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

Objectives To explore the circumstances and factors that explain the associ ation between private health insurance cover and a high rate of caesarean s ections in Chile. Design Qualitative analysis of audiotaped in-depth interviews with obstetri cians and pregnant women; quantitative analysis of data from face to face s emistructured interview survey conducted postnatally (with women who had gi ven 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; quantita tive arm: 540 postnatal women. Main outcome measures Rates of caesarean section in different types of inst itutions; 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 u niversity hospitals (range 27-28%). Only a minority of women receiving priv ate care reported that they had wanted this method of delivery (range 6-32% ). With the diversification in the healthcare market, most obstetricians no w have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend thes e private births in person, and the "programming" (or scheduling) of births is a common time management strategy The rate of elective caesarean sectio ns was 30-68% in women with private obstetricians and 12-14% in women not a ttended by private obstetricians. Conclusions Policies on healthcare financing can influence maternity care m anagement 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.