Social class and elective caesareans in the NHS
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《英国医生杂志》
EDITOR—We thank Macfarlane for pointing out that in our paper we do not describe an analysis by social class. The title was changed without our consent and is misleading. As explained in the text, we examine elective caesareans on the basis of electoral ward of residence. We agree that residents at ward level are not socially homogeneous and again acknowledge this in the text. However, we would argue that any heterogeneity would be likely to dilute an association with area deprivation and propose that our findings are still valid. We also clearly say that we are not able to adjust for provider factors such as teaching status and indicate this as being a possible confounder.
Grant says that we show our ignorance of obstetrics in implying that elective caesarean section means a caesarean section performed solely at the request of the pregnant woman. Nowhere in our paper do we imply this: we write that maternal request is reported to be only the fifth most common reason given for performing a caesarean section.1 We clearly say in the text that we were unable to adjust for key factors such as obstetric complications, antenatal care, and previous caesareans.
Grant also says that our findings are explained by maternal age, despite adjusting for maternal age (among other factors) in our analysis. Although we agree that there may be some residual confounding, it is unlikely that this would account for our findings. It is also at odds with the pattern we found for emergency caesareans, which does not seem to vary by socioeconomic deprivation once fully adjusted for the same factors (including age). The odds ratio for an emergency caesarean section in the most deprived quintile compared with the least deprived is 1.00 (95% confidence interval 0.97 to 1.04).
Paul Aylin
Dr Foster Unit at Imperial, Department of Epidemiology and Public Health, Imperial College, London W2 1PG p.aylin@imperial.ac.uk
Brian Jarman, Alex Bottle, Katherine Barley
Dr Foster Unit at Imperial, Department of Epidemiology and Public Health, Imperial College, London W2 1PG
Competing interests: AB and PA are funded by a grant from Dr Foster.
Dr Foster is an independent research and publishing organisation created to examine measures of clinical performance.
References
Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The national sentinel caesarean section audit report. London: RCOG Press, 2001. www.rcog.org.uk/resources/public/nscs_audit.pdf (accessed 4 Jun 2004).
Grant says that we show our ignorance of obstetrics in implying that elective caesarean section means a caesarean section performed solely at the request of the pregnant woman. Nowhere in our paper do we imply this: we write that maternal request is reported to be only the fifth most common reason given for performing a caesarean section.1 We clearly say in the text that we were unable to adjust for key factors such as obstetric complications, antenatal care, and previous caesareans.
Grant also says that our findings are explained by maternal age, despite adjusting for maternal age (among other factors) in our analysis. Although we agree that there may be some residual confounding, it is unlikely that this would account for our findings. It is also at odds with the pattern we found for emergency caesareans, which does not seem to vary by socioeconomic deprivation once fully adjusted for the same factors (including age). The odds ratio for an emergency caesarean section in the most deprived quintile compared with the least deprived is 1.00 (95% confidence interval 0.97 to 1.04).
Paul Aylin
Dr Foster Unit at Imperial, Department of Epidemiology and Public Health, Imperial College, London W2 1PG p.aylin@imperial.ac.uk
Brian Jarman, Alex Bottle, Katherine Barley
Dr Foster Unit at Imperial, Department of Epidemiology and Public Health, Imperial College, London W2 1PG
Competing interests: AB and PA are funded by a grant from Dr Foster.
Dr Foster is an independent research and publishing organisation created to examine measures of clinical performance.
References
Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The national sentinel caesarean section audit report. London: RCOG Press, 2001. www.rcog.org.uk/resources/public/nscs_audit.pdf (accessed 4 Jun 2004).