Public-private differentials in health care delivery: the case of cesarean deliveries in Algeria

Akin to other developing countries, Algeria has witnessed an increasing role of the private health sector in the past two decades. Our study sheds light on the public-private overlap and the phenomenon of physician dual practice in the provision of health care services using the particular case of cesarean deliveries in Algeria. Existing studies have reported that, compared to the public sector, delivering in a private health facility increases the risk of enduring a cesarean section. While confirming this result for the case of Algeria, our study also reveals the existence of public-private differentials in the effect of medical variables on the probability of cesarean delivery. After controlling for selection in both sectors, we show that cesarean deliveries in the private sector tend to be less medically justified compared with those taking place in the public sector, thus, potentially leading to maternal and neonatal health problems. As elsewhere, the contribution of the private health sector to the unmet need for health care in Algeria hinges on an appropriate legal framework that better coordinates the activities of the two sectors and reinforces their complementarity.

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study

Background

Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.

Methods

This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.

Results

The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government’s reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers’ concern.

Conclusion

The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

Nonclinical Factors of Cesarean Section Birth: A Review of the Literature

The rate of cesarean section (CS) birth has increased dramatically across the world during the last few decades, mainly in high-income and middle-income countries. The aim of this study is to explore the nonclinical risk factors of CS birth and to look into its similarities and dissimilarities influencing CS birth between developed and developing countries. A search of the existing literature was conducted on electronic databases, such as PubMed, JSTOR, SpringerLink, ScienceDirect, and so forth. The maternal age is the most common factor of CS birth in almost all studies of developed and developing countries. Furthermore, type of hospitals is another predominant factor of CS birth as seen in more than half of the studies of developing countries and in several studies of developed countries. Nevertheless, it is also found that there is variation in main findings of CS birth according to the level of development. In most of the studies in developed countries, CS birth is highly associated with maternal age and birth weight of the baby. On the contrary, in developing countries, most of the studies show that CS birth is highly associated with maternal age, maternal education, type of hospitals, place of residence, number of antenatal care, and parity.

A glance into the hidden burden of maternal morbidity and patterns of management in a Palestinian governmental referral hospital

BACKGROUND

Little is known about the burden and patterns of maternal morbidity during childbirth, particularly in the Middle East Region. Investigating the patterns of maternal morbidity can be useful in guiding improvement in the quality of maternal services, and informing policy debates on women's health.

OBJECTIVE

To examine the incidence, types and patterns of management of severe and non-severe maternal morbidities of Palestinian women during pregnancy, labour, delivery and up to seven days postpartum in one Palestinian hospital.

METHODS

A prospective hospital-based study was conducted for a 3-month period in 2011-2012, reviewing hospital records for all pregnant women (1.583) admitted to the governmental hospital in Ramallah, Palestine.

FINDINGS

Of all pregnant women included in this analysis (1.558), 419 (26.9%) women experienced one or more maternal morbidities and 15 (0.96%) women survived a life-threatening complication (near miss). Of all women who suffered morbidities, 69 (16.5%) had vaginal deliveries, 61 (14.6%) had cesarean sections, 179 (42.7%) had abortions/miscarriage, and 110 (26.3%) experienced complications during pregnancy or the post-partum. Hemorrhage during pregnancy, birth or postpartum was the most common morbidity. Of those who gave birth, women who gave birth by cesarean sections were three times more likely to suffer from morbidities than those who had vaginal delivery.

CONCLUSIONS

The burden of maternal morbidity for Palestinian women between the ages of 16 and 48 is high. In Palestine, maternal morbidity can be prevented by promoting a rational use of cesarean section, avoiding unnecessary medicalization, reducing unwanted pregnancies and updating practices of providers related to abortion/miscarriage care.