Caesarean sections: ‘Too posh to push’ or ‘too poor to choose’

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.

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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?

React with horror

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 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”.