Obstetric interventions among private and public patients. High rates of operative vaginal interventions in private patients need analysis

Frequency and determinants of misuse of augmentation of labor in France: A population-based study

Introduction

While use of augmentation of labor (AL) is appropriate for labor dystocia, it is frequently used inadequately and unnecessarily. The objective was to assess at a national level, the frequency and determinants of misuse of augmentation of labor (AL).

Material and methods

Women of the French perinatal survey of 2016 with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. “Misuse of AL” was defined by artificial rupture of the membranes (ROM) and/or oxytocin within one hour of admission and/or duration between ROM and oxytocin of less than one hour. Women, labor and maternity unit’s characteristics were compared between the “misuse of AL” and “no misuse of AL” groups by bivariate analysis. To identify the determinants of misuse of AL, a multivariable multilevel logistic regression was performed taking into account the data’s hierarchical structure (first level: women, second level: maternity units).

Results

Among the 7196 women included, 1524 (21.2%) had a misuse of AL. The determinants of misuse of AL were middle school educational level (reference high school), aOR = 1.21; 95%CI[1.01–1.45], gestational age at delivery ≥41weeks (reference 39–40 weeks), aOR = 1.19; 95%CI[1.00–1.42], cervical dilation ≥6cm at admission (reference <3cm), aOR = 1.39; 95%CI[1.10–1.76], epidural analgesia aOR = 1.63; 95%CI[1.35–1.96], delivery in a private hospital (reference public teaching hospital), aOR = 2.25; 95%CI[1.57–3.23]; and maternity units with <1000 deliveries/year and 1000–1999 deliveries/year (reference ≥3000 deliveries/year), respectively aOR = 1.52; 95%CI[1.11–2.08] and aOR = 1.42; 95%CI[1.05–1.92]. Less than 3% of the variance was explained by women characteristics, and 24.17% by the maternity units’ characteristics.

Conclusions

In France, one spontaneous laboring woman among five is subject to misuse of AL. The misuse is mostly explained by maternity unit’s characteristics. The determinants identified in this study can be used to implement targeted actions in small and private maternity units.

Do you pay to go private?: a single centre comparison of induction of labour and caesarean section rates in private versus public patients

Background

The aim of this study was to compare rates of induction and subsequent caesarean delivery among nulliparous women with private versus publicly funded health care at a single institution. This is a retrospective cohort study using the electronic booking and delivery records of nulliparous women with singleton pregnancies who delivered between 2010 and 2015 in an Irish Tertiary Maternity Hospital (approx. 9000 deliveries per annum).

Methods

Data were extracted from the National Maternity Hospital (NMH), Dublin, Patient Administration System (PAS) on all nulliparous women who delivered a liveborn infant at ≥37 weeks gestation during the 6-year period. At NMH, all women in spontaneous labour are managed according to a standardised intrapartum protocol. Twenty-two thousand two hundred thirty-two women met the inclusion criteria. Of these, 2520 (12.8%) were private patients; the remainder (19,712; 87.2%) were public. Mode of and gestational age at delivery, rates of and indications for induction of labour, rates of pre-labour caesarean section, and maternal and neonatal outcomes were examined. Rates of labour intervention and subsequent maternal and neonatal outcomes were compared between those with and without private health cover.

Results

Women attending privately were more than twice as likely to have a pre-labour caesarean section (12.7% vs. 6.5%, RR = 2.0, [CI 1.8–2.2])); this finding persisted following adjustment for differences in maternal age and body mass index (BMI) (adjusted relative risk 1.74, [CI 1.5–2.0]). Women with private cover were also more likely to have induction of labour and significantly less likely to labour spontaneously. Women who attended privately were significantly more likely to have an operative vaginal delivery, whether labour commenced spontaneously or was induced.

Conclusions

These findings demonstrate significant differences in rates of obstetric intervention between those with private and public health cover. This division is unlikely to be explained by differences in clinical risk factors as no significant difference in outcomes following spontaneous onset of labour were noted. Further research is required to determine the roots of the disparity between private and public decision-making. This should focus on the relative contributions of both mothers and maternity care professionals in clinical decision making, and the potential implications of these choices.

Obstetric interventions for low-risk pregnant women in France: do maternity unit characteristics make a difference?

BACKGROUND

In many countries the closure of small maternity units has raised concerns about how the concentration of low-risk pregnancies in large specialized units might affect the management of childbirth. We aimed to assess the role of maternity unit characteristics on obstetric intervention rates among low-risk women in France.

METHODS

Data on low-risk deliveries came from the 2010 French National Perinatal Survey of a representative sample of births (n = 9,530). The maternity unit characteristics studied were size, level of care, and private or public status; the interventions included induction of labor; cesarean section; operative vaginal delivery (forceps, spatulas or vacuum); and episiotomy. Multilevel logistic regression analyses were adjusted for maternal confounding factors, gestational age, and infant birthweight.

RESULTS

The rates of induction, cesarean section, operative delivery, and episiotomy in this low-risk population were 23.9 percent, 10.1 percent, 15.2 percent, and 19.6 percent, respectively, and 52.0 percent of deliveries included at least one of them. Unit size was unrelated to any intervention except operative delivery (adjusted odds ratio [aOR] = 1.47 (95% CI, 1.10-1.96) for units with >3,000 deliveries per year vs units with <1,000). The rate of every intervention was higher in private units, and the aOR for any intervention was 1.82 (95% CI, 1.59-2.08). After adjustment for maternal characteristics and facility size and status, significant variations in the use of interventions remained between units, especially for episiotomies. Results for level of care were similar to those for unit size.

CONCLUSIONS

The concentration of births in large maternity units in France is not associated with higher rates of interventions for low-risk births. The situation in private units could be explained by differences in the organization of care. Additional research should explore the differences in practices between maternity units with similar characteristics.

Disciplinary discourses: rates of cesarean section explained by medicine, midwifery, and feminism

In the context of international concern about increasing rates of cesarean sections, we used discourse analysis to examine explanations arising from feminism and the disciplines of medicine and midwifery, and found that each was positioned differently in relation to the rising rates. Medical discourses asserted that doctors are authorities on birth and that, although cesareans are sometimes medically necessary, women recklessly choose unnecessary cesareans against medical advice. Midwifery discourses portrayed medicine as paternalistic toward both women and midwifery, and feminist discourses situated birth and women's bodies in the context of a patriarchally structured society. The findings illustrate the complex ways in which this intervention in birth is discursively constructed, and demonstrate its significance as a site of disciplinary conflict.

The philosophy of practice governs the rate of obstetric intervention: analysis of 212 units in the United Kingdom

OBJECTIVE

To investigate the relationship between the practices of obstetric intervention in individual units.

STUDY DESIGN

A retrospective analysis of the annual statistical returns to the Royal College of Obstetricians and Gynaecologists of 222 units in the UK for 1997-98.

RESULTS

A total of 212 units that delivered more than 1000 babies were analyzed. A positive correlation was found between the rates of assisted vaginal delivery and emergency Cesarean section (Spearman's rho = 0.207, p = 0.003) and the rates of emergency and elective Cesarean section (Spearman's rho = 0.205, p < 0.001). There was a significant difference between unit size and the rate of spontaneous vaginal delivery (Kruskall-Wallis chi2 = 14.5, p = 0.002) with larger units having a lower spontaneous vaginal delivery rate.

CONCLUSION

These results indicate that those units which have a high emergency Cesarean section rate also have a high elective Cesarean section rate and assisted vaginal delivery rate. The philosophy of an individual unit towards intervention is a general philosophy and determines the intervention rates for all procedures.

Perineal outcomes in NSW public and private hospitals: analysing recent trends

Women using private health insurance for pregnancy care may be unaware of the impact that this choice has in increasing their risk of experiencing a range of interventions during childbirth. This paper identifies recent trends in episiotomy rates and perineal outcomes for New South Wales (NSW) public and private hospitals between 1997 and 1999. Clear and consistent differences exist in birth outcomes in NSW private hospitals in respect to greater episiotomy use and poorer overall perineal outcomes, higher caesarean section rates and higher instrumental birth rates. Given the potential health impact for women who experience intervention during childbirth, identification of clinically unjustified practices is an important step towards ensuring that women's choices provide them with optimal childbirth outcomes regardless of their health insurance status.