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Zbiri S, Rozenberg P, Milcent C. Staff Resources in Public and Private Hospitals and Their Implication for Medical Practice: A French Study of Caesareans. Healthcare (Basel) 2024; 12:1007. [PMID: 38786416 PMCID: PMC11120882 DOI: 10.3390/healthcare12101007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
This study aimed to investigate the effect of hospital staffing resources on medical practice in public versus private hospitals. We used exhaustive delivery data from a French district of 11 hospitals over an 11-year period, from 2008 to 2018, including 168,120 observations. We performed multilevel logistic regression models with hospital fixed or random effects, while controlling for factors known to influence obstetric practice. We found that hospital staff ratios of obstetricians and that of midwives affected caesarean rates, but with different effects depending on the hospital sector. In public hospitals, the higher the ratio of obstetricians and that of midwives, the lower the probability of planned caesareans. In private hospitals, the higher the ratio of obstetricians, the greater the probability of planned caesareans. Indeed, in public hospitals, obstetricians and midwives, both salaried employees, do not have financial or organizational incentives to perform more caesareans. In private hospitals, obstetricians, who are independent doctors, may have such incentives. Our results underline the importance of having an adequate supply of health professionals in healthcare facilities to ensure appropriate care, with specific regard to the different characteristics of the public and private sectors.
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Affiliation(s)
- Saad Zbiri
- Research Unit 7285 RISCQ, UVSQ, Paris-Saclay University, 78180 Montigny-le-Bretonneux, France
| | - Patrick Rozenberg
- Department of Obstetrics and Gynecology, American Hospital of Paris, 92200 Neuilly-sur-Seine, France
- UVSQ, Inserm, Team U1018, Clinical Epidemiology, CESP, Paris Saclay University, 78180 Montigny-le-Bretonneux, France
| | - Carine Milcent
- Paris-Jourdan Sciences Economiques, French National Centre for Scientific Research (CNRS), 75014 Paris, France
- Paris School of Economics (PSE), 75014 Paris, France
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Chou WH, Lee SO, Sun MH, Tseng YC, Chan KC, Chen YH, Wu CY. Validation of Chinese version of a global anesthetic recovery questionnaire: A multicenter observational trial on ObsQoR-11. J Formos Med Assoc 2022; 122:479-485. [PMID: 36593133 DOI: 10.1016/j.jfma.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The obstetric quality of recovery (ObsQoR-11) is considered one of the best patient-reported outcome measures of post-cesarean recovery. However, it has been neither validated in Chinese nor evaluated at >24 h after delivery. METHODS Parturients from three hospitals (n = 279) completed the Chinese ObsQoR-11 at 24 h (T1) and 96 h (T2) after elective cesarean delivery. Convergent validity was assessed by correlation of Chinese ObsQoR-11 with a 100-mm numerical rating scale (NRS) of general health status; discriminant validity of good recovery (NRS ≥ 70-mm); and construct validity by correlation with influential factors to post-cesarean recovery. The reliability and responsiveness were also assessed. RESULTS The Chinese ObsQoR-11 correlated moderately with the NRS [T1: r = 0.38 (95% confidence interval: 0.28-0.48), p < 0.0001; T2: r = 0.43 (95% confidence interval: 0.32-0.52), p < 0.0001] and discriminated between good and poor recovery [T1: mean (SD) score: 64 (20) vs 49 (17), p < 0.0001; T2: median (IQR) score: 81 (66-94) vs. 61 (53-72); p = 0.0002]; weakly correlated with gestational age, successful breastfeeding, and operation time. It was reliable (internal consistency: 0.75 (T1) and 0.82 (T2); split-half: 0.77 (T1) and 0.85 (T2); test-retest intraclass correlation coefficient r > 0.6 for each item) and responsive (Cohen effect size: 0.88; standardized response mean: 0.81). CONCLUSION The Chinese ObsQoR-11may be used for assessing recovery at 24 h and 96 h after cesarean delivery. However, its' cutoff value for good recovery may be lower than that of other versions.
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Affiliation(s)
- Wei-Han Chou
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan
| | - Sing-Ong Lee
- Department of Anesthesiology, Hsinchu Cathay General Hospital, Taiwan
| | - Min-Hsuan Sun
- Department of Anesthesiology, National Taiwan University Hospital, Yunlin Branch, Taiwan
| | - Ying-Chih Tseng
- Department of Gynecology and Obstetrics, Hsinchu Cathay General Hospital, Taiwan
| | - Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan
| | - Ying-Hsi Chen
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan
| | - Chun-Yu Wu
- Department of Anesthesiology, National Taiwan University Hospital, Taiwan.
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Tegegne TK, Chojenta C, Getachew T, Smith R, Loxton D. Spatial and hierarchical Bayesian analysis to identify factors associated with caesarean delivery use in Ethiopia: Evidence from national population and health facility data. PLoS One 2022; 17:e0277885. [PMID: 36395274 PMCID: PMC9671448 DOI: 10.1371/journal.pone.0277885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/06/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia. METHOD Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure. RESULTS Women's age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had ≥4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women's age at first childbirth and ≥4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia. CONCLUSION Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.
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Affiliation(s)
- Teketo Kassaw Tegegne
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Victoria, Australia
- * E-mail:
| | - Catherine Chojenta
- Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Theodros Getachew
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Roger Smith
- Mothers and Babies Research Centre, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Deborah Loxton
- Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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Chen N, Pan J. The causal effect of delivery volume on severe maternal morbidity: an instrumental variable analysis in Sichuan, China. BMJ Glob Health 2022; 7:bmjgh-2022-008428. [PMID: 35537760 PMCID: PMC9092146 DOI: 10.1136/bmjgh-2022-008428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Findings regarding the association between delivery volume and maternal health outcomes are mixed, most of which explored their correlation. This study aims to demonstrate the causal effect of delivery volume on severe maternal morbidity (SMM) in China. Methods We analysed all women giving birth in the densely populated Sichuan province with 83 million residents in China, during the fourth quarters of each of 4 years (from 2016 to 2019). The routinely collected discharge data, the health institutional annual report data and road network data were used for analysis. The maternal health outcome was measured by SMM. Instrumental variable (IV) methods were applied for estimation, while the surrounding average number of delivery cases per institution was used as the instrument. Results The study included 4545 institution-years of data from 1456 distinct institutions with delivery services, reflecting 810 049 associated delivery cases. The average SMM rate was approximately 33.08 per 1000 deliveries during 2016 and 2019. More than 86% of delivery services were provided by a third of the institutions with the highest delivery volume (≥143 delivery cases quarterly). In contrast, less than 2% of delivery services were offered by a third of the institutions with the lowest delivery volume (<19 delivery cases quarterly). After adjusting the confounders in the IV-logistic models, the average marginal effect of per 1000 cases in delivery volume was −0.162 (95% CI −0.169 to –0.155), while the adjusted OR of delivery volume was 0.005 (95% CI 0.004 to 0.006). Conclusion Increased delivery volume has great potential to improve maternal health outcomes, while the centralisation of delivery services might facilitate maternal health promotion in China. Our study also provides implications for other developing countries confronted with similar challenges to China.
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Affiliation(s)
- Nan Chen
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China .,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
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Ahmed MS, Islam M, Jahan I, Shaon IF. Multilevel analysis to identify the factors associated with caesarean section in Bangladesh: evidence from a nationally representative survey. Int Health 2022; 15:30-36. [PMID: 35194644 PMCID: PMC9808510 DOI: 10.1093/inthealth/ihac006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/23/2021] [Accepted: 01/25/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Caesarean delivery has a significant role in reducing maternal and child death. However, unnecessary utilization has adverse health effects. This study aimed to assess the prevalence and associated factors of caesarean delivery in Bangladesh. METHODS Data from the latest Bangladesh Multiple Indicator Cluster Survey (MICS, 2019) was used in this study. Since MICS data are hierarchical in nature, multilevel modelling was used. RESULTS The prevalence of caesarean section (CS) was 67.4% among Bangladeshi women. Multilevel analysis suggests the age of the women, household wealth status, utilization of antenatal care (ANC) , delivery at a health facility and division were significantly associated with CS. Women who delivered in a private health facility had the highest odds for CS (odds ratio [OR] 10.35 [95% confidence interval {CI} 8.55 to 12.54]). Women 30-34 y of age had a 36% higher likelihood of CS compared with women 15-19 y of age (OR 1.36 [95% CI 1.03 to 1.79]). The odds of CS positively increased with household wealth status. Women who had at least one ANC visit had a 1.7 times higher possibility of CS (OR 1.70 [95% CI 1.26 to 2.30]). CONCLUSIONS Policy guidelines on caesarean deliveries are urgently needed in Bangladesh to avoid unnecessary caesarean deliveries and protect mothers from the consequences.
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Affiliation(s)
- Md Sabbir Ahmed
- Department of Community Health and Hygiene, Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Dumki, Patuakhali-8602, Bangladesh
| | | | - Ishrat Jahan
- Department of Food Microbiology, Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Dumki, Patuakhali-8602, Bangladesh
| | - Imran Faisal Shaon
- Department of Animal Nutrition, Faculty of Animal Husbandry, Bangladesh Agricultural University, Mymensingh 2202, Bangladesh
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Indraccolo U, Bianchi B, Borghi C, Greco P. Assessing the regional policies of Italian regions in managing the Cesarean delivery phenomenon: a fractal analysis. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021042. [PMID: 33682821 PMCID: PMC7975957 DOI: 10.23750/abm.v92i1.9139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 03/20/2020] [Indexed: 11/23/2022]
Abstract
Objectives. Assessing the 2017 administrative data on Cesareans delivery in Italy by using fractal statistic. Methods. 2017 administrative data on Italian Cesarean deliveries are freely available as crude numbers and rates according to each Italian region, according to Italian health institute type and according to first or repeated Cesarean. As already reported, the Italian Cesarean delivery phenomenon is in relationship with hospital, regional, cultural perspectives in caring pregnancy and delivery. Fractal statistics can best assess the biocomplexity underlying the Italian Cesarean section phenomenon. Fractal shapes and self-organized criticality of the Cesarean section phenomenon for each Italian region were done. Fractal shapes were compared to find similarities by using global test of coincidence among regression lines. Results. In the regions where the health care institutes are more than a type, there are evanescent similar fractal shapes. Self-organized criticality assessment demonstrates that chaos is largely involved in Cesarean delivery phenomenon in all Italian regions and in Italy. The fractal images for each region are able to highlight the item causing the deviation from fractal shapes in each region. Conclusion. Fractal statistics could be used to compare regional or hospital policies in performing Cesareans, starting from Cesareans rates extracted from administrative data. (www.actabiomedica.it)
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Affiliation(s)
- Ugo Indraccolo
- Maternal-Infantile Department, Complex Operative Unit of Obstetrics and Gynecology, "Alto Tevere" Hospital of Città di Castello - ASL 1 Umbria.
| | - Beatrice Bianchi
- Department of Medical Sciences, Section of Obstetric and Gynaecology, University of Ferrara, Ferrara, Italy..
| | - Chiara Borghi
- Department of Medical Sciences, Section of Obstetric and Gynaecology, University of Ferrara, Ferrara, Italy..
| | - Pantaleo Greco
- Department of Medical Sciences, Section of Obstetric and Gynaecology, University of Ferrara, Ferrara, Italy..
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Jung CH, Jung SH, Choi D, Kim BY, Kim CH, Mok JO. Gestational diabetes in Korea: Temporal trends in prevalence, treatment, and short-term consequences from a national health insurance claims database between 2012 and 2016. Diabetes Res Clin Pract 2021; 171:108586. [PMID: 33316311 DOI: 10.1016/j.diabres.2020.108586] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 10/16/2020] [Accepted: 11/26/2020] [Indexed: 11/15/2022]
Abstract
AIMS This population-based cross-sectional study aimed to investigate recent trends in the prevalence and treatment of gestational diabetes mellitus (GDM) in Korea. We also investigated trends in annual prevalence rate of pregnancy-induced hypertension (PIH) and cesarean section (C-section) in GDM patients. METHODS We used data from the Health Insurance Review and Assessment-National Patient Sample (HIRA-NPS) database, 2012-2016. Non-GDM (n = 53,698) and GDM (n = 7956) patient data were analyzed for each year. RESULTS The annual increase in the prevalence of GDM was 11.1% over 2012-2016, with a significant continuously increasing trend (p < 0.0001). Age-stratified analysis showed that the annual prevalence of GDM significantly increased in patients below 40 years of age, but was not statistically significant as an increasing trend in patients above 40 years of age. Annual PIH prevalence rate among GDM women showed decreasing trend but was not statistically significant. An annual increase in C-section rate above 5% in GDM patients was statistically significant in both unadjusted and adjusted for age and PIH models. CONCLUSIONS The prevalence of GDM in Korean women and C-section rates in women with GDM showed a significantly increasing trend, 2012-2016. There is a need for further efforts to monitor this trend and to identify associated risk factors for GDM in Korean women.
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Affiliation(s)
- Chan-Hee Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, South Korea
| | - Sang-Hee Jung
- Department of Obstetrics and Gynecology, Cha University School of Medicine, Bundang Hospital, South Korea
| | - Dughyun Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, South Korea
| | - Bo-Yeon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, South Korea
| | - Chul-Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, South Korea
| | - Ji-Oh Mok
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, South Korea.
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Zaiden L, Nakamura-Pereira M, Gomes MAM, Esteves-Pereira AP, Leal MDC. Influence of hospital characteristics on the performance of elective cesareans in Southeast Brazil. CAD SAUDE PUBLICA 2020; 36:e00218218. [PMID: 31939550 DOI: 10.1590/0102-311x00218218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 07/08/2019] [Indexed: 11/22/2022] Open
Abstract
This article aims to assess the influence of hospital characteristics on the odds of performing an elective cesarean in the Southeast region of Brazil. Data were obtained from the Birth in Brazil study, conducted from February 2011 to October 2012. The current analysis includes the sample from Southeast Brazil, with 10,155 women. The group of women that underwent elective cesareans was compared to the women who went into labor or underwent labor induction, regardless they had intrapartum cesarean or vaginal delivery. Except for gestational age, all the obstetric characteristics analyzed were associated with elective cesarean. In this group, 60.5% had no prior cesarean and 64.7% had low-risk gestations. Among the births with public financing, there were higher odds of elective cesareans in women treated at hospitals with < 1,500 births/year (OR = 2.11; 95%CI: 1.37-3.26) and 1,500-2,999 births/year (OR = 1.45; 95%CI: 1.04-2.02) and in mixed hospitals (OR = 1.81; 95%CI: 1.37-2.39). In the mixed hospitals, the association was stronger when located in non-capital cities with > 3,000 births/year (OR = 3.45; 95%CI: 1.68-7.08), reaching the highest level in hospitals in non-capital cities with < 3,000 births/year (OR = 4.08; 95%CI: 2.61-6.37). Meanwhile, no association was seen between elective cesarean and public hospitals located in non-capital cities of the Southeast region. Prevalence rates of elective cesareans in public hospitals in Southeast Brazil are high when compared to other countries, and they are heavily influenced by hospital characteristics.
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Affiliation(s)
- Laura Zaiden
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil.,Faculdade de Medicina de Petrópolis, Petrópolis, Brasil
| | - Marcos Nakamura-Pereira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Maria Auxiliadora Mendes Gomes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Maria do Carmo Leal
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Hoxha I, Braha M, Syrogiannouli L, Goodman DC, Jüni P. Caesarean section in uninsured women in the USA: systematic review and meta-analysis. BMJ Open 2019; 9:e025356. [PMID: 30833323 PMCID: PMC6443081 DOI: 10.1136/bmjopen-2018-025356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/14/2018] [Accepted: 12/19/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use. STUDY DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018. ELIGIBILITY CRITERIA We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women. OUTCOMES The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women. RESULTS 12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72). CONCLUSIONS CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.
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Affiliation(s)
- Ilir Hoxha
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth Hanover, New Hampshire, USA
- Heimerer College, Prishtina, Kosovo
| | - Medina Braha
- International Business College Mitrovica, Mitrovica, Kosovo
| | | | - David C Goodman
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, USA
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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