C-sec­tions: ‘too posh to push’ or ‘too poor to choose’?

The Irish Times - Tuesday - Health - - Front Page - Muiris Hous­ton

Ac­cord­ing to a study pub­lished this month in the Lancet, the num­ber of ba­bies born by Cae­sarean sec­tion in Ire­land has in­creased al­most five-fold since the early 1980s.

Is this proof the “too posh to push” phe­nom­e­non is flour­ish­ing here?

While part of a ris­ing global trend, we are ahead of the world­wide av­er­age: Cae­sare­ans ac­counted for 30 per cent of all births in Ire­land in 2015, and 21 per cent of births glob­ally in the same year.

Although the “too posh to push” moniker has been used in­ter­na­tion­ally, it gained ad­di­tional trac­tion in Ire­land fol­low­ing the pub­li­ca­tion of re­search in BMJ Open in 2013. It found that preg­nant women in the Re­pub­lic of Ire­land who opted for pri­vate med­i­cal care were more than twice as likely as those who use pub­lic health ser­vices to have a planned Cae­sarean.

Re­searchers an­a­lysed de­liv­er­ies among 30,000 women with sin­gle preg­nan­cies who gave birth in a large ur­ban ma­ter­nity hospi­tal here be­tween Jan­uary 2008 and July 2011. They found some 34 per cent of pri­vate pa­tients had a Cae­sarean com­pared with 22 per cent of pub­lic pa­tients. In­ter­est­ingly, the great­est dif­fer­ence be­tween the two groups was seen in the pro­por­tion of planned Cae­sare­ans, and this dif­fer­ence re­mained af­ter the re­searchers con­trolled for med­i­cal and so­cial fac­tors. Among women on their first preg­nancy, 12 per cent of those treated pri­vately and 5 per cent of pub­licly-funded women had a sched­uled Cae­sarean.

More strik­ing

The dif­fer­ence was even more strik­ing for women who were on their sec­ond or sub­se­quent preg­nancy: in this group, 26 per cent of these treated pri­vately and 12 per cent of those treated in the pub­lic sec­tor had a sched­uled Cae­sarean. And while more pri­vate pa­tients asked for a Cae­sarean, a woman’s re­quest was not a com­mon rea­son for the pro­ce­dure, the re­searchers found.

“We found the dif­fer­ences ob­served in re­la­tion to op­er­a­tive de­liv­er­ies were not ex­plained by higher rates of med­i­cal or ob­stet­ric com­pli­ca­tions among pri­vate pa­tients,” the authors said, adding that older age and higher in­come among pri­vate pa­tients may have played a part.

The find­ings raised im­por­tant ques­tions about eq­uity: “Health­care sys­tems that in­clude pub­lic and pri­vate pa­tients need to re­flect on the po­ten­tial for dis­parate rates of in­ter­ven­tion and the im­pli­ca­tions in terms of eq­uity, re­source use, and in­come gen­er­a­tion,” the authors noted.

But that was five years ago. Since then, pa­tient au­ton­omy has grown ex­po­nen­tially. The em­pha­sis is now on choice, as evinced most re­cently by the de­bate around the re­cent ref­er­en­dum to re­peal the Eighth Amend­ment to the Con­sti­tu­tion. Should women not have the choice of nat­u­ral birth or Cae­sarean when they sit down to dis­cuss de­liv­ery op­tions with their ob­ste­tri­cian?

Tra­di­tion­al­ists will re­act with hor­ror. What of the many med­i­cal risks of hav­ing an op­er­a­tive de­liv­ery? And how can we jus­tify the ad­di­tional cost of Cae­sare­ans in women who are well ca­pa­ble of hav­ing a nat­u­ral child­birth?

The Lancet study sug­gests the av­er­age Cae­sarean rate should lie in the 10-15 per cent range, based on

Should women not have the choice of nat­u­ral birth or Cae­sarean when they sit down to dis­cuss de­liv­ery op­tions with their ob­ste­tri­cian?

the es­ti­mated pro­por­tion of births re­quir­ing med­i­cal in­ter­ven­tion when com­pli­ca­tions oc­cur. Make the sys­tem one of pa­tient choice and these per­cent­ages will rise sub­stan­tially.

Rather than con­tin­u­ing to try to re­duce the over­all num­ber of Cae­sare­ans, in my view the time has come to in­crease the per­cent­age of op­er­a­tive in­ter­ven­tions for women who are treated in the pub­lic sys­tem.

As long as ob­stet­ric units refuse women Cae­sare­ans based on a com­mit­ment to min­imis­ing med­i­cal in­ter­ven­tion, and on cost grounds, eq­uity be­tween pri­vate and pub­lic prac­tice will be im­pos­si­ble to achieve. While there are of­ten good med­i­cal rea­sons to avoid surgery, this should be a mat­ter of in­di­vid­ual choice, not blan­ket pol­icy.

So rather than see­ing this in­equity as a prob­lem of “too posh to push”, I be­lieve we should look at it as a case of “too poor to choose”.

Newspapers in English

Newspapers from Ireland

© PressReader. All rights reserved.