Tuesday November 26 2013
A caesarean section may be the preferred option for older mothers
"Well-off mothers really are 'too posh to push'," the Mail Online reports after an Irish study found that mothers who use private healthcare services had twice the odds of having a planned caesarean section as women using state-funded care.
The study involved women in Ireland and not NHS patients. Ireland has a slightly different healthcare system where publically funded hospitals can also offer services to patients on a private basis on an 80:20 public-private ratio.
Researchers found that women who received private care were more likely to give birth by caesarean section and more likely to have an operative vaginal delivery, where a doctor uses forceps or a vacuum device to assist the delivery. The greatest difference was seen for planned caesarean sections.
It is unclear why women receiving private care had different modes of delivery to women receiving publically funded care. Interestingly, the women had the same doctors and midwives, so it would be expected that their care would be similar. It could be that any difference in their treatment was associated with the patients and not the health professionals.
Women on a private health plan tended to be older and of a higher socioeconomic status, which implies they were better educated. They therefore may have been more willing to agree to having a caesarean section if recommended to.
Reassuringly, outcomes for the baby around the time of birth were similar in the two groups.
Where did the story come from?
The study was carried out by researchers from Trinity College, University of Dublin and the Royal College of Surgeons in Ireland. The research was not funded by a specific funding agency.
It was published in the peer-reviewed medical journal BMJ Open. BMJ Open is an open access journal, so its articles can be read online free of charge.
The research was covered reasonably accurately by the UK media, but Mail Online's headline writers and ITV News got a little confused, describing this as a comparison between private and NHS patients.
What kind of research was this?
This was a retrospective cohort study. It aimed to examine whether there was a link between how women gave birth and whether they were receiving private or public care in the same hospital in Ireland.
In Ireland publically funded hospitals are allowed to treat public and private patients at a ratio of 80:20. This is currently different from the situation in England. However, the NHS is in the process of introducing a system not dissimilar to the current Irish system, allowing up to 49% of hospital income to be generated from self-funded patients.
Cohort studies can provide valuable information, but cannot prove that public or private care was responsible for the differences seen in the mode of delivery, as there may be other differences that were not accounted for.
What did the research involve?
The researchers analysed 30,053 women who had given birth between 2008 and 2011. Women who had given birth to multiple babies (for example, twins) were not included. Women were divided based on whether they received private care (5,479 women) or public care (24,574 women).
The researchers looked at whether there was a link between the way women gave birth (spontaneous vaginal delivery, operative vaginal delivery, or planned or emergency caesarean section) and the type of care they received.
They adjusted for a number of factors that could explain any association seen (confounders), including:
- maternal characteristics – maternal age, body mass index (BMI), marital status, socioeconomic group, nationality and smoking
- medical factors – medical and psychiatric disorders, and antenatal and foetal complications
- obstetric history – for example, how many children a woman had previously, if she had had children who died around the time of birth, and whether the current pregnancy was the result of assisted conception
What were the basic results?
There were differences seen between women who received private and public care. Women who received private care were older, of higher socioeconomic status, more likely to be Irish and to have a history of assisted conception, recurrent miscarriage or the previous death of a baby around the time of birth.
They were less likely to be single, not have had a baby before, have an unplanned pregnancy or to have booked a caesarean late, to smoke, drink or take drugs, have a medical or psychiatric disorder, have a positive test for hepatitis C or HIV, or have an increased BMI. However, the rate of foetal and maternal complications was similar between the two groups.
Compared with women who received public care, women who received private care were:
- less likely to have a spontaneous vaginal delivery – 61% of women receiving publically funded care had a spontaneous vaginal delivery, compared with 45% of women receiving private care: after adjusting for potential confounders, the odds of women receiving private care having a spontaneous vaginal delivery were reduced by 45% (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.52 to 0.60)
- more likely to give birth by caesarean section – 23% of women receiving publically funded care had a caesarean section, compared with 34% of women receiving private care (OR 1.57, 95% CI 1.45 to 1.70)
- more likely to have an operative vaginal delivery – 16% of women receiving publically funded care had an operative vaginal delivery, compared with 20% of women receiving private care (OR 1.44, 95% CI 1.31 to 1.58)
The greatest difference seen between women who received private and public care was in scheduled or planned caesarean sections (private 21%, compared with public 9%, OR 1.99, 95% CI 1.80 to 2.18).
Outcomes for the baby around the time of birth (perinatal outcomes) were similar, although women receiving public care were more likely to have a small baby or a baby with a congenital abnormality such as Down's syndrome.
Maternal request for a caesarean without medical indication was higher among privately funded women, but in general terms was relatively low in both groups (4.3% of caesareans versus 0.2% of caesareans among publically funded women).
How did the researchers interpret the results?
The researchers concluded that, "Privately funded obstetric care is associated with higher rates of operative deliveries that are not fully accounted for by medical or obstetric risk differences."
This study has highlighted important differences in modes of delivery for women receiving privately or publically funded care in Ireland. It found that women who were treated privately were more likely to give birth by caesarean section and more likely to have an operative vaginal delivery. The greatest difference was seen for planned caesarean sections.
It is unclear why women receiving private care had different modes of delivery to women receiving publically funded care. Interestingly, the women receiving public and private care had the same doctors and midwives, so it would be expected that their care would be similar.
Women who received private care were older, of higher socioeconomic status and more likely to have become pregnant through assisted conception. The researchers tried to account for medical or obstetric risk differences, and state that these cannot fully account for the differences seen in how the babies were delivered.
However, the study can't exclude the possibility that there were other differences between the groups that were not accounted for. The researchers speculate that the private patients may be more willing to agree to have a caesarean section if it was recommended by their doctors.
The media's often-used term that women who choose to have a caesarean section are "too posh to push" is both unhelpful and distasteful. It implies a sense of entitlement and laziness, and ignores the wide range of reasons why a caesarean section may be recommended.
Ultimately, what really matters is the health of the baby. Reassuringly, in this study outcomes for the baby around the time of birth, such as prematurity, very low birth weight or admission to neonatal special care, were similar in both groups.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.