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:

Quackery at Dr Fosters? This analysis is not really about social class

Although purporting to investigate social class differences, this
article actually analysed differences according to area deprivation score.
It cannot be assumed that residents of all geographical areas are socially
homogeneous. As analyses of differences in low birthweight show
inequalities both within and between areas with similar deprivation
scores,1 it would not be surprising if the same applied to caesarean
section rates. Although there is nothing new in the observation that
caesarean section rates are higher among older mothers, the fact that
women in professional occupations are more likely than others to have
babies at older ages may or may not add to the differences which are
likely be related to maternal complications among older women.

In any case, the authors have not allowed for the possibility of
systematic differences between maternity units. An analysis of Maternity
HES data for earlier years, which adjusted for available data about
factors associated with caesarean section found that they accounted very
little of the differences between units' caesarean section rates.2 This
suggested strongly that differences between units' and consultants'
policies are likely to play an important role.

1. Macfarlane A, Stafford M, Moser K. Social inequalities. In: Office
for National Statistics. The health of children and young people. London :
Office for National Statistics, 2004.

2. Alves B. MSc dissertation. London School of Hygiene and Tropical

Competing interests:
None declared

Competing interests: No competing interests

11 June 2004
Alison J Macfarlane
Professor of Perinatal Health
Department of Midwifery, City University, 24 Chiswell Street, London EC1Y 4TY