Adhikari Kamala, McNeil Deborah A, McDonald Sheila, Patel Alka B, Metcalfe Amy
Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
Faculty of Nursing, University of Calgary, Calgary, AB, Canada.
Paediatr Perinat Epidemiol. 2018 Jul;32(4):309-317. doi: 10.1111/ppe.12484. Epub 2018 Jul 5.
The existing inconsistent association between the caesarean rate and maternal socio-economic status (SES) may be the result of a failure to examine the association across indications for caesarean. This study examined the variation in caesarean rates by maternal SES across diverse obstetric-indications.
Data on demographics, education, insurance status, medical-conditions, and obstetric characteristics needed to classify deliveries according to Robson's 10 obstetric-groups were extracted from the 2015 US birth certificate data (n = 3 988 733). Multivariable log-binomial regression was used to analyse the data adjusting for confounders.
The caesarean rate was 34.1% for women with high SES and 26.8% for those with low SES. After adjustment for confounders, the rate was similar between women with graduate degrees and those who did not complete high school (relative risk (RR) 1.0, 95% confidence interval (CI) 0.9, 1.1). However, different rates of caesareans across SES were observed for particular obstetric-indications. Notably, women with graduate education compared to those who did not complete high school were more likely to have a caesarean (RR 3.0, 95% CI 2.9, 3.1) for a low-risk condition (group 1: nulliparous women with single, cephalic, ≥37 gestational weeks, and spontaneous labour). Women with private insurance were more likely to have a caesarean in almost all obstetric groups, compared to those without private insurance or Medicaid.
Examining the overall caesarean rate obscures the relationship between SES and the use of caesarean for particular obstetric-indications. The unequal utilisation of caesareans across SES highlights overuse and potential underuse of the caesareans among American women.
剖宫产率与孕产妇社会经济地位（SES）之间现有的不一致关联可能是未能全面考察剖宫产不同指征与SES之间关联的结果。本研究调查了不同产科指征下，孕产妇SES与剖宫产率的差异。
从2015年美国出生证明数据（n = 3988733）中提取人口统计学、教育程度、保险状况、医疗条件以及根据罗布森10个产科组对分娩进行分类所需的产科特征数据。采用多变量对数二项回归分析数据，并对混杂因素进行校正。
高SES女性的剖宫产率为34.1%，低SES女性为26.8%。校正混杂因素后，研究生学历女性与未完成高中学业女性的剖宫产率相似（相对风险（RR）为1.0，95%置信区间（CI）为0.9至1.1）。然而，对于特定产科指征，不同SES水平的剖宫产率存在差异。值得注意的是，与未完成高中学业的女性相比，研究生学历女性在低风险情况（第1组：单胎、头位、≥37孕周且自然分娩的初产妇）下更有可能进行剖宫产（RR为3.0，95%CI为2.9至3.1）。与没有私人保险或医疗补助的女性相比，有私人保险的女性在几乎所有产科组中更有可能进行剖宫产。
仅考察总体剖宫产率会掩盖SES与特定产科指征下剖宫产使用之间的关系。SES不同水平间剖宫产使用的不平等突出了美国女性剖宫产存在过度使用和潜在使用不足的情况。
