Tuesday, 22 April 2014

ANALYSIS - NEW STUDY: Private Health Coverage is an Independent Risk factor for Caesarean Section

Last week, an important new study was released: "Private health care coverage and increased risk of obstetric intervention"

AIMS Ireland examines the new study and key points.

What was the study looking for?

When complications arise during pregnancy, labour, or birth interventions are often necessary to improve the health of women and/or babies. This medical need is often called clinical or medical indications. Appropriate use of intervention is necessary and important to ensure that women and their babies are safe.

In Ireland there are wide variations in rates of interventions. Rates can vary significantly across the 19 public maternity units. This suggests that practice in maternity units is not standardised and that interventions may not be used appropriately - based on medical need.

Previous studies have shown that women who choose obstetric led care and private obstetric led care have higher intervention rates than women who attend midwife led care or public obstetric led care. Discussion following these studies often focused on risk factors between the two groups - that women who opted for private obstetric led care were of higher risk groups (have more risk factors) than women who did not.

This study wanted to see if there is a difference in interventions used in Irish maternity hospitals between women who book into public maternity care (without using private health insurance) vs women who book into private maternity care (with private health insurance).

This study is significant as researchers controlled for relevant risk factors between public and private patients.

* Obstetric Led Care is hospital based care where a consultant obstetrician is the lead clinician. The policies, practice, and guidelines in the maternity unit are based on a medical care model.

What are "obstetric interventions"?

This study looked at the outcomes of 403, 642 births across Ireland - a third of which were private consultant led care - and examined the births WITH and WITHOUT the following:

* Caesarean Section

* Operative Vaginal Delivery (some times called   'assisted  delivery' - use of forceps or vacuum)

* Induction of Labour

* Episiotomy

Why is controlling for risk factors significant?

When we talk about "risk factors" this is a way of estimating the odds of a woman requiring intervention during her pregnancy, labour, or birth. Some risk factors suggest that a woman is more likely to require an induction of labour, episiotomy, emergency caesarean, or planned caesarean.

Sometimes risk factors can be conditions occurring in a pregnancy, like gestational diabetes or placenta previa. Others can be age (we hear a lot of older mothers), previous births, epidural, or if you are having multiples.

 This study isolated known risk factors for each obstetric intervention, in order to compare like with like.

The following risk factors were adjusted for each intervention group:

Induction of Labour

* Age
* heart disease
* diabetes
* placental disorders
* previous caesarean section

Planned and Emergency Caesarean Section

* age
* heart disease
* diabetes
* placental disorders
* previous caesarean section
* multiple births

(Due to recent evidence, use of epidural and induction of labour were not considered risk factors for Caesarean Section)

Assisted/operative Vaginal Births (Forceps and Vacuum)

* age
* heart disease
* diabetes
* previous caesarean section
* multiple birth
* induction of labour
* epidural


* age
* multiple birth
* assisted/operative vaginal birth (forceps or vacuum)

What did the study find?

After controlling the public and private groups for relevant risk factors, the study looked at the birth outcomes between women who chose public vs private health coverage. The study found:

* women with private health coverage were more likely to have a planned caesarean section

* women with private health coverage were more likely to have an emergency caesarean section

* in vaginal births, women with private health coverage were 40% more likely to have an episiotomy

Key Points: Quotes from the full study which AIMSI feel are of significance.

"Irrespective of obstetric risk factors, we found that women who opted for private maternity care in Ireland were significantly more likely to have an obstetric intervention than women who opted for public care."

"assessing the influence of health care coverage status in a variety of health care settings is critical given that rates of obstetric intervention are likely impacted by a country’s prevailing model of obstetric care (i.e. midwifeled, obstetrician-led or shared care models) and health care system (i.e. socialised medicine or fee-for-service).

"health care coverage status is part of a broad spectrum of non-clinical reasons, including obstetrician preference [27,28], litigation fears [29-31], maternal preference [32,33], and fewer women attempting a trial of labour after previous caesarean [34,35]. For this reason, to better understand both clinical and non-clinical dynamics, in future studies of health care coverage status and caesarean delivery, mixed-method research would be a clear advantage."

"We are unable to confirm why differences in episiotomy rates were observed in this population. Speculatively, however, uncomplicated deliveries in the public scheme are largely attended by midwives, who may be less likely to carry out an episiotomy [44]."

"residual confounding is of concern as we were not able to adjust for all maternal (e.g. parity, obesity, assisted conception, ethnicity and socio-economic status) and fetal (e.g. position, intrauterine growth restriction, macrosomia, heart rate) risks factors which may have increased risk of obstetric intervention."

"Data extracted from hospital records may underreport the true extent of covariates and outcomes of interest in this population."


In relation to increased C-section rates:

"While undoubtedly such trends are impacted by differences in obstetric profiles, our study suggests that health care coverage status is likely an independent risk factor for caesarean delivery."

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