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Predictors of choice of public and private maternity care among nulliparous women in Ireland, and implications for maternity care and birth experience
Health Policy 124 (2020) 556–562
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Predictors of choice of public and private maternity care among nulliparous women in Ireland, and implications for maternity care and birth experience Patrick S. Moran a,∗ , Deirdre Daly a , Francesca Wuytack a , Margaret Carroll a , Michael Turner b , Charles Normand c,d , Cecily Begley a a
School of Nursing and Midwifery, Trinity College Dublin, Ireland School of Medicine, University College Dublin, Ireland c Centre for Health Policy and Management, Trinity College Dublin, Ireland d Economics of Palliative Care and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom b
a r t i c l e
i n f o
Article history: Received 26 June 2019 Received in revised form 13 February 2020 Accepted 17 February 2020 Keywords: Maternity care Choice Birth experience Obstetric intervention Risk stratification
a b s t r a c t Maternity care in Ireland is provided through a mixture of free public and fee-based private or semiprivate services. We examined factors associated with choice of care pathway among nulliparous women and how this influences the care they receive and their experience of childbirth using data from a prospective cohort study. Complete data were available for 1,789 women on choice of care pathway and birth outcomes, and for 1,336 women on birth experience. Maternal age (marginal effect [ME] 1.6 percentage points [ppts], p < 0.01), socioeconomic status (ME 0.5ppts, p < 0.01) and being born in Ireland (ME 10.3ppts, p < 0.01) were all positively associated with choosing private care, but level of risk in early pregnancy did not influence this decision. Intervention rates in public and semi-private care were comparable, but women in private care were more likely to receive epidural anaesthesia (odds ratio [OR] 1.65, p < 0.01) and give birth by caesarean section (ratio of relative risks [RRR] 1.98, p < 0.01). Private care was also associated with longer hospital stays (28 % longer, p < 0.01). Increased risk was negatively correlated with birth experience in public and semi-private care, but not in private care. Policies promoting the allocation of maternity care resources by level of risk, along with the standardisation of clinical practice across care pathways, could reduce rates of obstetric intervention and address risk-based disparities in birth experience outcomes. © 2020 Published by Elsevier B.V.
1. Background The costs of providing modern maternity services are substantial, and are rising in line with increasing rates of childbirth interventions such as caesarean section and epidural anaesthesia [1,2]. In Ireland, maternity care accounts for 17 % of total inpatient discharges each year, and annual healthcare expenditures of over D 200 million [3,4]. This care is provided through a mixture of public and private services, with public care being available free at the point of use, and private care being funded through health insurance cover and out of pocket payments. Approximately 17 %
∗ Corresponding author at: School of Nursing and Midwifery, Trinity College Dublin, No.2 Clare Street, Dublin 2, D02 CK80, Ireland. E-mail addresses: [email protected] (P.S. Moran), [email protected] (D. Daly), [email protected] (F. Wuytack), [email protected] (M. Carroll), [email protected] (M. Turner), [email protected] (C. Normand), [email protected] (C. Begley). https://doi.org/10.1016/j.healthpol.2020.02.008 0168-8510/© 2020 Published by Elsevier B.V.
of maternity-related discharges are of women opting for private maternity care [5]. Knowing why women choose public or private care and how this decision influences the type of treatment they receive can help us understand healthcare utilisation patterns within maternity care, and identify opportunities to improve how services are delivered. The hypothesis under investigation in this study is that the existence of markets for private maternity care introduces a price mechanism that improves resource allocation, since those most in need have the greatest willingness to sacrifice other goods and services to access consultant delivered care, all other things being equal [6]. This is known as the rationing function of the price mechanism. An expectation that perceived level of clinical need influences choice of care pathway is consistent with the findings of previous studies examining women’s stated preferences for maternity care in Ireland, which have reported that safety is one of the most important factors for women when choosing the type of care they want, with availability of pain relief, continuity of carer, and access to specialist care also strongly influencing this decision [7–10]. Our
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study examines these issues in an Irish context, to provide insights into how the current organisation of maternity care influences the allocation of maternity care resources at a societal level. The aim of this study is, therefore, to examine the factors associated with choice of maternity care pathway among nulliparous women in Ireland, and estimate the impact, if any, this has on the type of care women receive during labour and birth, or their experience of childbirth. 2. Methods 2.1. Study setting The study was set in Ireland, a country with a population of 4.7 million people, and approximately 65,000 births annually, 25,000 of which are to first-time mothers [11]. Women in Ireland give birth almost exclusively in one of 19 maternity hospitals nationwide, with home births accounting for less than 1% of total births [12]. Antenatal care is primarily provided through a combination of general practitioner (GP) and hospital clinic appointments, with women in some areas having the option of receiving midwife-led care in hospital-linked clinics in community primary care settings. Pregnant women in Ireland can choose to receive public or private maternity care, with a third option of semi-private care available in some hospitals. These options differ primarily in terms of the level of consultant obstetrician involvement, type of hospital accommodation, and costs. In the public system women generally attend hospital-based antenatal clinics where they are seen by the midwife or nonconsultant doctor on duty at the time, and women may see a different midwife or doctor at every appointment. There is also an option of attending community midwifery clinics in some areas. Labour and birth are attended by midwives, and doctors are not called unless complications arise. Postnatal care is provided in a public ward with typically 4–12 beds. Ireland has universal access to public maternity care, free at the point of use. Semi-private care is provided in three of the 19 maternity hospitals in Ireland, and there are minor differences in the type of care provided between hospitals. Two of the three maternity hospitals offering semi-private care are included in this study. In both of these, women opting to receive semi-private care attend antenatal clinics run separately from public clinics, which are conducted by a consultant obstetrician or senior members of their team. Labour and birth are attended by midwives, and the obstetric registrar on duty will be called to attend if complications arise. Postnatal care is provided in semi-private wards which typically contain 3–4 beds. Women opting to receive semi-private care are liable for the cost of accommodation, antenatal care, ultrasound scans, birth procedures and anaesthesia, some of which may be covered by private health insurance. The average out-of-pocket cost to women and families with private health insurance who choose semi-private care is approximately D 1200 [13]. Women attending privately have an individual consultant obstetrician who they see at all antenatal care visits. This consultant also attends the birth, which is conducted by midwives unless an instrumental birth or caesarean section is required. Postnatal care is provided in private single occupancy rooms, subject to availability. The benefit of private care, therefore, is that women have continuous care from a consultant obstetrician who will also be present at the birth, as well as improved postnatal hospital accommodation. Women choosing private care are liable for the same costs of inpatient care as those choosing semi-private care, some of which may also be covered by private health insurance, as well as individual consultant fees, which are not fully covered by private health insurance. The total costs associated with private care depend on the treatment received, the fees charged by individual consultants,
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and the level of coverage provided by private health insurance. The average out-of-pocket costs to women and families with private health insurance who choose private care is between D 2500 and D 4500 [13]. Aside from these differences, there is considerable overlap in the intrapartum care received across all three pathways, as all are provided in shared facilities (there are no standalone private maternity hospitals in Ireland at present), and all units are required to adhere to common national clinical guidelines [14]. Labour ward midwives provide care to women in all three care pathways, often on a oneto-one basis. Also, while non-consultant medical staff (registrars or senior house officers) attend for any operative interventions in public and semi-private care, and consultants attend for any operative interventions in private care, in the event of an obstetric emergency, the consultant is called in all three models. 2.2. Study data Data for the study were gathered as part of the Maternal health And Maternal Morbidity in Ireland MAMMI study. The MAMMI study is a prospective cohort study exploring the health and health problems experienced by nulliparous women recruited from three maternity hospitals in Ireland. All three are public hospitals with colocated private facilities, with over 8000 babies being born annually in two sites, and about 3000 births annually in the third site. Data on maternity care and clinical outcomes were collected during pregnancy and at 3, 6, 9 and 12 months postpartum. Hospital record information was also obtained for consenting participants from two hospitals. Staggered recruitment from each hospital was carried out between 2012 and 2017. No sampling strategy was used, all eligible first-time mothers who attended for a booking-in appointment during active recruitment were offered the chance to participate. Of the 3053 women recruited to the study, a total of 3041 completed the first survey, which they received following their booking-in appointment, and 2123 mothers completed the second survey, which was posted to their home at 3 months postpartum. Ethical approval for the study was granted by the Faculty of Health Sciences, Trinity College Dublin, and by each of the three participating hospitals. Socioeconomic status was estimated based on geographical area of residence using the Pobal HP Deprivation Index constructed using data on demographic profile, social class composition, and labour market participation [15]. An average of the deprivation index score in 2011 and 2016 was used in this analysis, to reflect the period over which women were recruited to the MAMMI study. An indicator of the level of clinical risk was estimated based on self-reported data of women’s medical history and their health in the first trimester, which was collected through the survey distributed to women at their first antenatal appointment at 12 weeks gestation. The following known risk factors were included in the analysis; obesity (Body Mass Index (BMI) ≥30 kg/m2 ), use of assisted reproduction technology (ART), history of hypertension, diabetes mellitus, kidney disease, thyroid disease, epilepsy, depression, and anxiety [16–20]. The relationship between clinical risk and choice of maternity care pathway was examined for each risk factor individually, and for the total number of risk factors that each women had. The cumulative risk score ranged from zero, if the women had none of the risk factors before giving birth, to nine, if all were present. Risk score and deprivation index score were treated as continuous independent variables in the primary analysis, to improve the statistical power to detect relationships [21]. Maternal age was not included in the risk score but was controlled for separately as an independent continuous variable. Smoking and alcohol intake status (1 if any smoking/alcohol consumption, 0 otherwise) during pregnancy were not included in the risk score either but were controlled for separately in all analyses.
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Country of birth was coded as a binary variable indicating whether or not the woman was born in Ireland. Women-reported outcomes included autonomy, satisfaction with pain relief methods used, confidence in caring for their baby after discharge from hospital, intention to have another baby, and breastfeeding status at three months postpartum. Autonomy was defined as the extent to which women felt they had an active say in making decisions about their care during labour and birth (1 if ‘Yes in all cases’ or ‘Yes in most cases’; 0 if ‘Sometimes but not others’, ‘Rarely’ or ‘Not at all’). Satisfaction with pain relief was coded 1 if a woman reported that she was satisfied with the methods of pain relief during her labour and birth, or 0 if she reported that she was not satisfied. Maternal confidence is a measure of how confident mothers reported feeling about looking after their baby in the first week at home (1 if very or fairly confident; 0 if not confident, fairly anxious, or mixed), and was included based on data showing a positive correlation between positive birth experience and parenting self-efficacy immediately after the birth [22]. Intention to have another baby was included based on previously reported associations between negative childbirth experiences and a decision not to have another child [23]. This was defined as whether the woman reported that she was hoping to have another baby in the future (1 if Yes, 0 if No or Not Sure). Breastfeeding status at 3 months postpartum was coded 1 for exclusive or continued (in conjunction with formula) breastfeeding at 3 months, or 0 if not breastfeeding. The inclusion of breastfeeding among the birth experience outcomes was based on previous research showing that lactation and breastfeeding are influenced by a range of factors that are relevant to a comparision of different care pathways, such as stress during labour and mode of birth [24,25]. Each of the birth experience outcomes was assessed individually, and as a composite birth satisfaction score ranging from 0 (negative experience in all five indicators) to 5 (positive experience in all five indicators). While some outcomes included in the combined score are directly relevant to any assessment of birth experience (e.g. autonomy, satisfaction with pain relief) there are others that are more complex endpoints that may also be influenced by factors we do not control for, such as prior intent to breastfeed (for breastfeeding) and partner relationships (for maternal confidence). Therefore we conducted sensitivity analysis on the results of the composite birth satisfaction score by running the analysis with breastfeeding omitted, with maternal confidence omitted, and with both breastfeeding and maternal confidence omitted, to identify whether these were a significant driver of the overall result. Mode of birth was classified as either spontaneous vaginal birth, instrumental birth involving the use of forceps or vacuum, or caesarean section, either planned or emergency. For the analysis of mode of birth we controlled for differences in the incidence of fetal macrosomia between groups coded 1 if birth weight ≥4000 g, 0 otherwise. Other pregnancy and birth outcomes included use of epidural anaesthesia, pethidine injection, length of hospital stay in days, and any hospital readmission (emergency room attendance or unscheduled readmission for maternal health reasons only) within 3 months. Perineal outcomes were categorised into intact perineum (intact perineum, labial or first-degree tear not requiring sutures), episiotomy, or clinically significant perineal tears (first-degree tear requiring sutures or 2nd , 3rd or 4th -degree perineal tear). Where detailed information on the degree of tear was missing, women were categorised using self-reported data on whether they experienced a tear or had an episiotomy.
determine the statistical significance of associations for continuous and categorical variables, respectively. The standard multinomial logit and probit models assume that all women are offered a complete set of choices (in this case public, semi-private and private maternity care). As semi-private care was not offered in one of the three maternity hospitals included in our study, the alternative-specific multinomial probit model was used, specifying independent and homoskedastic errors, with results presented as marginal effects [26,27]. The alternativespecific model allows for situations where some cases had the ability to choose between all possible alternatives while others were only able to choose from a subset of these alternatives [28]. Sensitivity analysis was carried out to assess the potential for biased or inconsistent coefficient estimation due to choice of model specification, by restricting the analysis to the two hospitals that offered all three care pathways, and by developing binary logit and probit models where semi-private care was grouped with either private care or public care. We also ran a subgroup analysis that was limited to full term (≥37 weeks gestation), singleton births only, to check for confounding due to differences between care pathways in the rate of multiple or preterm births. For the analysis of the impact of choice of care pathway on mode of birth, the Hausman test showed that the independence of irrelevant alternatives (IIA) assumption was met (see supplementary material Table S1), so a multinomial logistic regression model was used, with results presented as relative risk ratios (RRR) [29]. Logistic regression was used in the analysis of all binary outcomes, with results expressed as odds ratios (OR). Given the skewed nature of length of hospital stay, risk score, and birth experience score, differences in these outcomes were estimated using a generalised linear model (GLM) with a gamma distribution and log link function, with results expressed as the proportional change in mean length of stay, risk score or birth satisfaction score. P values of less than 0.05 were considered statistically significant and all statistical analysis was carried out in Stata 14 [30]. 3. Results 3.1. Descriptive statistics Complete data on choice of maternity care pathway and clinical outcomes were available for 1789 women 59 % of total recruited cohort, 84 % of those who completed the postpartum survey, and 1336 women reported complete data for all indicators of birth experience 44 % of total recruited cohort, 63 % of those who completed the postpartum survey). See Fig S1 in supplementary material for participant flowchart and Table S2 for comparison of study sample and those lost to follow up. Most women in the study chose public maternity care (61 %), with 24 % opting for semiprivate care, and 14 % choosing private care. Mode of birth within the overall study cohort was approximately equally distributed across vaginal, instrumental and caesarean births (34 %, 35 %, 31 %, respectively). While the proportion of all vaginal versus caesarean births is broadly consistent with mode of birth patterns within the overall population of first-time mothers between 2012 and 2016 in Ireland, the study cohort had a slightly higher rate of instrumental birth (39 % vaginal, 30 % instrumental, 31 % caesarean section) [31]. The average age of first-time mothers enrolled in the study was also higher than the overall population (32.3 years versus 30.4 years) [31]. Approximately half of women (52 %) had none of the nine risk factors assessed in this study. Descriptive statistics for the study sample are provided in Table 1.
2.3. Statistical analysis 3.2. Choice of maternity care Descriptive statistics are used to describe the study population, broken down by choice of care pathway (public, semi-private and private). Analysis of variance and Chi-squared tests were used to
Results of the multinomial probit regression analysis showed that older age, higher socioeconomic status, and being born in
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Table 1 Descriptive statistics for study population and comparison of treatment and birth outcomes by model of care. Demographic data (n = 1789)
Public n = 1,097
Semi-Private n = 437
Private n = 255
pa
Maternal age [years, mean (SD)] Born in Ireland [n (%)] Deprivation index score [mean (SD)] Number of risk factors [mean (SD)]
31 (4.6) 686 (63 %) 4.15 (9.42) 0.72 (0.92)
34 (3.5) 359 (82 %) 6.05 (8.46) 0.69 (0.93)
35 (3.5) 218 (85 %) 8.44 (8.89) 0.76 (0.94)
<0.01 <0.01 0.03 0.90
Clinical outcomes (n = 1789) All modes of birth
Public n = 1,097
Semi-Private n = 437
Private n = 255
pa
Caesarean section [n (%)] Instrumental birth [n (%)] Spontaneous vaginal births [n (%)] Epidural anaesthesia [n (%)] Pethidine injection [n (%)] Length of postpartum hospital stay [days, mean (SD)] ED attendance or hospital readmission within 3 months postpartumb [n (%)]
302 (28 %) 388 (35 %) 407 (37 %) 835 (76 %) 232 (21 %) 2.94 (1.49) 148 (13 %)
152 (35 %) 147 (34 %) 138 (32 %) 335 (77 %) 87 (20 %) 3.75 (1.39) 48 (11 %)
98 (38 %) 91 (36 %) 66 (26 %) 212 (83 %) 34 (13 %) 4.02 (1.43) 29 (11 %)
<0.01 0.79 <0.01 0.05 0.02 0.20 0.34
Clinical outcomes (n = 1237)Vaginal or instrumental births only
Public n = 795
Semi-Private n = 285
Private n = 157
pa
Perineal tear [n (%)] Episiotomy [n (%)]
309 (39 %) 436 (55 %)
97 (34 %) 174 (61 %)
62 (39 %) 91 (58 %)
0.32 0.18
Birth experience outcomes (n = 1336)
All modes of birth
High degree of autonomy during labour and birth [n (%)] Satisfied with pain relief during labour and birth [n (%)] Confidence in caring for baby after hospital discharge [n (%)] Breastfeeding at 3 months [n (%)] Intention to have another baby [n (%)] Birth satisfaction score [mean (SD)]
Public n = 808
Semi-private n = 323
Private n = 205
pa
612 (76 %) 696 (86 %) 439 (54 %) 487 (60 %) 639 (79 %) 3.56 (1.13)
258 (80 %) 275 (85 %) 162 (50 %) 198 (61 %) 256 (79 %) 3.56 (1.09)
167 (81 %) 180 (88 %) 103 (50 %) 124 (60 %) 168 (82 %) 3.62 (0.99)
0.12 0.69 0.33 0.95 0.65 0.06
N number of observations; SD standard deviation; ED Emergency Department; a p values using chi2 test for categorical outcomes and ANOVA for continuous outcomes b for maternal health reasons only.
Table 2 Factors associated with choosing semi-private or private versus public maternity care and comparison of maternity care and birth experience outcomes relative to public care1 . Individual factors
Semi-private versus public care (ME, 95 %CI)
Private versus public care (ME, 95 %CI)
Maternal age Born in Ireland Deprivation index score Number of risk factors
2.2ppts (1.7–2.8) ** 18.6ppts (13.2–24.1) ** 0.3ppts (0.0 to 0.5) NS −2.2ppts (-4.7 to 0.4) NS
1.6ppts (1.3–2.0) ** 10.3ppts (6.8–13.8) ** 0.5ppts (0.4 to 0.7) ** 0.0ppts (-1.5 to 1.5) NS
Clinical outcomes
Semi-private versus public care(Mean estimate, 95 %CI)
Private versus public care (Mean estimate, 95 %CI)
Caesarean section vs spontaneous vaginal birthi, ii Instrumental birth vs spontaneous vaginal birthi, ii Epidural anaesthesiai Pethidine injectioni Difference in postpartum length of stayi, iii Hospital readmissioni, iiI Episiotomy OR perineal tear vs intact perineumi, iv
RRR 1.28 (0.92–1.78) NS RRR 1.00 (0.73–1.36) NS OR 1.09 (0.83–1.44) NS OR 1.01 (0.76–1.36) NS 23 % longer (18–29) ** OR 0.83 (0.57–1.19) NS OR 1.00 (0.58–1.75) NS
RRR 1.98 (1.27–3.07) ** RRR 1.17 (0.74–1.83) NS OR 1.65 (1.13–2.41) ** OR 0.65 (0.43 to 0.97) * 28 % longer (21–36) ** OR 0.88 (0.56–1.38) NS OR 1.29 (0.58–2.87) NS
Birth experience outcome
Semi-private versus public care (Mean estimate, 95 %CI)
Private versus public care (Mean estimate, 95 %CI)
Feeling of autonomy during labour and birthi Satisfied with pain relief during labour and birthi Confidence in caring for baby after hospital dischargei Breastfeeding at 3 monthsi Intention to have another babyi Difference in cumulative satisfaction scorei
OR 1.26 (0.90–1.75) NS OR 0.98 (0.67–1.44) NS OR 0.77 (0.59–1.01) NS OR 1.06 (0.80–1.40) NS OR 1.03 (0.74–1.46) NS 0% (-4 to 4) NS
OR 1.36 (0.90–2.06) NS OR 1.24 (0.76–2.03) NS OR 0.76 (0.54–1.06) NS OR 0.99 (0.70–1.39) NS OR 1.27 (0.83–1.95) NS 2% (-3 to 7) NS
1 Controlling for differences in alcohol intake and smoking status during pregnancy; ME Marginal Effect, the percentage point change in the probability of choosing semiprivate or private care given a one unit increase in each of the specified parameters; CI confidence interval; ppts – percentage points; p = p value; ** p < 0.01, * p < 0.05, NS p ≥ 0.05; RRR relative risk ratio; OR Odds ratio; i - controlling for risk score, age, deprivation index, and country of birth; ii - controlling for macrosomia (birthweight ≥4,000 g); iii - controlling for mode of birth; iv - spontaneous or instrumental vaginal births only.
Ireland were strongly associated with choosing private maternity care (Table 2). However, there was no correlation between level of risk in early pregnancy and choice of semi-private or private maternity care, controlling for differences in socioeconomic status (Table 2). Results of sensitivity and subgroup analyses using alter-
native model specifications and inclusion criteria were consistent with those of the primary analysis, with all of these robustness checks showing that level of risk was not associated with choice of care pathway (see supplementary material Tables S3–S5).
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We also examined the relationship between choice of maternity care pathway and each risk factor individually. This found that apart from a relatively small increase in the probability of choosing private care among women who received fertility treatment (ME 5.4ppts, 95 % CI 1.2–9.5, p < 0.05), having any of the other included risk factors was not associated with a higher probability of choosing private care. The full set of results for each risk factor is provided in Table S6 in the supplementary material. Public care was the most popular choice across all socioeconomic groups. The probability of choosing private care increased with age, and women who were having their first baby in their late thirties were more likely to choose semi-private or private in preference to public care. In contrast, the number of risk factors women had in early pregnancy did not influence choice of maternity care pathway. The relationship between choice of care pathway and socioeconomic status, risk score and maternal age is illustrated in Fig S2 in the supplementary material. 3.3. Choice of care pathway and maternity care outcomes and birth experience Results of logistic regression revealed significant differences between public and private care pathways in pain management during labour, mode of birth and length of hospital stay (Table 2). Women receiving private care were twice as likely to have a caesarean birth compared with those attending public services (RRR 1.98, 95 % CI 1.27–3.07). Private care was also associated with an increased likelihood of using epidural anaesthesia (OR 1.65, 95 % CI 1.13–2.41), and longer postpartum hospital stays (28 % longer, 95 % CI 21–36). Semi-private care was found to be similar to public care, with the only significant difference being observed for length of hospital stay, which was nearly one quarter longer than women in public maternity wards (23 % longer, 95 % CI 17–28). 3.4. Risk status by deprivation level, maternity care outcomes and birth experience Average risk scores were found to be inversely related to deprivation index score, with those in lower socioeconomic groups tending to have a greater number of risk factors in early pregnancy compared with more affluent groups (see supplementary material Fig S3). Examination of the effect of risk score on intervention rates showed that higher risk women (>1 risk factor) were more likely to have an epidural, caesarean section, and longer hospital stay compared to those with no risk factors (Table 3). Risk status was strongly correlated with birth experience, with those at higher risk experiencing poorer outcomes across all five indicators (autonomy, pain relief, maternal confidence, second baby intention, and breastfeeding, Table 3). Although average birth satisfaction scores did not differ between care pathways (Table 2), an analysis of the marginal effect of risk score on satisfaction levels within each care pathway showed that while increasing risk score was negatively correlated with birth experience in public and semi-private care (marginal effect [ME] −0.24, 95 % CI −0.33 to −0.16, p < 0.01; and ME −0.22, 95 % CI −0.35 to −0.09, p < 0.01, respectively, Fig. 1) having more risk factors was not associated with a lower birth experience score within private care (ME 0.00, 95 % CI −0.17 to 0.18, p = 0.97, Fig. 1). Results of a subgroup analysis limited to singleton full-term (≥37 weeks gestation) were consistent with this (see supplementary material Fig S4). Sensitivity analysis carried out to examine the effect of including breastfeeding and maternal confidence in the composite score found that these correlations remained when one or both of these outcomes were omitted (Table S7 in supplementary material).
Table 3 Comparison of maternity care and birth experience outcomes in low (0 risk factors) and high (>1 risk factor) risk groups. Birth outcomes (n = 1243)
Mean estimate (95 % CI)
Caesarean section vs spontaneous vaginal birthi, ii Instrumental birth vs spontaneous vaginal birthi, ii Epidural anaesthesiai Pethidine injectioni Difference in postpartum length of stay (days) i, iii Hospital readmissioni, iii Episiotomy OR perineal tear versus intact perineum (for spontaneous or instrumental vaginal births only) i, iv
RRR 2.03 (1.04–2.95) **
Birth experience (n = 946)
Mean estimate (95 % CI)
Feeling of autonomy during labour and birthi Satisfied with pain relief during labour and birthi Confidence in caring for baby after hospital dischargei Breastfeeding at 3 monthsi Intention to have another babyi Difference in cumulative satisfaction scorei
OR 0.62 (0.44 to 0.87) **
RRR 1.17 (0.81–1.70) NS OR 1.68 (1.20–2.35) ** OR 0.87 (0.62–1.23) NS 10 % (4–16) ** OR 1.10 (0.75–1.61) NS OR 1.40 (0.70–2.79) NS
OR 0.51 (0.34 to 0.76) ** OR 0.68 (0.50 to 0.91) ** OR 0.64 (0.47 to 0.87) ** OR 0.64 (0.45 to 0.92) * −12% (-16 to -8) **
RRR = relative risk ratio; CI = confidence interval; ** p < 0.01; * p < 0.05; NS p ≥ 0.05; i - controlling for choice of maternity care pathway, age, deprivation index, country of birth and smoking/drinking status; ii - controlling for macrosomia (birthweight ≥4,000 g); iii - controlling for mode of birth; iv - spontaneous or instrumental vaginal births only.
While the availability of data for the analysis of birth experience were comparable across all three sites (range 58%–64% of those who completed the postpartum survey), less usable data on treatment rates and clinical outcomes was available from one site (site 2, 64 % of those who completed the postpartum survey) than the other two (site 1, 89 %; site 3, 87 %,). Sensitivity analysis was carried out to assess the potential for this missing data to affect the overall findings by running the analysis with and without site #2 included. This had no impact of the results (Table S8 in supplementary material), indicating that the relatively higher proportion of missing data in site 2 is unlikely to introduce significant selection effects. 4. Discussion We show that choice of public or private maternity care among first time mothers in Ireland was not influenced by level of risk in early pregnancy, though older women were more likely to opt for private care. Choice of care pathway was, however, associated with significant differences in pain management during labour, mode of birth and length of hospital stay, after controlling for difference in age. Nulliparous women in private care were more than one and a half times as likely to have an epidural, and twice as likely to have a caesarean section as those choosing public maternity care. After adjusting for these differences in mode of birth, length of hospital stay in private wards was over a quarter longer than in public wards. No significant difference in mode of birth or pain management were observed in semi-private care compared with public care, but semiprivate care was also associated with longer hospital stays. 4.1. Efficiency of maternity services These results indicate that the operation of a private maternity care market alongside the universally accessible public system in Ireland may be associated with suboptimal allocation of maternity care resources, since decisions about whether to opt for consultant delivered private care are not influenced by the clinical risk profiles
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Fig. 1. Relationship between satisfaction score and number of risk factors, by care pathway.
of pregnant women. In addition to these demand side issues, private care may also be associated with supply side inefficiencies resulting from the overprovision of labour and birth interventions, controlling for any differences in clinical risk factors between groups. However, more work is needed to examine the reasons behind these differences in intervention rates, and the extent to which they may be explainable by differences in organisational, clinician and maternal characteristics between care pathways. 4.2. Birth experience As far as we are aware, our study is the first to examine the impact of choice of care pathway on self-reported outcomes related to women’s experience of labour and birth, which are not routinely gathered but are highly relevant to comparisons of different maternity care models. These include the extent to which women felt they had control over decisions about their care during labour and birth, satisfaction with pain relief provided, and level of confidence caring for their baby in the first week after discharge from hospital. It also included breastfeeding outcomes, and intentions towards having another child, both of which have previously been shown to be impacted by negative birth experiences [23,32]. Our analysis found no difference between care pathways in average outcomes for these indicators. Interpretation of these results is challenging. If maternal choice was the driving factor behind higher epidural and caesarean rates one might expect women in private care to report relatively higher levels of autonomy, and greater satisfaction with pain relief. However, previous analysis has found that both elective and emergency caesarean sections were generally associated with poorer birth experience outcomes, which would suggest that higher intervention rates observed in private care should negatively affect this outcome [33,34]. Perhaps more revealing than comparing group averages is the analysis of the marginal effect of changes in risk score within each care pathway. This shows that while higher risk scores are inversely correlated with birth experience in public and semi-private care, increased risk does not adversely affect birth experiences of women in private care. This implies that choosing private care confers a benefit on women at higher risk, and the magnitude of this benefit increases as the level of risk increases. 4.3. Policy implications Our findings highlight the potential to improve the allocation of maternity care resources based on clinical need, standardise intervention rates across care pathways, and improve birth experience outcomes for women at greater risk of complications. It is noteworthy that the Irish maternity strategy currently being implemented includes the creation of risk-based care pathways within the public system and the targeting of consultant-delivered care according to level of risk [35]. This analysis provides empirical support for this approach, with the caveat that accompanying measures to manage intervention rates may also be necessary. Evidence-based measures that could be pursued to standardise care across different pathways include the introduction of
evidence-based clinical guidelines and mandatory second opinion, combined with regular audit and clinician feedback [36–39]. Unbundling of private maternity services may also present opportunities to target resources more effectively, by allowing women to combine desired aspects of different care pathways. 4.4. Strengths, limitations and future research There is a substantial body of literature examining differences in obstetric intervention rates between public and private care pathways in Ireland and internationally [38–45]. We sought to extend this by carrying out a broader analysis that links differences in resource utilisation in public and private care with the factors that influence women’s choice of care pathway in early pregnancy, and combine this with differences in birth experience outcomes. However, we did not carry out an examination of the underlying reasons for the market failures observed in the provision of private maternity care, and we were unable to distinguish between planned and emergency caesarean sections. More research is needed to understanding the reasons behind the increased use of medical interventions in private practice, and whether this is driven by supplier induced demand on the part of health professionals, or so-called demand-induced supply as a result of maternal request for planned CS, or both [46]. Similarly, additional research is needed to provide insight into why women’s clinical risk status, and by extension their propensity to benefit from greater continuity of consultant-delivered maternity care, does not affect choice of care pathway. A further limitation of our study is that while we control for differences in the risk profile of women when they are choosing which care pathway to take, we do not adjust for differences between groups in the emergence of all complications in later-pregnancy and during the birth that may affect treatment decisions. While we show that the results are not confounded by differences in preterm delivery, multiple births or macrosomia, there are others, such as shoulder dystocia and prolonged labour which were not included. Several previous studies that have adjusted for differences in a range of peripartum and intrapartum complications between public and private care, including four separate retrospective analyses of Irish hospital discharge records. These found that private care was associated with increases in the rate of caesarean section that were not fully explainable by differences in clinical characteristics and intrapartum complications [38–45]. Two of these Irish studies classified semi-private patients as private patients [38,43], one classified semi-private patients as public patients [44], and one did not explicitly report how they classified them, but based on the data sources they used, semi-private care was likely grouped with private care [39]. Our study extends current knowledge by showing that there are significant differences between private and semi-private care, with intervention rates for women attending semi-privately being comparable to those in the public care system. We used simple measures of risk and birth experience scores that were based on the total number of risk factors or positive birth experience indicators that women reported. These were not
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exhaustive lists of all relevant variables that could potentially be included, and no weighting was applied. More research is needed to examine the construct validity of these measures, particularly for birth experience, given the inherent difficulties in assessing this outcome. To mitigate this, we examined the relationship between level of risk and each birth experience indicator individually, as well as collectively. The consistent finding that being at higher risk was associated with poorer outcomes in all five indicators makes it less likely that the observed association between level of risk and overall birth experience score is a spurious result. Finally, in the absence of alternative-specific variables, the generalised multinomial probit model is susceptible to violations of the independence of irrelevant alternatives (IIA) assumption, since we specified independent, homoscedastic errors in the model. Although previous research has shown that in many instances the IIA property is not particularly restrictive, we carried out sensitivity analysis to assess the potential for this to influence our results by collapsing the data into a binary decision problem, with the middle option (semi-private care) grouped with either public care or private care (Table S3 in supplementary material) [47]. The results of the multinomial probit model were consistent with those of the binary model specifications, indicating robust findings that are insensitive to choice of regression model. 5. Conclusions The operation of a private maternity care market alongside the universally accessible public system in Ireland is associated with demand and supply-side inefficiencies in the provision of maternity care. Stratification measures that target the allocation of resources according to level of risk in early pregnancy, combined with the introduction of standardised criteria for the use of epidural anaesthesia and caesarean section have the potential to reduce rates of obstetric intervention, and address risk-based disparities in birth experience outcomes. Acknowledgment This research was funded by the Health Research Board in Ireland (grant ref: HRB ICE-2015-1019). Declaration of Competing Interest Professor Turner is a consultant obstetrician working in public and private practice in Ireland. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.healthpol.2020. 02.008. References [1] Miller S, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016;388(10056):2176–92. [2] Christiaens W, Nieuwenhuijze MJ, de Vries R. Trends in the medicalisation of childbirth in Flanders and the Netherlands. Midwifery 2013;29(1):e1–8. [3] Healthcare Pricing Office (HPO). Activity in acute public hospitals in Ireland annual report, 2017; 2018. Dublin, Ireland. [4] Healthcare Pricing Office (HPO). Hospital in-patient enquiry (HIPE). Dublin, Ireland: Health Service Executive; 2018. [5] Statistics and Analytics Unit. Trends in public / private patient activity in public acute hospitals. Ireland: Department of Health Dublin; 2017. [6] Weitzman ML. Is the price system or rationing more effective in getting a commodity to those who need it most? Bell J Econ 1977;8(2):517–24. [7] Byrne C, et al. What models of maternity care do pregnant women in Ireland want? Ir Med J 2011;104(6):180–2. [8] Fawsitt CG, et al. What women want: exploring pregnant women’s preferences for alternative models of maternity care. Health Policy 2017;121(1):66–74.
[9] Fawsitt CG, et al. What do women want? Valuing women’s preferences and estimating demand for alternative models of maternity care using a discrete choice experiment. Health Policy 2017;121(11):1154–60. [10] Larkin P, Begley CM, Devane D. Women’s preferences for childbirth experiences in the Republic of Ireland; a mixed methods study. BMC Pregnancy Childbirth 2017;17(1):19. [11] Central Statistics Office. Vital statistics. Dublin, Ireland: CSO; 2018. [12] Healthcare Pricing Office (HPO). Perinatal statistics report 2015. Dublin, Ireland: Health Service Executive (HSE); 2017. [13] Moran P. Personal communication with maternity hospital accounts departments; 2018. [14] Royal College of Physicians in Ireland (RCPI) Institute of Obstetricians and Gynaecologists, Available from: National clinical guidelines in obstetrics and gynaecology; 2018 www.rcpi.ie/faculties/obstetricians-andgynaecologists/national-clinical-guidelines-in-obstetrics-and-gynaecology/. [15] Haase T, Pratschke J. The pobal HP deprivation index for small areas in the Republic of Ireland. Dublin, Ireland: Pobal; 2018. [16] Marchi J, et al. Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews. Obes Rev 2015;16(8):621–38. [17] Committee Opinion No 671. Perinatal risks associated with assisted reproductive technology. Obstet Gynecol 2016;128(3):e61–8. [18] National Institute of Child Health and Human Development [cited 2018; Available from: What are the factors that put a pregnancy at risk?; 2017 https:// www.nichd.nih.gov/health/topics/high-risk/conditioninfo/factors. [19] Viale L, et al. Epilepsy in pregnancy and reproductive outcomes: a systematic review and meta-analysis. Lancet 2015;386(10006):1845–52. [20] Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Curr Opin Psychiatry 2012;25(2):141–8. [21] Altman DG, Royston P. The cost of dichotomising continuous variables. BMJ 2006;332(7549):1080. [22] Bryanton J, et al. Predictors of early parenting self-efficacy: results of a prospective cohort study. Nurs Res 2008;57(4):252–9. [23] Shorey S, Yang YY, Ang E. The impact of negative childbirth experience on future reproductive decisions: a quantitative systematic review. J Adv Nurs 2018. [24] Dewey KG. Maternal and fetal stress are associated with impaired lactogenesis in humans. J Nutr 2001;131(11):3012s–5s. [25] Hurst NM. Recognizing and treating delayed or failed lactogenesis II. J Midwifery Womens Health 2007;52(6):588–94. [26] StataCorp. Base reference manual - mprobit. College Station, TX: US: Stata Press; 2017. [27] StataCorp. Base reference manual - asmprobit postestimation. College Station, TX: US: Stata Press; 2017. [28] StataCorp. Base reference manual - asmprobit. College Station, TX: US: Stata Press; 2017. [29] Hausman J, McFadden D. Specification tests for the multinomial logit model. Econometrica 1984;52(5):1219–40. [30] StataCorp. Stata statistical software: release 14. College Station, TX: StataCorp LP; 2015. [31] Healthcare Pricing Office (HPO). Perinatal statistics reports 2011-2016; 2018. Dublin, Ireland. [32] Cook N, Ayers S, Horsch A. Maternal posttraumatic stress disorder during the perinatal period and child outcomes: a systematic review. J Affect Disord 2018;225:18–31. [33] Guittier M-J, et al. Impact of mode of delivery on the birth experience in firsttime mothers: a qualitative study. BMC Pregnancy Childbirth 2014;14:254. [34] Nystedt A, Hildingsson I. Women’s and men’s negative experience of child birth—a cross-sectional survey. Women Birth 2018;31(2):103–9. [35] Creating a better future together – National Maternity Strategy 2016–2026. Dublin, Ireland: Department of Health; 2016. [36] Chen I, et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 2018;9:Cd005528. [37] Chaillet N, Dumont A. Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth 2007;34(1):53–64. [38] Sinnott SJ, et al. National variation in caesarean section rates: a cross sectional study in Ireland. PLoS One 2016;11(6):e0156172. [39] Lutomski JE, et al. Private health care coverage and increased risk of obstetric intervention. BMC Pregnancy Childbirth 2014;14:13. [40] Hoxha I, et al. Caesarean sections and private insurance: systematic review and meta-analysis. BMJ Open 2017;7(8):e016600. [41] Soltani H, Sandall J. Organisation of maternity care and choices of mode of birth: a worldwide view. Midwifery 2012;28(2):146–9. [42] Boerma T, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018;392(10155):1341–8. [43] Brick A, et al. Differences in nulliparous caesarean section rates across models of care: a decomposition analysis. BMC Health Serv Res 2016;16:239. [44] Murphy DJ, Fahey T. A retrospective cohort study of mode of delivery among public and private patients in an integrated maternity hospital setting. BMJ Open 2013;3(11):e003865. [45] Alonso BD, et al. Caesarean birth rates in public and privately funded hospitals: a cross-sectional study. Rev Saude Publica 2017;51:101. [46] Shih Y-CT, Tai-Seale M. Physicians’ perception of demand-induced supply in the information age: a latent class model analysis. Health Econ 2012;21(3):252–69. [47] Dow JK, Endersby JW. Multinomial probit and multinomial logit: a comparison of choice models for voting research. Elect Stud 2004;23(1):107–22.
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Health Policy journal homepage: www.elsevier.com/locate/healthpol
Predictors of choice of public and private maternity care among nulliparous women in Ireland, and implications for maternity care and birth experience Patrick S. Moran a,∗ , Deirdre Daly a , Francesca Wuytack a , Margaret Carroll a , Michael Turner b , Charles Normand c,d , Cecily Begley a a
School of Nursing and Midwifery, Trinity College Dublin, Ireland School of Medicine, University College Dublin, Ireland c Centre for Health Policy and Management, Trinity College Dublin, Ireland d Economics of Palliative Care and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom b
a r t i c l e
i n f o
Article history: Received 26 June 2019 Received in revised form 13 February 2020 Accepted 17 February 2020 Keywords: Maternity care Choice Birth experience Obstetric intervention Risk stratification
a b s t r a c t Maternity care in Ireland is provided through a mixture of free public and fee-based private or semiprivate services. We examined factors associated with choice of care pathway among nulliparous women and how this influences the care they receive and their experience of childbirth using data from a prospective cohort study. Complete data were available for 1,789 women on choice of care pathway and birth outcomes, and for 1,336 women on birth experience. Maternal age (marginal effect [ME] 1.6 percentage points [ppts], p < 0.01), socioeconomic status (ME 0.5ppts, p < 0.01) and being born in Ireland (ME 10.3ppts, p < 0.01) were all positively associated with choosing private care, but level of risk in early pregnancy did not influence this decision. Intervention rates in public and semi-private care were comparable, but women in private care were more likely to receive epidural anaesthesia (odds ratio [OR] 1.65, p < 0.01) and give birth by caesarean section (ratio of relative risks [RRR] 1.98, p < 0.01). Private care was also associated with longer hospital stays (28 % longer, p < 0.01). Increased risk was negatively correlated with birth experience in public and semi-private care, but not in private care. Policies promoting the allocation of maternity care resources by level of risk, along with the standardisation of clinical practice across care pathways, could reduce rates of obstetric intervention and address risk-based disparities in birth experience outcomes. © 2020 Published by Elsevier B.V.
1. Background The costs of providing modern maternity services are substantial, and are rising in line with increasing rates of childbirth interventions such as caesarean section and epidural anaesthesia [1,2]. In Ireland, maternity care accounts for 17 % of total inpatient discharges each year, and annual healthcare expenditures of over D 200 million [3,4]. This care is provided through a mixture of public and private services, with public care being available free at the point of use, and private care being funded through health insurance cover and out of pocket payments. Approximately 17 %
∗ Corresponding author at: School of Nursing and Midwifery, Trinity College Dublin, No.2 Clare Street, Dublin 2, D02 CK80, Ireland. E-mail addresses: [email protected] (P.S. Moran), [email protected] (D. Daly), [email protected] (F. Wuytack), [email protected] (M. Carroll), [email protected] (M. Turner), [email protected] (C. Normand), [email protected] (C. Begley). https://doi.org/10.1016/j.healthpol.2020.02.008 0168-8510/© 2020 Published by Elsevier B.V.
of maternity-related discharges are of women opting for private maternity care [5]. Knowing why women choose public or private care and how this decision influences the type of treatment they receive can help us understand healthcare utilisation patterns within maternity care, and identify opportunities to improve how services are delivered. The hypothesis under investigation in this study is that the existence of markets for private maternity care introduces a price mechanism that improves resource allocation, since those most in need have the greatest willingness to sacrifice other goods and services to access consultant delivered care, all other things being equal [6]. This is known as the rationing function of the price mechanism. An expectation that perceived level of clinical need influences choice of care pathway is consistent with the findings of previous studies examining women’s stated preferences for maternity care in Ireland, which have reported that safety is one of the most important factors for women when choosing the type of care they want, with availability of pain relief, continuity of carer, and access to specialist care also strongly influencing this decision [7–10]. Our
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study examines these issues in an Irish context, to provide insights into how the current organisation of maternity care influences the allocation of maternity care resources at a societal level. The aim of this study is, therefore, to examine the factors associated with choice of maternity care pathway among nulliparous women in Ireland, and estimate the impact, if any, this has on the type of care women receive during labour and birth, or their experience of childbirth. 2. Methods 2.1. Study setting The study was set in Ireland, a country with a population of 4.7 million people, and approximately 65,000 births annually, 25,000 of which are to first-time mothers [11]. Women in Ireland give birth almost exclusively in one of 19 maternity hospitals nationwide, with home births accounting for less than 1% of total births [12]. Antenatal care is primarily provided through a combination of general practitioner (GP) and hospital clinic appointments, with women in some areas having the option of receiving midwife-led care in hospital-linked clinics in community primary care settings. Pregnant women in Ireland can choose to receive public or private maternity care, with a third option of semi-private care available in some hospitals. These options differ primarily in terms of the level of consultant obstetrician involvement, type of hospital accommodation, and costs. In the public system women generally attend hospital-based antenatal clinics where they are seen by the midwife or nonconsultant doctor on duty at the time, and women may see a different midwife or doctor at every appointment. There is also an option of attending community midwifery clinics in some areas. Labour and birth are attended by midwives, and doctors are not called unless complications arise. Postnatal care is provided in a public ward with typically 4–12 beds. Ireland has universal access to public maternity care, free at the point of use. Semi-private care is provided in three of the 19 maternity hospitals in Ireland, and there are minor differences in the type of care provided between hospitals. Two of the three maternity hospitals offering semi-private care are included in this study. In both of these, women opting to receive semi-private care attend antenatal clinics run separately from public clinics, which are conducted by a consultant obstetrician or senior members of their team. Labour and birth are attended by midwives, and the obstetric registrar on duty will be called to attend if complications arise. Postnatal care is provided in semi-private wards which typically contain 3–4 beds. Women opting to receive semi-private care are liable for the cost of accommodation, antenatal care, ultrasound scans, birth procedures and anaesthesia, some of which may be covered by private health insurance. The average out-of-pocket cost to women and families with private health insurance who choose semi-private care is approximately D 1200 [13]. Women attending privately have an individual consultant obstetrician who they see at all antenatal care visits. This consultant also attends the birth, which is conducted by midwives unless an instrumental birth or caesarean section is required. Postnatal care is provided in private single occupancy rooms, subject to availability. The benefit of private care, therefore, is that women have continuous care from a consultant obstetrician who will also be present at the birth, as well as improved postnatal hospital accommodation. Women choosing private care are liable for the same costs of inpatient care as those choosing semi-private care, some of which may also be covered by private health insurance, as well as individual consultant fees, which are not fully covered by private health insurance. The total costs associated with private care depend on the treatment received, the fees charged by individual consultants,
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and the level of coverage provided by private health insurance. The average out-of-pocket costs to women and families with private health insurance who choose private care is between D 2500 and D 4500 [13]. Aside from these differences, there is considerable overlap in the intrapartum care received across all three pathways, as all are provided in shared facilities (there are no standalone private maternity hospitals in Ireland at present), and all units are required to adhere to common national clinical guidelines [14]. Labour ward midwives provide care to women in all three care pathways, often on a oneto-one basis. Also, while non-consultant medical staff (registrars or senior house officers) attend for any operative interventions in public and semi-private care, and consultants attend for any operative interventions in private care, in the event of an obstetric emergency, the consultant is called in all three models. 2.2. Study data Data for the study were gathered as part of the Maternal health And Maternal Morbidity in Ireland MAMMI study. The MAMMI study is a prospective cohort study exploring the health and health problems experienced by nulliparous women recruited from three maternity hospitals in Ireland. All three are public hospitals with colocated private facilities, with over 8000 babies being born annually in two sites, and about 3000 births annually in the third site. Data on maternity care and clinical outcomes were collected during pregnancy and at 3, 6, 9 and 12 months postpartum. Hospital record information was also obtained for consenting participants from two hospitals. Staggered recruitment from each hospital was carried out between 2012 and 2017. No sampling strategy was used, all eligible first-time mothers who attended for a booking-in appointment during active recruitment were offered the chance to participate. Of the 3053 women recruited to the study, a total of 3041 completed the first survey, which they received following their booking-in appointment, and 2123 mothers completed the second survey, which was posted to their home at 3 months postpartum. Ethical approval for the study was granted by the Faculty of Health Sciences, Trinity College Dublin, and by each of the three participating hospitals. Socioeconomic status was estimated based on geographical area of residence using the Pobal HP Deprivation Index constructed using data on demographic profile, social class composition, and labour market participation [15]. An average of the deprivation index score in 2011 and 2016 was used in this analysis, to reflect the period over which women were recruited to the MAMMI study. An indicator of the level of clinical risk was estimated based on self-reported data of women’s medical history and their health in the first trimester, which was collected through the survey distributed to women at their first antenatal appointment at 12 weeks gestation. The following known risk factors were included in the analysis; obesity (Body Mass Index (BMI) ≥30 kg/m2 ), use of assisted reproduction technology (ART), history of hypertension, diabetes mellitus, kidney disease, thyroid disease, epilepsy, depression, and anxiety [16–20]. The relationship between clinical risk and choice of maternity care pathway was examined for each risk factor individually, and for the total number of risk factors that each women had. The cumulative risk score ranged from zero, if the women had none of the risk factors before giving birth, to nine, if all were present. Risk score and deprivation index score were treated as continuous independent variables in the primary analysis, to improve the statistical power to detect relationships [21]. Maternal age was not included in the risk score but was controlled for separately as an independent continuous variable. Smoking and alcohol intake status (1 if any smoking/alcohol consumption, 0 otherwise) during pregnancy were not included in the risk score either but were controlled for separately in all analyses.
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Country of birth was coded as a binary variable indicating whether or not the woman was born in Ireland. Women-reported outcomes included autonomy, satisfaction with pain relief methods used, confidence in caring for their baby after discharge from hospital, intention to have another baby, and breastfeeding status at three months postpartum. Autonomy was defined as the extent to which women felt they had an active say in making decisions about their care during labour and birth (1 if ‘Yes in all cases’ or ‘Yes in most cases’; 0 if ‘Sometimes but not others’, ‘Rarely’ or ‘Not at all’). Satisfaction with pain relief was coded 1 if a woman reported that she was satisfied with the methods of pain relief during her labour and birth, or 0 if she reported that she was not satisfied. Maternal confidence is a measure of how confident mothers reported feeling about looking after their baby in the first week at home (1 if very or fairly confident; 0 if not confident, fairly anxious, or mixed), and was included based on data showing a positive correlation between positive birth experience and parenting self-efficacy immediately after the birth [22]. Intention to have another baby was included based on previously reported associations between negative childbirth experiences and a decision not to have another child [23]. This was defined as whether the woman reported that she was hoping to have another baby in the future (1 if Yes, 0 if No or Not Sure). Breastfeeding status at 3 months postpartum was coded 1 for exclusive or continued (in conjunction with formula) breastfeeding at 3 months, or 0 if not breastfeeding. The inclusion of breastfeeding among the birth experience outcomes was based on previous research showing that lactation and breastfeeding are influenced by a range of factors that are relevant to a comparision of different care pathways, such as stress during labour and mode of birth [24,25]. Each of the birth experience outcomes was assessed individually, and as a composite birth satisfaction score ranging from 0 (negative experience in all five indicators) to 5 (positive experience in all five indicators). While some outcomes included in the combined score are directly relevant to any assessment of birth experience (e.g. autonomy, satisfaction with pain relief) there are others that are more complex endpoints that may also be influenced by factors we do not control for, such as prior intent to breastfeed (for breastfeeding) and partner relationships (for maternal confidence). Therefore we conducted sensitivity analysis on the results of the composite birth satisfaction score by running the analysis with breastfeeding omitted, with maternal confidence omitted, and with both breastfeeding and maternal confidence omitted, to identify whether these were a significant driver of the overall result. Mode of birth was classified as either spontaneous vaginal birth, instrumental birth involving the use of forceps or vacuum, or caesarean section, either planned or emergency. For the analysis of mode of birth we controlled for differences in the incidence of fetal macrosomia between groups coded 1 if birth weight ≥4000 g, 0 otherwise. Other pregnancy and birth outcomes included use of epidural anaesthesia, pethidine injection, length of hospital stay in days, and any hospital readmission (emergency room attendance or unscheduled readmission for maternal health reasons only) within 3 months. Perineal outcomes were categorised into intact perineum (intact perineum, labial or first-degree tear not requiring sutures), episiotomy, or clinically significant perineal tears (first-degree tear requiring sutures or 2nd , 3rd or 4th -degree perineal tear). Where detailed information on the degree of tear was missing, women were categorised using self-reported data on whether they experienced a tear or had an episiotomy.
determine the statistical significance of associations for continuous and categorical variables, respectively. The standard multinomial logit and probit models assume that all women are offered a complete set of choices (in this case public, semi-private and private maternity care). As semi-private care was not offered in one of the three maternity hospitals included in our study, the alternative-specific multinomial probit model was used, specifying independent and homoskedastic errors, with results presented as marginal effects [26,27]. The alternativespecific model allows for situations where some cases had the ability to choose between all possible alternatives while others were only able to choose from a subset of these alternatives [28]. Sensitivity analysis was carried out to assess the potential for biased or inconsistent coefficient estimation due to choice of model specification, by restricting the analysis to the two hospitals that offered all three care pathways, and by developing binary logit and probit models where semi-private care was grouped with either private care or public care. We also ran a subgroup analysis that was limited to full term (≥37 weeks gestation), singleton births only, to check for confounding due to differences between care pathways in the rate of multiple or preterm births. For the analysis of the impact of choice of care pathway on mode of birth, the Hausman test showed that the independence of irrelevant alternatives (IIA) assumption was met (see supplementary material Table S1), so a multinomial logistic regression model was used, with results presented as relative risk ratios (RRR) [29]. Logistic regression was used in the analysis of all binary outcomes, with results expressed as odds ratios (OR). Given the skewed nature of length of hospital stay, risk score, and birth experience score, differences in these outcomes were estimated using a generalised linear model (GLM) with a gamma distribution and log link function, with results expressed as the proportional change in mean length of stay, risk score or birth satisfaction score. P values of less than 0.05 were considered statistically significant and all statistical analysis was carried out in Stata 14 [30]. 3. Results 3.1. Descriptive statistics Complete data on choice of maternity care pathway and clinical outcomes were available for 1789 women 59 % of total recruited cohort, 84 % of those who completed the postpartum survey, and 1336 women reported complete data for all indicators of birth experience 44 % of total recruited cohort, 63 % of those who completed the postpartum survey). See Fig S1 in supplementary material for participant flowchart and Table S2 for comparison of study sample and those lost to follow up. Most women in the study chose public maternity care (61 %), with 24 % opting for semiprivate care, and 14 % choosing private care. Mode of birth within the overall study cohort was approximately equally distributed across vaginal, instrumental and caesarean births (34 %, 35 %, 31 %, respectively). While the proportion of all vaginal versus caesarean births is broadly consistent with mode of birth patterns within the overall population of first-time mothers between 2012 and 2016 in Ireland, the study cohort had a slightly higher rate of instrumental birth (39 % vaginal, 30 % instrumental, 31 % caesarean section) [31]. The average age of first-time mothers enrolled in the study was also higher than the overall population (32.3 years versus 30.4 years) [31]. Approximately half of women (52 %) had none of the nine risk factors assessed in this study. Descriptive statistics for the study sample are provided in Table 1.
2.3. Statistical analysis 3.2. Choice of maternity care Descriptive statistics are used to describe the study population, broken down by choice of care pathway (public, semi-private and private). Analysis of variance and Chi-squared tests were used to
Results of the multinomial probit regression analysis showed that older age, higher socioeconomic status, and being born in
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Table 1 Descriptive statistics for study population and comparison of treatment and birth outcomes by model of care. Demographic data (n = 1789)
Public n = 1,097
Semi-Private n = 437
Private n = 255
pa
Maternal age [years, mean (SD)] Born in Ireland [n (%)] Deprivation index score [mean (SD)] Number of risk factors [mean (SD)]
31 (4.6) 686 (63 %) 4.15 (9.42) 0.72 (0.92)
34 (3.5) 359 (82 %) 6.05 (8.46) 0.69 (0.93)
35 (3.5) 218 (85 %) 8.44 (8.89) 0.76 (0.94)
<0.01 <0.01 0.03 0.90
Clinical outcomes (n = 1789) All modes of birth
Public n = 1,097
Semi-Private n = 437
Private n = 255
pa
Caesarean section [n (%)] Instrumental birth [n (%)] Spontaneous vaginal births [n (%)] Epidural anaesthesia [n (%)] Pethidine injection [n (%)] Length of postpartum hospital stay [days, mean (SD)] ED attendance or hospital readmission within 3 months postpartumb [n (%)]
302 (28 %) 388 (35 %) 407 (37 %) 835 (76 %) 232 (21 %) 2.94 (1.49) 148 (13 %)
152 (35 %) 147 (34 %) 138 (32 %) 335 (77 %) 87 (20 %) 3.75 (1.39) 48 (11 %)
98 (38 %) 91 (36 %) 66 (26 %) 212 (83 %) 34 (13 %) 4.02 (1.43) 29 (11 %)
<0.01 0.79 <0.01 0.05 0.02 0.20 0.34
Clinical outcomes (n = 1237)Vaginal or instrumental births only
Public n = 795
Semi-Private n = 285
Private n = 157
pa
Perineal tear [n (%)] Episiotomy [n (%)]
309 (39 %) 436 (55 %)
97 (34 %) 174 (61 %)
62 (39 %) 91 (58 %)
0.32 0.18
Birth experience outcomes (n = 1336)
All modes of birth
High degree of autonomy during labour and birth [n (%)] Satisfied with pain relief during labour and birth [n (%)] Confidence in caring for baby after hospital discharge [n (%)] Breastfeeding at 3 months [n (%)] Intention to have another baby [n (%)] Birth satisfaction score [mean (SD)]
Public n = 808
Semi-private n = 323
Private n = 205
pa
612 (76 %) 696 (86 %) 439 (54 %) 487 (60 %) 639 (79 %) 3.56 (1.13)
258 (80 %) 275 (85 %) 162 (50 %) 198 (61 %) 256 (79 %) 3.56 (1.09)
167 (81 %) 180 (88 %) 103 (50 %) 124 (60 %) 168 (82 %) 3.62 (0.99)
0.12 0.69 0.33 0.95 0.65 0.06
N number of observations; SD standard deviation; ED Emergency Department; a p values using chi2 test for categorical outcomes and ANOVA for continuous outcomes b for maternal health reasons only.
Table 2 Factors associated with choosing semi-private or private versus public maternity care and comparison of maternity care and birth experience outcomes relative to public care1 . Individual factors
Semi-private versus public care (ME, 95 %CI)
Private versus public care (ME, 95 %CI)
Maternal age Born in Ireland Deprivation index score Number of risk factors
2.2ppts (1.7–2.8) ** 18.6ppts (13.2–24.1) ** 0.3ppts (0.0 to 0.5) NS −2.2ppts (-4.7 to 0.4) NS
1.6ppts (1.3–2.0) ** 10.3ppts (6.8–13.8) ** 0.5ppts (0.4 to 0.7) ** 0.0ppts (-1.5 to 1.5) NS
Clinical outcomes
Semi-private versus public care(Mean estimate, 95 %CI)
Private versus public care (Mean estimate, 95 %CI)
Caesarean section vs spontaneous vaginal birthi, ii Instrumental birth vs spontaneous vaginal birthi, ii Epidural anaesthesiai Pethidine injectioni Difference in postpartum length of stayi, iii Hospital readmissioni, iiI Episiotomy OR perineal tear vs intact perineumi, iv
RRR 1.28 (0.92–1.78) NS RRR 1.00 (0.73–1.36) NS OR 1.09 (0.83–1.44) NS OR 1.01 (0.76–1.36) NS 23 % longer (18–29) ** OR 0.83 (0.57–1.19) NS OR 1.00 (0.58–1.75) NS
RRR 1.98 (1.27–3.07) ** RRR 1.17 (0.74–1.83) NS OR 1.65 (1.13–2.41) ** OR 0.65 (0.43 to 0.97) * 28 % longer (21–36) ** OR 0.88 (0.56–1.38) NS OR 1.29 (0.58–2.87) NS
Birth experience outcome
Semi-private versus public care (Mean estimate, 95 %CI)
Private versus public care (Mean estimate, 95 %CI)
Feeling of autonomy during labour and birthi Satisfied with pain relief during labour and birthi Confidence in caring for baby after hospital dischargei Breastfeeding at 3 monthsi Intention to have another babyi Difference in cumulative satisfaction scorei
OR 1.26 (0.90–1.75) NS OR 0.98 (0.67–1.44) NS OR 0.77 (0.59–1.01) NS OR 1.06 (0.80–1.40) NS OR 1.03 (0.74–1.46) NS 0% (-4 to 4) NS
OR 1.36 (0.90–2.06) NS OR 1.24 (0.76–2.03) NS OR 0.76 (0.54–1.06) NS OR 0.99 (0.70–1.39) NS OR 1.27 (0.83–1.95) NS 2% (-3 to 7) NS
1 Controlling for differences in alcohol intake and smoking status during pregnancy; ME Marginal Effect, the percentage point change in the probability of choosing semiprivate or private care given a one unit increase in each of the specified parameters; CI confidence interval; ppts – percentage points; p = p value; ** p < 0.01, * p < 0.05, NS p ≥ 0.05; RRR relative risk ratio; OR Odds ratio; i - controlling for risk score, age, deprivation index, and country of birth; ii - controlling for macrosomia (birthweight ≥4,000 g); iii - controlling for mode of birth; iv - spontaneous or instrumental vaginal births only.
Ireland were strongly associated with choosing private maternity care (Table 2). However, there was no correlation between level of risk in early pregnancy and choice of semi-private or private maternity care, controlling for differences in socioeconomic status (Table 2). Results of sensitivity and subgroup analyses using alter-
native model specifications and inclusion criteria were consistent with those of the primary analysis, with all of these robustness checks showing that level of risk was not associated with choice of care pathway (see supplementary material Tables S3–S5).
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We also examined the relationship between choice of maternity care pathway and each risk factor individually. This found that apart from a relatively small increase in the probability of choosing private care among women who received fertility treatment (ME 5.4ppts, 95 % CI 1.2–9.5, p < 0.05), having any of the other included risk factors was not associated with a higher probability of choosing private care. The full set of results for each risk factor is provided in Table S6 in the supplementary material. Public care was the most popular choice across all socioeconomic groups. The probability of choosing private care increased with age, and women who were having their first baby in their late thirties were more likely to choose semi-private or private in preference to public care. In contrast, the number of risk factors women had in early pregnancy did not influence choice of maternity care pathway. The relationship between choice of care pathway and socioeconomic status, risk score and maternal age is illustrated in Fig S2 in the supplementary material. 3.3. Choice of care pathway and maternity care outcomes and birth experience Results of logistic regression revealed significant differences between public and private care pathways in pain management during labour, mode of birth and length of hospital stay (Table 2). Women receiving private care were twice as likely to have a caesarean birth compared with those attending public services (RRR 1.98, 95 % CI 1.27–3.07). Private care was also associated with an increased likelihood of using epidural anaesthesia (OR 1.65, 95 % CI 1.13–2.41), and longer postpartum hospital stays (28 % longer, 95 % CI 21–36). Semi-private care was found to be similar to public care, with the only significant difference being observed for length of hospital stay, which was nearly one quarter longer than women in public maternity wards (23 % longer, 95 % CI 17–28). 3.4. Risk status by deprivation level, maternity care outcomes and birth experience Average risk scores were found to be inversely related to deprivation index score, with those in lower socioeconomic groups tending to have a greater number of risk factors in early pregnancy compared with more affluent groups (see supplementary material Fig S3). Examination of the effect of risk score on intervention rates showed that higher risk women (>1 risk factor) were more likely to have an epidural, caesarean section, and longer hospital stay compared to those with no risk factors (Table 3). Risk status was strongly correlated with birth experience, with those at higher risk experiencing poorer outcomes across all five indicators (autonomy, pain relief, maternal confidence, second baby intention, and breastfeeding, Table 3). Although average birth satisfaction scores did not differ between care pathways (Table 2), an analysis of the marginal effect of risk score on satisfaction levels within each care pathway showed that while increasing risk score was negatively correlated with birth experience in public and semi-private care (marginal effect [ME] −0.24, 95 % CI −0.33 to −0.16, p < 0.01; and ME −0.22, 95 % CI −0.35 to −0.09, p < 0.01, respectively, Fig. 1) having more risk factors was not associated with a lower birth experience score within private care (ME 0.00, 95 % CI −0.17 to 0.18, p = 0.97, Fig. 1). Results of a subgroup analysis limited to singleton full-term (≥37 weeks gestation) were consistent with this (see supplementary material Fig S4). Sensitivity analysis carried out to examine the effect of including breastfeeding and maternal confidence in the composite score found that these correlations remained when one or both of these outcomes were omitted (Table S7 in supplementary material).
Table 3 Comparison of maternity care and birth experience outcomes in low (0 risk factors) and high (>1 risk factor) risk groups. Birth outcomes (n = 1243)
Mean estimate (95 % CI)
Caesarean section vs spontaneous vaginal birthi, ii Instrumental birth vs spontaneous vaginal birthi, ii Epidural anaesthesiai Pethidine injectioni Difference in postpartum length of stay (days) i, iii Hospital readmissioni, iii Episiotomy OR perineal tear versus intact perineum (for spontaneous or instrumental vaginal births only) i, iv
RRR 2.03 (1.04–2.95) **
Birth experience (n = 946)
Mean estimate (95 % CI)
Feeling of autonomy during labour and birthi Satisfied with pain relief during labour and birthi Confidence in caring for baby after hospital dischargei Breastfeeding at 3 monthsi Intention to have another babyi Difference in cumulative satisfaction scorei
OR 0.62 (0.44 to 0.87) **
RRR 1.17 (0.81–1.70) NS OR 1.68 (1.20–2.35) ** OR 0.87 (0.62–1.23) NS 10 % (4–16) ** OR 1.10 (0.75–1.61) NS OR 1.40 (0.70–2.79) NS
OR 0.51 (0.34 to 0.76) ** OR 0.68 (0.50 to 0.91) ** OR 0.64 (0.47 to 0.87) ** OR 0.64 (0.45 to 0.92) * −12% (-16 to -8) **
RRR = relative risk ratio; CI = confidence interval; ** p < 0.01; * p < 0.05; NS p ≥ 0.05; i - controlling for choice of maternity care pathway, age, deprivation index, country of birth and smoking/drinking status; ii - controlling for macrosomia (birthweight ≥4,000 g); iii - controlling for mode of birth; iv - spontaneous or instrumental vaginal births only.
While the availability of data for the analysis of birth experience were comparable across all three sites (range 58%–64% of those who completed the postpartum survey), less usable data on treatment rates and clinical outcomes was available from one site (site 2, 64 % of those who completed the postpartum survey) than the other two (site 1, 89 %; site 3, 87 %,). Sensitivity analysis was carried out to assess the potential for this missing data to affect the overall findings by running the analysis with and without site #2 included. This had no impact of the results (Table S8 in supplementary material), indicating that the relatively higher proportion of missing data in site 2 is unlikely to introduce significant selection effects. 4. Discussion We show that choice of public or private maternity care among first time mothers in Ireland was not influenced by level of risk in early pregnancy, though older women were more likely to opt for private care. Choice of care pathway was, however, associated with significant differences in pain management during labour, mode of birth and length of hospital stay, after controlling for difference in age. Nulliparous women in private care were more than one and a half times as likely to have an epidural, and twice as likely to have a caesarean section as those choosing public maternity care. After adjusting for these differences in mode of birth, length of hospital stay in private wards was over a quarter longer than in public wards. No significant difference in mode of birth or pain management were observed in semi-private care compared with public care, but semiprivate care was also associated with longer hospital stays. 4.1. Efficiency of maternity services These results indicate that the operation of a private maternity care market alongside the universally accessible public system in Ireland may be associated with suboptimal allocation of maternity care resources, since decisions about whether to opt for consultant delivered private care are not influenced by the clinical risk profiles
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Fig. 1. Relationship between satisfaction score and number of risk factors, by care pathway.
of pregnant women. In addition to these demand side issues, private care may also be associated with supply side inefficiencies resulting from the overprovision of labour and birth interventions, controlling for any differences in clinical risk factors between groups. However, more work is needed to examine the reasons behind these differences in intervention rates, and the extent to which they may be explainable by differences in organisational, clinician and maternal characteristics between care pathways. 4.2. Birth experience As far as we are aware, our study is the first to examine the impact of choice of care pathway on self-reported outcomes related to women’s experience of labour and birth, which are not routinely gathered but are highly relevant to comparisons of different maternity care models. These include the extent to which women felt they had control over decisions about their care during labour and birth, satisfaction with pain relief provided, and level of confidence caring for their baby in the first week after discharge from hospital. It also included breastfeeding outcomes, and intentions towards having another child, both of which have previously been shown to be impacted by negative birth experiences [23,32]. Our analysis found no difference between care pathways in average outcomes for these indicators. Interpretation of these results is challenging. If maternal choice was the driving factor behind higher epidural and caesarean rates one might expect women in private care to report relatively higher levels of autonomy, and greater satisfaction with pain relief. However, previous analysis has found that both elective and emergency caesarean sections were generally associated with poorer birth experience outcomes, which would suggest that higher intervention rates observed in private care should negatively affect this outcome [33,34]. Perhaps more revealing than comparing group averages is the analysis of the marginal effect of changes in risk score within each care pathway. This shows that while higher risk scores are inversely correlated with birth experience in public and semi-private care, increased risk does not adversely affect birth experiences of women in private care. This implies that choosing private care confers a benefit on women at higher risk, and the magnitude of this benefit increases as the level of risk increases. 4.3. Policy implications Our findings highlight the potential to improve the allocation of maternity care resources based on clinical need, standardise intervention rates across care pathways, and improve birth experience outcomes for women at greater risk of complications. It is noteworthy that the Irish maternity strategy currently being implemented includes the creation of risk-based care pathways within the public system and the targeting of consultant-delivered care according to level of risk [35]. This analysis provides empirical support for this approach, with the caveat that accompanying measures to manage intervention rates may also be necessary. Evidence-based measures that could be pursued to standardise care across different pathways include the introduction of
evidence-based clinical guidelines and mandatory second opinion, combined with regular audit and clinician feedback [36–39]. Unbundling of private maternity services may also present opportunities to target resources more effectively, by allowing women to combine desired aspects of different care pathways. 4.4. Strengths, limitations and future research There is a substantial body of literature examining differences in obstetric intervention rates between public and private care pathways in Ireland and internationally [38–45]. We sought to extend this by carrying out a broader analysis that links differences in resource utilisation in public and private care with the factors that influence women’s choice of care pathway in early pregnancy, and combine this with differences in birth experience outcomes. However, we did not carry out an examination of the underlying reasons for the market failures observed in the provision of private maternity care, and we were unable to distinguish between planned and emergency caesarean sections. More research is needed to understanding the reasons behind the increased use of medical interventions in private practice, and whether this is driven by supplier induced demand on the part of health professionals, or so-called demand-induced supply as a result of maternal request for planned CS, or both [46]. Similarly, additional research is needed to provide insight into why women’s clinical risk status, and by extension their propensity to benefit from greater continuity of consultant-delivered maternity care, does not affect choice of care pathway. A further limitation of our study is that while we control for differences in the risk profile of women when they are choosing which care pathway to take, we do not adjust for differences between groups in the emergence of all complications in later-pregnancy and during the birth that may affect treatment decisions. While we show that the results are not confounded by differences in preterm delivery, multiple births or macrosomia, there are others, such as shoulder dystocia and prolonged labour which were not included. Several previous studies that have adjusted for differences in a range of peripartum and intrapartum complications between public and private care, including four separate retrospective analyses of Irish hospital discharge records. These found that private care was associated with increases in the rate of caesarean section that were not fully explainable by differences in clinical characteristics and intrapartum complications [38–45]. Two of these Irish studies classified semi-private patients as private patients [38,43], one classified semi-private patients as public patients [44], and one did not explicitly report how they classified them, but based on the data sources they used, semi-private care was likely grouped with private care [39]. Our study extends current knowledge by showing that there are significant differences between private and semi-private care, with intervention rates for women attending semi-privately being comparable to those in the public care system. We used simple measures of risk and birth experience scores that were based on the total number of risk factors or positive birth experience indicators that women reported. These were not
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exhaustive lists of all relevant variables that could potentially be included, and no weighting was applied. More research is needed to examine the construct validity of these measures, particularly for birth experience, given the inherent difficulties in assessing this outcome. To mitigate this, we examined the relationship between level of risk and each birth experience indicator individually, as well as collectively. The consistent finding that being at higher risk was associated with poorer outcomes in all five indicators makes it less likely that the observed association between level of risk and overall birth experience score is a spurious result. Finally, in the absence of alternative-specific variables, the generalised multinomial probit model is susceptible to violations of the independence of irrelevant alternatives (IIA) assumption, since we specified independent, homoscedastic errors in the model. Although previous research has shown that in many instances the IIA property is not particularly restrictive, we carried out sensitivity analysis to assess the potential for this to influence our results by collapsing the data into a binary decision problem, with the middle option (semi-private care) grouped with either public care or private care (Table S3 in supplementary material) [47]. The results of the multinomial probit model were consistent with those of the binary model specifications, indicating robust findings that are insensitive to choice of regression model. 5. Conclusions The operation of a private maternity care market alongside the universally accessible public system in Ireland is associated with demand and supply-side inefficiencies in the provision of maternity care. Stratification measures that target the allocation of resources according to level of risk in early pregnancy, combined with the introduction of standardised criteria for the use of epidural anaesthesia and caesarean section have the potential to reduce rates of obstetric intervention, and address risk-based disparities in birth experience outcomes. Acknowledgment This research was funded by the Health Research Board in Ireland (grant ref: HRB ICE-2015-1019). Declaration of Competing Interest Professor Turner is a consultant obstetrician working in public and private practice in Ireland. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.healthpol.2020. 02.008. References [1] Miller S, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016;388(10056):2176–92. [2] Christiaens W, Nieuwenhuijze MJ, de Vries R. Trends in the medicalisation of childbirth in Flanders and the Netherlands. Midwifery 2013;29(1):e1–8. [3] Healthcare Pricing Office (HPO). Activity in acute public hospitals in Ireland annual report, 2017; 2018. Dublin, Ireland. [4] Healthcare Pricing Office (HPO). Hospital in-patient enquiry (HIPE). Dublin, Ireland: Health Service Executive; 2018. [5] Statistics and Analytics Unit. Trends in public / private patient activity in public acute hospitals. Ireland: Department of Health Dublin; 2017. [6] Weitzman ML. Is the price system or rationing more effective in getting a commodity to those who need it most? Bell J Econ 1977;8(2):517–24. [7] Byrne C, et al. What models of maternity care do pregnant women in Ireland want? Ir Med J 2011;104(6):180–2. [8] Fawsitt CG, et al. What women want: exploring pregnant women’s preferences for alternative models of maternity care. Health Policy 2017;121(1):66–74.
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