Caesarean section rates in women in the Republic of Ireland who chose to attend their obstetrician privately: a retrospective observational study

Abstract

Background Caesarean section (CS) rates are increasing and there are wide variations in rates internationally and nationally. There is evidence that women who attend their obstetrician privately have a higher incidence of CS than those who attend publicly. The purpose of this observational study was to further investigate why CS rates may be higher in women who chose to attend their obstetrician privately. Methods This study analysed data collected as part of the clinical records by midwives at the woman’s first antenatal appointment in a large European maternity hospital. All women who delivered between the years 2009 and 2017 were included. Data were analysed both cross-sectionally and longitudinally. Results Overall, 73,266 women had a singleton pregnancy and 1830 had a multiple pregnancy. Of the packages of maternity care, 75.2% chose public, 10.8% chose semiprivate and 14.0% chose private. During the study, 11,991 women attended the hospital for their first and second pregnancies. Overall, women who attended privately were older and had higher proportions of infertility treatment and history of miscarriage (all p < 0.001) compared to those publicly-funded. Private patients were more likely to have a history of infertility, a history of miscarriage, a multiple pregnancy and to be ≥35 yrs. They had lower rates of obesity, smoking and illicit drug use in pregnancy (all p < 0.001). In women who chose private care, the overall rate of CS was higher compared to women choosing publicly-funded (42.7% vs 25.3%, p < 0.001) The increase was due to an increase in elective rather than emergency CS. The increase in elective CS fell after adjustment for clinical risks. In the longitudinal analysis, 89.7% chose the same package second time around. Women who changed from public to private care for the second pregnancy were more likely to have had a previous emergency CS or admission to the Neonatal Unit. Conclusions This study suggests that the increased CS rate in women privately insured may be attributed, in part, to the fact that women who can afford health insurance choose continuity of care from a senior obstetrician because they are risk adverse and wish to have the option of an elective CS.

Dynamic Changes in the Human Milk Metabolome Over 25 Weeks of Lactation

“…The cohort consisted of 59 mothers delivering birth at term, of whom 30 provided samples at one time point throughout the study period, 18 provided two HM samples, nine provided three and two provided samples at all four time points (weeks 1-2, 3-5, 7-9, and 20-25, Table 1). As further presented in Table 1, the GA of the mothers was on average of 39.6 weeks, and they had an average BMI of 25.95 kg/m 2 and had given birth once before; 66% underwent spontaneous vaginal delivery, and 25.4% had Caesarean section, in line with population data from publiclyfunded deliveries (30). The female/male infants' ratio was quite even, including about 47.5% females, and all infants were within the normal weight range at birth (2,500-4,500 g) (Table 1).…”

Factors associated with cesarean birth in nulliparous women: A multicenter prospective cohort study

“…Several studies have explored the underlying reasons for this association. Decision‐making in private practice, in some countries, is often described as being related to pay and reimbursement system, the financial incentives associated with CB, and benefits to the consultants; others have attributed it to continuity of care and women being inclined to go with the flow of their consultant obstetricians' recommendation, or clinicians' “convenience,” 41 or women being able to afford health care insurance to choose private and continuity of care by a senior obstetrician 6 . Findings from this study resonate with what has been reported previously 41 suggesting a significantly increased risk of both planned and unplanned CBs for women in private care compared with women in public care.…”

“…40 Private care is one of the frequently reported factors associated with an increased risk of CB. 5,6,41 Several studies have explored the underlying reasons for this association. Decision-making in private practice, in some countries, is often described as being related to pay and reimbursement system, the financial incentives associated with CB, and benefits to the consultants; others have attributed it to continuity of care and women being inclined to go with the flow of their consultant obstetricians' recommendation, or clinicians' "convenience," 41 or women being able to afford health care insurance to choose private and continuity of care by a senior obstetrician.…”

Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

“…For example, programs with midwives and Aboriginal Health Workers (Indigenous health providers) [14,[75][76][77][78]; collaborations with general practitioners, obstetricians or a social worker [44,[79][80][81]. Just two examples did not include midwives; a model in Finland where continuity of care is provided by a nurse who takes care of the family from the pregnancy until the child reaches school age [26,82], and an example in Ireland [83], where continuity of care was provided by a privately practising obstetrician.…”