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Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7275.1501 (Published 16 December 2000) Cite this as: BMJ 2000;321:1501
  1. Susan F Murray, lecturer (s.murray{at}ich.ucl.ac.uk)
  1. Centre for International Child Health, Institute of Child Health, University College London, London WC1N 1EH
  • Accepted 28 September 2000

Abstract

Objectives: To explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.

Design: Qualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.

Setting: Santiago, Chile.

Participants: Qualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.

Main outcome measures: Rates of caesarean section in different types of institutions; consultants' views on private practice; work patterns in private practice; women's reasons for choosing private care; women's preferences on method of delivery.

Results: Private health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.

Conclusions: Policies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.

Footnotes

  • Funding The study was supported by grant RD352 from the UK Department for International Development (DFID). The views expressed, however, are those of the author and do not represent the views of the DFID.

  • Competing interests None declared.

  • Embedded Image Two tables with data on the characteristics of participating obstetricians and pregnant women appear on the BMJ's website

  • Accepted 28 September 2000
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