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.

Cesarean delivery rates using Robson classification system in Ireland: What can we learn?

OBJECTIVE: It has been proposed that the Robson Ten-Group Classification System be used as a global standard for assessing, monitoring and comparing cesarean delivery (CD) rates within and between maternity services. Our objective was to compare the change of CD rates within the 10-Group Classification System in our institution over 10 years. STUDY DESIGN: From 2005-2014 inclusive data was collected prospectively and all women were classified using the obstetric concepts and parameters described in the Ten-Group Classification System. Linear regression and weighted Least Squares regression analyses were used to analyze trends over time. RESULTS: During 2005-2014 inclusive, 88,004 mothers delivered 89,649 babies ≥500 g. Over the 10 year period there was an increase in CD rate from 18.3% to 23.5%, with a linear increase in CD rate by 0.6% annually (95% CI:0.52, 0.75;p < 0.001). The main contribution to the increase in the CD rate was Group 2a (induced single cephalic nulliparous women at term), Group 2b (pre-labor single cephalic nulliparous women at term) and Group 5 (single cephalic multiparous women at term with a previous CD). No increase in CD rate was noted in Group 1 (single cephalic nulliparous women presenting in spontaneous labor at term). The percentage of women ≥35 years of age increased from 28.4% to 39.8% over the study period (0.98% per year; 95% CI:0.64, 1.33;p < 0.001). CONCLUSION: The driving force for the increase in CD in the National Maternity Hospital has been induction of labor and pre-labor CD in nulliparous women with a single cephalic pregnancy at term. This inevitably results in a larger population of women with a previous CD and therefore a secondary contribution to the increase in the overall CD rate.

Quality assurance: The 10-Group Classification System (Robson classification), induction of labor, and cesarean delivery.

Quality assurance in labor and delivery is needed. The method must be simple and consistent, and be of universal value. It needs to be clinically relevant, robust, and prospective, and must incorporate epidemiological variables. The 10-Group Classification System (TGCS) is a simple method providing a common starting point for further detailed analysis within which all perinatal events and outcomes can be measured and compared. The system is demonstrated in the present paper using data for 2013 from the National Maternity Hospital in Dublin, Ireland. Interpretation of the classification can be easily taught. The standard table can provide much insight into the philosophy of care in the population of women studied and also provide information on data quality. With standardization of audit of events and outcomes, any differences in either sizes of groups, events or outcomes can be explained only by poor data collection, significant epidemiological variables, or differences in practice. In April 2015, WHO proposed that the TGCS (also known as the Robson classification) is used as a global standard for assessing, monitoring, and comparing cesarean delivery rates within and between healthcare facilities.