We recruited 1612 women, 1093 public patients and 519 private patients. There were 1136 women in the final sample as 476 women were lost to follow up. Of these, 376 were public patients and 100 were private patients. All three interviews were completed by 717 (66%) women in the public sector and 419 (81%) women in the private sector. Most of the loss to follow up (405 women) occurred between the first and second interviews. Table shows details of the groups and differences between the final sample and those lost to follow up.
Baseline characteristics of respondents in final sample and of those lost to follow up, by sector
In the final sample, 90% (377) of private patients were attended at delivery by a private doctor and 9% (38) by a staff physician. The corresponding figures for the public patients were 12% (86) and 85% (609), with 5% (36) being attended by midwives or nurses. The rates of caesarean delivery were 31% (222/707) in the public sector and 72% (302/419) in the private sector. In both groups about 3% of deliveries were forceps deliveries, and 66% in the public sector and 25% in the private sector were spontaneous vaginal deliveries.
Among primiparous women in the final sample 90% (280) in the public sector and 84% (189) in the private sector declared a preference for a vaginal delivery in the first interview (fig ). Among multiparous women with no previous caesarean delivery, the preference for a vaginal delivery was over 80% in the first interview in both sectors. Finally, among women with a previous caesarean delivery, over 42% in both sectors stated a preference for vaginal delivery. There was no significant difference in preferences between the two sectors for any of the three categories.
Preference for type of delivery at first interview, according to parity and previous delivery, by sector
Table shows that most of the women preferred a vaginal delivery either because recovery is faster or because it is the natural way to deliver. The reasons the respondents who wanted a caesarean gave for their preferences, however, were more diverse. Avoidance of pain and concurrent tubal ligation were often mentioned, and women in the private sector often cited a positive experience with a previous caesarean section. Concern for preservation of coital function was hardly mentioned as a reason for preferring caesarean delivery.
Reasons given by women for preferring vaginal birth, by sector. Figures are number (percentage) of women
In both sectors stated preferences regarding type of delivery were mostly consistent between the first and the second interview (table ). A large proportion of women consistently declared preferences for a vaginal delivery. The next largest category comprised women who consistently expressed a preference for a caesarean. Only a small proportion of women changed their preference between the two interviews.
Women's preferences for method of delivery in first and second interview, by sector. Figures are number (percentage) of women
Figure shows how women who had twice declared their preference for a vaginal delivery actually delivered. Compared with women in the public sector, a much larger proportion of women in the private sector subsequently had a caesarean section. All differences between sectors according to parity and previous birth experience were significant (P<0.00).
Caesarean section rates for women who preferred vaginal delivery in first and second interviews, by sector, parity, and previous birth experience
Most of the women who consistently expressed a preference for vaginal delivery but actually had a caesarean delivery, over 83% in both sectors, agreed with the statement that they would have liked to have had a vaginal delivery, but many also agreed with the statement that they were happy to have had a caesarean (60% among public patients and 70% among private patients).
Among the private patients who eventually underwent an unwanted caesarean, 73% had talked to their doctor about type of delivery by the time of the second interview, but most frequently at their own rather than the doctor's initiative. Only 16% reported that the doctor had recommended a caesarean section in this conversation. Among the public patients with unwanted caesareans, only 37% reported a conversation with their doctor regarding type of delivery.
The timing of the decision to have a caesarean delivery differed between public and private patients. Table shows that a much higher proportion of caesarean deliveries were decided on in advance among private than among public patients, and among scheduled caesarean sections more were decided on more than one day in advance among private patients. Similarly, among caesareans that were decided on after admission, the proportion of decisions taken less than six hours after admission was much greater among private patients than it was among public patients.
Timing of decision to perform caesarean delivery, by sector. Figures are number (percentage) of women*