study

Background Ethnic differences in body fat distribution contribute to ethnic differences in cardiovascular morbidities and diabetes. However few data are available on differences in fat distribution in Asian children from various backgrounds. Therefore, the current study aimed to explore ethnic differences in body fat distribution among Asian children from four countries. Methods A total of 758 children aged 8-10 y from China, Lebanon, Malaysia and Thailand were recruited using a non-random purposive sampling approach to enrol children encompassing a wide BMI range. Height, weight, waist circumference (WC), fat mass (FM, derived from total body water [TBW] estimation using the deuterium dilution technique) and skinfold thickness (SFT) at biceps, triceps, subscapular, supraspinale and medial calf were collected. Results After controlling for height and weight, Chinese and Thai children had a significantly higher WC than their Lebanese and Malay counterparts. Chinese and Thais tended to have higher trunk fat deposits than Lebanese and Malays reflected in trunk SFT, trunk/upper extremity ratio or supraspinale/upper extremity ratio after adjustment for age and total body fat. The subscapular/supraspinale skinfold ratio was lower in Chinese and Thais compared with Lebanese and Malays after correcting for trunk SFT. Conclusions Asian pre-pubertal children from different origins vary in body fat distribution. These results indicate the importance of population-specific WC cut-off points or other fat distribution indices to identify the population at risk of obesity-related health problems.

An analysis of the differences in audit processes used in the audit of nonprofit and profit organisations

Nonprofits constitute a large part of collective behaviour in society. Presently there is little formal research addressing the role of audits in nonprofit organisations. Before models can be developed for the production of nonprofit auditing information, it is necessary to examine the present conduct of nonprofit audits. The Australian Accounting Research Foundation - Legislation Review Board has released a position paper on the Association Incorporation Acts in Australia - the most frequently used legal form for nonprofit organisations. The Board is addressing the issue of financial statement reporting including audit. This is coinciding with the investigations resulting from the collapse of the National Safety Council (Victorian Division), (NSC). The NSC, a nonprofit organisation formed as a company limited by guarantee, is in liquidation and the auditors are being sued for damages resulting from their alleged failure to perform their duties adequately.

Socioeconomic differences in takeaway food consumption among adults

Background In Australia and other developed countries, there are consistent and marked socioeconomic inequalities in health. Diet is a major contributing factor to the poorer health of lower socioeconomic groups: the dietary patterns of disadvantaged groups are least consistent with dietary recommendations for the prevention of diet-related chronic diseases compared with their more advantaged counterparts. Part of the reason that lower socioeconomic groups have poorer diets may be their consumption of takeaway foods. These foods typically have nutrient contents that fail to comply with the dietary recommendations for the prevention of chronic disease and associated risk factors. A high level of takeaway food consumption, therefore, may negatively influence overall dietary intakes and, consequently, lead to adverse health outcomes. Despite this, little attention has focused on the association between socioeconomic position (SEP) and takeaway food consumption, with the limited number of studies showing mixed results. Additionally, studies have been limited by only considering a narrow range of takeaway foods and not examining how different socioeconomic groups make choices that are more (or less) consistent with dietary recommendations. While a large number of earlier studies have consistently reported socioeconomically disadvantaged groups consume a lesser amount of fruit and vegetables, there is limited knowledge about the role of takeaway food in socioeconomic variations in fruit and vegetable intake. Furthermore, no known studies have investigated why there are socioeconomic differences in takeaway food consumption. The aims of this study are to: examine takeaway food consumption and the types of takeaway food consumed (healthy and less healthy) by different socioeconomic groups, to determine whether takeaway food consumption patterns explain socioeconomic variations in fruit and vegetable intake, and investigate the role of a range of psychosocial factors in explaining the association between SEP and takeaway food consumption and the choice of takeaway food. Methods This study used two cross-sectional population-based datasets: 1) the 1995 Australian National Nutrition Survey (NNS) which was conducted among a nationally representative sample of adults aged between 25.64 years (N = 7319, 61% response rate); and 2) the Food and Lifestyle Survey (FLS) which was conducted by the candidate and was undertaken among randomly selected adults aged between 25.64 years residing in Brisbane, Australia in 2009 (N = 903, 64% response rate). The FLS extended the NNS in several ways by describing current socioeconomic differences in takeaway food consumption patterns, formally assessing the mediated effect of takeaway food consumption to socioeconomic inequalities in fruit and vegetable intake, and also investigating whether (and which) psychosocial factors contributed to the observed socioeconomic variations in takeaway food consumption patterns. Results Approximately 32% of the NNS participants consumed takeaway food in the previous 24 hours and 38% of the FLS participants reported consuming takeaway food once a week or more. The results from analyses of the NNS and the FLS were somewhat mixed; however, disadvantaged groups were likely to consume a high level of �\less healthy. takeaway food compared with their more advantaged counterparts. The lower fruit and vegetable intake among lower socioeconomic groups was partly mediated by their high consumption of �\less healthy. takeaway food. Lower socioeconomic groups were more likely to have negative meal preparation behaviours and attitudes, and weaker health and nutrition-related beliefs and knowledge. Socioeconomic differences in takeaway food consumption were partly explained by meal preparation behaviours and attitudes, and these factors along with health and nutrition-related beliefs and knowledge appeared to contribute to the socioeconomic variations in choice of takeaway foods. Conclusion This thesis enhances our understanding of socioeconomic differences in dietary behaviours and the potential pathways by describing takeaway food consumption patterns by SEP, explaining the role of takeaway food consumption in socioeconomic inequalities in fruit and vegetable intake, and identifying the potential impact of psychosocial factors on socioeconomic differences in takeaway food consumption and the choice of takeaway food. Some important evidence is also provided for developing policies and effective intervention programs to improve the diet quality of the population, especially among lower socioeconomic groups. This thesis concludes with a discussion of a number of recommendations about future research and strategies to improve the dietary intake of the whole population, and especially among disadvantaged groups.

Normative influences across cultures : conceptual differences and potential confounders among drivers in Australia and China

Normative influences on road user behaviour have been well documented and include such things as personal, group, subjective and moral norms. Commonly, normative factors are examined within one cultural context, although a few examples of exploring the issue across cultures exist. Such examples add to our understanding of differences in perceptions of the normative factors that may exert influence on road users and can assist in determining whether successful road safety interventions in one location may be successful in another. Notably, the literature is relatively silent on such influences in countries experiencing rapidly escalating rates of motorization. China is one such country where new drivers are taking to the roads in unprecedented numbers and authorities are grappling with the associated challenges. This paper presents results from qualitative and quantitative research on self-reported driving speeds of car drivers and related issues in Australia and China. Focus group interviews and questionnaires conducted in each country examined normative factors that might influence driving in each cultural context. Qualitative findings indicated perceptions of community acceptance of speeding were present in both countries but appeared more widespread in China, yet quantitative results did not support this difference. Similarly, with regard to negative social feedback from speeding, qualitative findings suggested no embarrassment associated with speeding among Chinese participants and mixed results among Australian participants, yet quantitative results indicated greater embarrassment for Chinese drivers. This issue was also examined from the perspective of self-identity and findings were generally similar across both samples and appear related to whether it is important to be perceived as a skilled/safe driver by others. An interesting and important finding emerged with regard to how Chinese drivers may respond to questions about road safety issues if the answers might influence foreigners’ perceptions of China. In attempting to assess community norms associated with speeding, participants were asked to describe what they would tell a foreign visitor about the prevalence of speeding in China. Responses indicated that if asked by a foreigner, people may answer in a manner that portrayed China as a safe country (e.g., that drivers do not speed), irrespective of the actual situation. This ‘faking good for foreigners’ phenomenon highlights the importance of considering ‘face’ when conducting research in China – a concept absent from the road safety literature. An additional noteworthy finding that has been briefly described in the road safety literature is the importance and strength of the normative influence of social networks (guanxi) in China. The use of personal networks to assist in avoiding penalties for traffic violations was described by Chinese participants and is an area that could be addressed to strengthen the deterrent effect of traffic law enforcement. Overall, the findings suggest important considerations for developing and implementing road safety countermeasures in different cultural contexts.

Gender differences in recreational and transport cycling : a cross-sectional mixed-methods comparison of cycling patterns, motivators, and constraints

Background: Gender differences in cycling are well-documented. However, most analyses of gender differences make broad comparisons, with few studies modeling male and female cycling patterns separately for recreational and transport cycling. This modeling is important, in order to improve our efforts to promote cycling to women and men in countries like Australia with low rates of transport cycling. The main aim of this study was to examine gender differences in cycling patterns and in motivators and constraints to cycling, separately for recreational and transport cycling. Methods: Adult members of a Queensland, Australia, community bicycling organization completed an online survey about their cycling patterns; cycling purposes; and personal, social and perceived environmental motivators and constraints (47% response rate). Closed and open-end questions were completed. Using the quantitative data, multivariable linear, logistic and ordinal regression models were used to examine associations between gender and cycling patterns, motivators and constraints. The qualitative data were thematically analysed to expand upon the quantitative findings. Results: In this sample of 1862 bicyclists, men were more likely than women to cycle for recreation and for transport, and they cycled for longer. Most transport cycling was for commuting, with men more likely than women to commute by bicycle. Men were more likely to cycle on-road, and women off-road. However, most men and women did not prefer to cycle on-road without designed bicycle lanes, and qualitative data indicated a strong preference by men and women for bicycle-only off-road paths. Both genders reported personal factors (health and enjoyment related) as motivators for cycling, although women were more likely to agree that other personal, social and environmental factors were also motivating. The main constraints for both genders and both cycling purposes were perceived environmental factors related to traffic conditions, motorist aggression and safety. Women, however, reported more constraints, and were more likely to report as constraints other environmental factors and personal factors. Conclusion: Differences found in men’s and women’s cycling patterns, motivators and constraints should be considered in efforts to promote cycling, particularly in efforts to increase cycling for transport.

Spot the differences in traditional and social entrepreneurial intention : highlighting the role of human and social capital

There is general agreement in the scientific community that entrepreneurship plays a central role in the growth and development of an economy in rapidly changing environments (Acs & Virgill 2010). In particular, when business activities are regarded as a vehicle for sustainable growth at large, that goes beyond mere economic returns of singular entities, encompassing also social problems and heavily relying on collaborative actions, then we more precisely fall into the domain of ‘social entrepreneurship’(Robinson et al. 2009). In the entrepreneurship literature, prior studies demonstrated the role of intentionality as the best predictor of planned behavior (Ajzen 1991), and assumed that the intention to start a business derives from the perception of desirability and feasibility and from a propensity to act upon an opportunity (Fishbein & Ajzen 1975). Recognizing that starting a business is an intentional act (Krueger et al. 2000) and entrepreneurship is a planned behaviour (Katz & Gartner 1988), models of entrepreneurial intentions have substantial implications for intentionality research in entrepreneurship. The purpose of this paper is to explore the emerging practice of social entrepreneurship by comparing the determinants of entrepreneurial intention in general versus those leading to startups with a social mission. Social entrepreneurial intentions clearly merit to be investigated given that the opportunity identification process is an intentional process not only typical of for profit start-ups, and yet there is a lack of research examining opportunity recognition in social entrepreneurship (Haugh 2005). The key argument is that intentionality in both traditional and social entrepreneurs during the decision-making process of new venture creation is influenced by an individual's perceptions toward opportunities (Fishbein & Ajzen 1975). Besides opportunity recognition, at least two other aspects can substantially influence intentionality: human and social capital (Davidsson, 2003). This paper is set to establish if and to what extent the social intentions of potential entrepreneurs, at the cognitive level, are influenced by opportunities recognition, human capital, and social capital. By applying established theoretical constructs, the paper draws comparisons between ‘for-profit’ and ‘social’ intentionality using two samples of students enrolled in Economy and Business Administration at the University G. d’Annunzio in Pescara, Italy. A questionnaire was submitted to 310 potential entrepreneurs to test the robustness of the model. The collected data were used to measure the theoretical constructs of the paper. Reliability of the multi-item scale for each dimension was measured using Cronbach alpha, and for all the dimensions measures of reliability are above 0.70. We empirically tested the model using structural equation modeling with AMOS. The results allow us to empirically contribute to the argument regarding the influence of human and social cognitive capital on social and non-social entrepreneurial intentions. Moreover, we highlight the importance for further researchers to look deeper into the determinants of traditional and social entrepreneurial intention so that governments can one day define better polices and regulations that promote sustainable businesses with a social imprint, rather than inhibit their formation and growth.

Knee extensor strength differences in obese and healthy-weight 10-13 year olds

The purpose of this study was to investigate if obese children have reduced knee extensor (KE) strength and to explore the relationship between adiposity and KE strength. An observational case-control study was conducted in three Australian states, recruiting obese [n=107 (51 female, 56 male)] and healthy-weight [n=132 (56 female, 76 male)] 10–13 year old children. Body mass index, body composition (dual energy X-ray absorptiometry), isokinetic/isometric peak KE torques (dynamometry) and physical activity (accelerometry) were assessed. Results revealed that compared with their healthy-weight peers, obese children had higher absolute KE torques (P≤0.005), equivocal KE torques when allometrically normalized for fat-free mass (FFM) (P≥0.448) but lower relative KE torques when allometrically normalized for body mass (P≤0.008). Adjustments for maternal education, income and accelerometry had little impact on group differences, except for isometric KE torques relative to body mass which were no longer significantly lower in obese children (P≥0.013, not significant after controlling for multiple comparisons). Percent body fat was inversely related to KE torques relative to body mass (r= -0.22 to -0.35, P≤0.002), irrespective of maternal education, income or accelerometry. In conclusion, while obese children have higher absolute KE strength and FFM, they have less functional KE strength (relative to mass) available for weight-bearing activities than healthy-weight children. The finding that FFM-normalized KE torques did not differ suggests that the intrinsic contractile properties of the KE muscles are unaffected by obesity. Future research is needed to see if deficits in KE strength relative to mass translate into functional limitations in weight-bearing activities.

Going public : do risk and choice explain differences in caesarean birth rates between public and private places of birth in Australia?

Background: Women who birth in private facilities in Australia are more likely to have a caesarean birth than women who birth in public facilities and these differences remain after accounting for sector differences in the demographic and health risk profiles of women. However, the extent to which women’s preferences and/or freedom to choose their mode of birth further account for differences in the likelihood of caesarean birth between the sectors remains untested. Method: Women who birthed in Queensland, Australia during a two-week period in 2009 were mailed a self-report survey approximately three months after birth. Seven hundred and fifty-seven women provided cross-sectional retrospective data on where they birthed (public or private facility), mode of birth (vaginal or caesarean) and risk factors, along with their preferences and freedom to choose their mode of birth. A hierarchical logistic regression was conducted to determine the extent to which maternal risk and freedom to choose one’s mode of birth explain sector differences in the likelihood of having a caesarean birth. Findings: While there was no sector difference in women’s preference for mode of birth, women who birthed in private facilities had higher odds of feeling able to choose either a vaginal or caesarean birth, and feeling able to choose only a caesarean birth. Women had higher odds of having caesarean birth if they birthed in private facilities, even after accounting for significant risk factors such as age, body mass index, previous caesarean and use of assisted reproductive technology. However, there was no association between place of birth and odds of having a caesarean birth after also accounting for freedom to choose one’s mode of birth. Conclusions: These findings call into question suggestions that the higher caesarean birth rate in the private sector in Australia is attributable to increased levels of obstetric risk among women birthing in the private sector or maternal preferences alone. Instead, the determinants of sector differences in the likelihood of caesarean births are complex and are linked to differences in the perceived choices for mode of birth between women birthing in the private and public systems.