Intended for healthcare professionals

Rapid response to:

Dr Foster's Case Notes

Social class and elective caesareans in the English NHS

BMJ 2004; 328 doi: (Published 10 June 2004) Cite this as: BMJ 2004;328:1399

Rapid Response:

Be more selective than ‘elective’!

The analysis of mode of delivery by social deprivation in Dr Foster’s
notes was both eye-catching and welcome since there has been little
analysis of socio-economic variation in childbirth in recent years.
However, any useful interpretation of the careful analysis reported is
limited by the use of the non-specific outcome measure ‘elective’
caesarean section.

Most women who deliver by elective caesarean section have a clinical
indication, such as previous Caesarean, breech presentation, or pregnancy
related complications such as pre-eclampsia. Few of these conditions are
related to socio-economic factors, and so the results of your analysis are
not suprising (especially since adjustment is made for birthweight, which
does have an association with socio-economic status). Women who have a
Caesarean section in the absence of any clinical indication are in a tiny

In the National Sentinel Audit of CS, obstetricians reported that 3%
of women requested elective caesarean section in the absence of any
medical indications.1 This agrees with the data from the survey of mothers
in the same Audit, where 3% of first-time mothers and 3% of women who had
experienced a previous spontaneous vaginal birth, expressed a preference
for Caesarean section. The obstetricians reported agreeing to these
requests in 50% of cases, and obstetricians were more likely to agree if
the woman was older and in her first pregnancy.

To seriously investigate the hypothesis of ‘too posh to push’, one
would need a more detailed clinical dataset which includes data on socio-
economic factors, and an analysis which takes account of clinical
confounders. Analytic strategies to take account of the many confounders
of obstetric outcomes have been used in previous studies.2,3

Of broader interest, perhaps, would be an investigation of the
association of socio-economic factors and the conditions and processes of
care in first-time mothers, which can initiate a pathway to operative
delivery. In the meantime your finding of no relation between emergency
Caesarean section and social deprivation is a reassuring start to that


1. Thomas J, Paranjothy. RCOG Clinical Effectiveness Support Unit.
National Sentinel Caesarean Section Audit Report. RCOG Press;2001.

2. Cleary R, Beard RW, Chapple J, Coles J, Griffin M, Joffe M et al. The
standard primipara as a basis for inter-unit comparisons of maternity
care. B J Obstet Gynaecol1996;103:223-29.

3. Ibison JM. Ethnicity and mode of delivery, in ‘low risk’ first-time
mothers. East London, 1988-1997. EJOG (In press)

Competing interests:
None declared

Competing interests: No competing interests

22 June 2004
Judith M Ibison
Lecturer in primary care
St George's Hospital Medical School, Cranmer Terrace, SW17 ORE