Demand and supply factors affecting the rising overmedicalization of birth in India

Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review

Importance

Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.

Objectives

To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.

Evidence Review

We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.

Findings

Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.

Conclusions and Relevance

This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

Trends in cesarean section rates in private and public facilities in rural eastern Maharashtra, India from 2010-2017

INTRODUCTION

Rates of cesarean sections (CS) have increased dramatically over the past two decades in India. This increase has been disproportionately high in private facilities, but little is known about the drivers of the CS rate increase and how they vary over time and geographically.

METHODS

Women enrolled in the Nagpur, India site of the Global Network for Women's and Children's Health Research Maternal and Neonatal Health Registry, who delivered in a health facility with CS capability were included in this study. The trend in CS rates from 2010 to 2017 in public and private facilities were assessed and displayed by subdistrict. Multivariable generalized estimating equations models were used to assess the association of delivering in private versus public facilities with having a CS, adjusting for known risk factors.

RESULTS

CS rates increased substantially between 2010 and 2017 at both public and private facilities. The odds of having a CS at a private facility were 40% higher than at a public facility after adjusting for other known risk factors. CS rates had unequal spatial distributions at the subdistrict level.

DISCUSSION

Our study findings contribute to the knowledge of increasing CS rates in both public and private facilities in India. Maps of the spatial distribution of subdistrict-based CS rates are helpful in understanding patterns of CS deliveries, but more investigation as to why clusters of high CS rates have formed in warranted.

Association between the type of provider and Cesarean section delivery in India: A socioeconomic analysis of the National Family Health Surveys 1999, 2006, 2016

BACKGROUND

Prevalence of Cesarean section (C-section) is unequally distributed. Since both extremely low and high levels of C-section can not only cause adverse birth outcomes but also impose a double burden of inefficiency within maternal health care, it is important to monitor the dynamics of key factors associated with the use of C-section.

OBJECTIVES

To examine the association between type of provider and C-section in India in three-time points: 1999, 2006, and 2016, and also to assess whether this association differed across maternal education and wealth level.

METHODS

Data were from three waves of cross-sectional and nationally representative Indian National Health Family Survey: Wave II (1999), III (2006), and IV (2016). Target population is women aged 15 and 49 who had an institutional delivery for the most recent live birth during the three or five years preceding the survey (depending on the survey round). Multivariate logistic regression models adjusting for state cluster effect were performed to determine the association between the type of providers and C-section. Differential association between the type of providers and C-section by maternal education and wealth level was examined by stratified analyses.

RESULTS

The prevalence of C-section among institutional delivery increased from 20.5% in 1999 to 24.8% in 2006 while it declined to 19.4% in 2016. The positive association between private providers and C-section became stronger over the study period (Odds Ratio (OR) = 1.39, 95% Confidence Interval (CI) 1.18-1.64 in 1999, OR = 3.71 95% CI 2.93-4.70 in 2016). The association was consistently significant across all states in 2016. The gap in C-section between public and private providers was greater among less-educated and poorer women. The ORs gradually increased from the poorest to the richest quintiles, and also from the least educated group (no formal education) to the most educated group (college graduate or above).

CONCLUSIONS

Our results suggest that disparity in C-section between private and public providers has increased over the last 15 years and was higher in lower SES women. The behavior of providers needs to be closely monitored to ensure that C-section is performed only when medically justified.

Does delivery in private hospitals contribute largely to Caesarean Section births? A path analysis using generalised structural equation modelling

BACKGROUND

The rate of Caesarean Section (CS) deliveries has shown an alarming rise in recent years. CS is a surgical procedure used when there is apprehension of risk to the life of mother or baby in case of vaginal delivery, but its rates higher than 10-15 per cent are not justifiable. It is well recognised that a CS delivery could have a large number of adverse impacts on women and infants. Several studies, especially in developing countries, have revealed that delivery in private hospitals is one of the most contributing factors in CS deliveries. The present study conceptualises a causal pathway in which the possible risk factors, socio-economic, maternal and pregnancy-related, as well as institutional, influence the chances of CS delivery. It is hypothesised that certain factors would contribute to CS deliveries largely indirectly through the place of delivery, that is, either a public or private institution.

METHODS AND FINDINGS

To test the hypotheses, this study analysed 146,280 most recent live births delivered in hospitals during the five years preceding the fourth round of India's National Family Health Survey (NFHS-4), carried out during 2015-2016. The analysis, using generalised structural equation modelling (GSEM), revealed that many exogenous variables considered in the path models influence CS deliveries significantly, directly and/or indirectly through the place of delivery factor. Prominent among these are wealth index and receiving ANC services at only private hospitals; the total effects of these variables are even higher than the direct/total effect of place of delivery.

CONCLUSION

From this finding, it could be said that the place of delivery is a proximate determinant of a CS delivery or a mediator of other co-factors. Interventions to curb higher CS deliveries should be focused on improving the quality of public health sectors and on developing protocols for CS deliveries.

Current status and determinants of maternal healthcare utilization in Afghanistan: Analysis from Afghanistan Demographic and Health Survey 2015

Background

Advancing maternal health is central to global health policy-making; therefore, considerable efforts have been made to improve maternal health. Still, in many developing countries, particularly in Sub-Saharan Africa and South Asia, including Afghanistan, the maternal mortality ratio (MMR) remains high. The objective of this study was to examine the determinants and current status of the utilization of maternal healthcare in Afghanistan.

Methods

This study used the most recent data from the Afghanistan Demographic and Health Survey 2015. The unit of analysis for this study was women who had a live birth in the five years preceding the survey. The outcome variables were four or more antenatal care (ANC) visits, delivery assistance by a skilled birth attendant (SBA), and delivery by cesarean section (CS). The explanatory variables were basic sociodemographic characteristics of the mothers. We examined the sociodemographic characteristics of women utilizing ANC, SBA, and CS using descriptive statistics and estimated usage of ANC, SBA and CS after adjusting for maternal age and parity groups via direct standardization. Multivariable logistic regression models were employed to investigate the determinants of maternal healthcare variables.

Results

Overall, 17.8% of women attended four or more ANC visits, 53.6% utilized an SBA, and 3.4% of women gave birth through CS. Women’s education, wealth status, urbanity, autonomy, and availability of their own transport were found to be the major determinants of service utilization.

Conclusions

This study underscores low utilization of maternal healthcare services with wide disparities in Afghanistan and highlighted the need for an adequate health strategy and policy implementation to improve maternal healthcare uptake.

'If I do 10-15 normal deliveries in a month I hardly ever sleep at home.' A qualitative study of health providers' reasons for high rates of caesarean deliveries in private sector maternity care in Delhi, India

Background

Although the overall rate of caesarean deliveries in India remains low, rates are higher in private than in public facilities. In a household survey in Delhi, for instance, more than half of women delivering in private facilities reported a caesarean section. Evidence suggests that not all caesarean sections are clinically necessary and may even increase morbidity. We present providers’ perspectives of the reasons behind the high rates of caesarean births in private facilities, and possible solutions to counter the trend.

Methods

Fourteen in-depth interviews were conducted with high-end private sector obstetricians and other allied providers in Delhi and its neighbouring cities, Gurgaon and Ghaziabad.

Results

Respondents were of the common view that private sector caesarean rates were unreasonably high and perceived time and doctors’ convenience as the foremost reasons. Financial incentives had an indirect effect on decision-making. Obstetricians felt that they must maintain high patient loads to be commercially successful. Many alluded to their busy working lives, which made it challenging for them to monitor every delivery individually. Besides fearing for patient safety in these situations, they were fearful of legal action if anything went wrong. A lack of context specific guidelines and inadequate support from junior staff and nurses exacerbated these problems. Maternal demand also played a role, as the consumer-provider relationship in private healthcare incentivised obstetricians to fulfil patient demands for caesarean section. Suggested solutions included more support, from either well-trained midwives and junior staff or using a ‘shared practice’ model; guidelines introduced by an Indian body; increased regulation within the sector and public disclosure of providers’ caesarean rates.

Conclusions

Commercial interests contribute indirectly to high caesarean rates, as solo obstetricians juggle the need to maintain high patient loads with inadequate support staff. Perceptions amongst providers and consumers of caesarean section as the ‘safe’ option have re-defined caesareans as the new ‘normal’, even for low-risk deliveries. At the policy level, guidelines and public disclosures, strong initiatives to develop professional midwifery, and increasing public awareness, could bring about a sustainable reduction in the present high rates.

Can India's primary care facilities deliver? A cross-sectional assessment of the Indian public health system's capacity for basic delivery and newborn services

OBJECTIVES

To assess input and process capacity for basic delivery and newborn (intrapartum care hereafter) care in the Indian public health system and to describe differences in facility capacity between rural and urban areas and across states.

DESIGN

Cross-sectional study.

SETTING

Data from the nationally representative 2012-2014 District Level Household and Facility Survey, which includes a census of community health centres (CHC) and sample of primary health centres (PHC) across 30 states and union territories in India.

PARTICIPANTS

8536 PHCs and 4810 CHCs.

OUTCOME MEASURES

We developed a summative index of 33 structural and process capacity items matching the Indian Public Health Standards for PHCs as a metric of minimum facility capacity for intrapartum care. We assessed differences in performance on this index across facility type and location.

RESULTS

About 30% of PHCs and 5% of CHCs reported not offering any intrapartum care. Among those offering services, volumes were low: median monthly delivery volume was 8 (IQR=13) in PHCs and 41 (IQR=73) in CHCs. Both PHCs and CHCs failed to meet the national standards for basic intrapartum care capacity. Mean facility capacity was low in PHCs in both urban (0.64) and rural (0.63) areas, while in CHCs, capacity was slightly higher in urban areas (0.77vs0.74). Gaps were most striking in availability of skilled human resources and emergency obstetric services. Poor capacity facilities were more concentrated in the more impoverished states, with 37% of districts from these states receiving scores in the lowest third of the facility capacity index (<0.70), compared with 21% of districts otherwise.

CONCLUSIONS

Basic intrapartum care capacity in Indian public primary care facilities is weak in both rural and urban areas, especially lacking in the poorest states with worst health outcomes. Improving maternal and newborn health outcomes will require focused attention to quality measurement, accountability mechanisms and quality improvement. Policies to address deficits in skilled providers and emergency service availability are urgently required.

Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

OBJECTIVE

To provide an update on economic related inequalities in caesarean section rates within countries.

DESIGN

Secondary analysis of demographic and health surveys and multiple indicator cluster surveys.

SETTING

72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time.

PARTICIPANTS

Women aged 15-49 years with a live birth during the two or three years preceding the survey.

MAIN OUTCOME MEASURES

Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change.

RESULTS

National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries.

CONCLUSIONS

Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.

Rising trends and inequalities in cesarean section rates in Pakistan: Evidence from Pakistan Demographic and Health Surveys, 1990-2013

Despite global efforts to improve maternal health, many developing countries including Pakistan have failed to achieve the target of a 75% reduction in maternal deaths by 2015. Addressing socioeconomic inequalities in access to emergency obstetric care is crucial for reducing the maternal mortality rate. This study was done to examine the time trends and socioeconomic inequalities in the utilization of cesarean section (C-section) in Pakistan during 1990-2013. We used data from the Pakistan Demographic and Health Surveys (PDHS) conducted during 1990 to 2013. All these surveys are nationally representative surveys of ever-married women aged 15-49 years with a sample size of 6611, 10,023, and 13,558 women in 1990-1991, 2006-2007, and 2012-2013, respectively, with an overall response rate of over 90%. The unit of analysis for this study was women with their most recent live birth in the five years preceding the surveys. Bivariate analyses and multivariable logistic regression models were employed to investigate the prevalence of cesarean sections according to selected sociodemographic characteristics of women. C-section rates were found to have increased during this period, with an especially significant rise from 2.7% in 1990-1991 to 15.8% in 2012-2013 with lower utilization among the non-educated women (7.5%), compared with the women with higher education (40.3%). C-section rates ranged from 5.5% in the poorest women to 35.3% in the richest women. Only 11.5% of the rural women had a C-section compared to 25.6% of the urban women. A greater likelihood of having a cesarean section was observed in the richest, highly educated, and urban-living women while there was no significant difference observed in cesarean section rates between the private and public sectors in all three surveys. To improve maternal health, routine monitoring and evaluation of the provision of emergency obstetric services are needed to address the underuse of C-section in poor and rural areas and overuse in rich and urban areas.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Impact of Alternative Maternal Demand-Side Financial Support Programs in India on the Caesarean Section Rates: Indications of Supplier-Induced Demand

Background

This paper examines two state-led public–private demand-side financial support programs aiming to raise hospital delivery rates in two neighbouring Indian states—Gujarat and Madhya Pradesh. The national Janani Suraksha Yojana (JSY) was complemented with a public–private partnership program Janani Sahayogi Yojana (JSaY) in Madhya Pradesh in which private obstetricians were paid to deliver poor women. A higher amount was paid for caesarean sections (CS) than for vaginal deliveries (VD). In Gujarat state, the state program Chiranjeevi Yojana (CY) paid private obstetricians a fixed amount for a block 100 deliveries irrespective of delivery mode. The two systems thus offered an opportunity to observe the influence of supplier-induced demand (SID) from opposite incentives related to delivery mode.

Methods

The data from the two programs was sourced from the Departments of Health and Family Welfare, Governments of Gujarat and Madhya Pradesh, India.

Results

In JSaY program the CS rate increased from 26.6 % (2007–2008) to 40.7 % (2010–2011), against the background rate for CS in Madhya Pradesh, of only 4.9 % (2004–2006). Meanwhile in CY program in Gujarat, the CS rate decreased to 4.3 % (2010–2011) against a background CS rate of 8.1 % (2004–2006).

Conclusions

The findings from India are unique in that they not only point to a significant impact from the introduction of the financial incentives but also how disincentives have an inverse impact on the choice of delivery method.