Economic aspects of caesarean section and alternative modes of delivery

Global increased cesarean section rates and public health implications: A call to action

Over the years; global caesarian section (CS) rates have significantly increased from around 7% in 1990 to 21% today surpassing the ideal acceptable CS rate which is around 10%-15% according to the WHO. However, currently, not all CS are done for medical reasons with rapidly increasing rate of nonmedically indicated CS and the so-called "caesarian on maternal request." These trends are projected to continue increasing over this current decade where both unmet needs and overuse are expected to coexist with the projected global rate of 29% by 2030. CS reduces both maternal and neonatal morbidity and mortality significantly when it is done under proper indications while at the same time, it can be of harm to the mother and the child when performed contrary. The later exposes both the mother and the baby to a number of unnecessary short and long-term complications and increase the chances of developing different noncommunicable diseases and immune-related conditions among babies later in life. The implications of lowering SC rate will ultimately lower healthcare expenditures. This challenge can be addressed by several ways including provision of intensive public health education regarding public health implications of increased CS rate. Assisted vaginal delivery approaches like the use of vacuum and forceps and other methods should be considered and encouraged during delivery as long as their indications for implementation are met. Conducting frequent external review and audits to the health facilities and providing feedback regarding the rates of CS deliveries can help to keep in check the rising CS trends as well as identifying the settings with unmet surgical needs. Moreover, the public especially expectant mothers during clinic visits and clinicians should be educated and be informed on the WHO recommendations on nonclinical interventions towards reduction of unnecessary CS procedures.

A time-driven activity-based costing approach for identifying variability in costs of childbirth between and within types of delivery

Background

Recently, time-driven activity-based costing (TDABC) is put forward as an alternative, more accurate costing method to calculate the cost of a medical treatment because it allows the assignment of costs directly to patients. The objective of this paper is the application of a time-driven activity-based method in order to estimate the cost of childbirth at a maternal department. Moreover, this study shows how this costing method can be used to outline how childbirth costs vary according to considered patient and disease characteristics. Through the use of process mapping, TDABC allows to exactly identify which activities and corresponding resources are impacted by these characteristics, leading to a more detailed understanding of childbirth cost.

Methods

A prospective cohort study design is performed in a maternity department. Process maps were developed for two types of childbirth, vaginal delivery (VD) and caesarean section (CS). Costs were obtained from the financial department and capacity cost rates were calculated accordingly.

Results

Overall, the cost of childbirth equals €1894,12 and is mainly driven by personnel costs (89,0%). Monitoring after birth is the most expensive activity on the pathway, costing €1149,70. Significant cost variations between type of delivery were found, with VD costing €1808,66 compared to €2463,98 for a CS. Prolonged clinical visit (+ 33,3 min) and monitoring (+ 775,2 min) in CS were the main contributors to this cost difference. Within each delivery type, age, parity, number of gestation weeks and education attainment were found to drive cost variations. In particular, for VD an age >  25 years, nulliparous, gestation weeks > 40 weeks and higher education attainment were associated with higher costs. Similar results were found within CS for age, parity and number of gestation weeks.

Conclusions

TDABC is a valuable approach to measure and understand the variability in costs of childbirth and its associated drivers over the full care cycle. Accordingly, these findings can inform health care providers, managers and regulators on process improvements and cost containment initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04134-4.

Method to Calculate Nurse-Specific Cesarean Rates for the First and Second Stages of Labor

To date, efforts to safely lower the cesarean birth rate for women with low-risk pregnancies have largely ignored the influence of labor and delivery nurses on mode of birth. This is mainly because of the complexity involved in attributing outcomes to specific nurses whose care had the greatest effect on mode of birth. An additional level of complexity arises from the type of care given to the woman during different stages of labor. In this article, we describe a strategy to designate nurses to births using an electronic medical record flowsheet, and we describe a method to calculate nurse-specific cesarean birth rates for the first and second stages of labor. Similar to physician-specific rates, we found wide variation in nurse-specific cesarean birth rates in both stages of labor, which suggests an opportunity to learn from best practices.

Perioperative anxiety and length of hospital stay after caesarean section - A cohort study

OBJECTIVE

The caesarean section is one of the most frequently performed surgeries. Due to growing economic challenges, hospitals are encouraged to improve their cost-efficiency. One factor that influences hospital costs of caesarean sections is a prolonged hospital stay.

STUDY DESIGN

The aim of the current prospective study was to investigate psychosocial factors, with an emphasis on anxiety, and sociodemographic factors that are associated with longer hospital stay after caesarean sections with no medical complications. Data of 195 women who gave birth by caesarean section was analyzed. As possible predictors anxiety levels measured pre-, peri- and postoperative as well as age, parity (primiparous/multiparous), repeated caesarean (yes/no), BMI (<30/ ≥30), STAI-Trait scores, duration of surgery, PH arterial and Apgar 5 min. were entered into a backward linear regression with duration of hospital stay as the dependent factor.

RESULTS

The analysis revealed that higher age, primiparity as well as higher anxiety scores during the postoperative phase are significant factors associated with prolonged hospital stay. The significant model explains 22.1 % of the variance.

CONCLUSION

The results should sensitize the medical team to these risk factors in order to improve patients' recovery and shorten hospital stays.

Cost-effectiveness of continuity of midwifery care for women with complex pregnancy: a structured review of the literature

BACKGROUND

Critical evaluation of the cost-effectiveness and clinical effectiveness of continuity of midwifery care models for women experiencing complex pregnancy is an important consideration in the review and reform of maternity services. Most studies either focus on women who experience healthy pregnancy or mixed risk samples. These results may not be generalised across the childbearing continuum to women with risk factors. This review critically evaluates studies that measure the cost of care for women with complex pregnancies, with a focus on method and quality.

AIMS / OBJECTIVES

To critically appraise and summarise the evidence relating to the combined cost-effectiveness, resource use and clinical effectiveness of midwifery continuity models for women who experience complex pregnancies and their babies in developed countries.

DESIGN

Structured review of the literature utilising a matrix method to critique the methods and quality of studies.

METHOD

A search of Medline, CINAHL, MIDIRS, DARE, EMBASE, OVID, PubMed, ProQuest, Informit, Science Direct, Cochrane Library, NHS Economic Evaluation Database (NHSEED) for the years 1994 - 2018 was conducted.

RESULTS

Nine articles met the inclusion criteria. The review identified four areas of economic evaluation that related to women who experienced complex pregnancy and continuity of midwifery care. (1) cost and clinical effectiveness comparisons between continuity of midwifery care versus obstetric-led units; (2) cost of continuity of midwifery care and/or team midwifery compared to Standard Care; (3) cost-effectiveness of continuity of midwifery care for Australian Aboriginal women versus standard care; (4) patterns of antenatal care for women of high obstetric risk and comparative provider cost. Cost savings specific to women from high risk samples who received continuity of midwifery care compared with obstetric-led standard care was stated for only one study in the review. Kenny et al. 1994 identified cost savings of AUS $29 in the antenatal period for women who received the midwifery team model from a stratified sub-set of high-risk pregnant woman within a mixed risk sample of 446 women. One systematic review relevant to the UK context, Ryan et al. (2013), applied sensitivity analysis to include women of all risk categories. Where risk ratio for overall fetal/neonatal death was systematically varied based on the 95% confidence interval of 0.79 to 1.09 from pooled studies, the aggregate annual net monetary benefit for continuity of midwifery care ranged extremely widely from an estimated gain of £472 million to a loss of £202 million. Net health benefit ranged from an annual gain of 15 723 QALYs to a loss of 6 738 QALYs. All other studies in this review reported cost savings narratively or within mixed risk samples where risk stratification was not clearly stated or related to the midwifery team model only.

CONCLUSIONS

Studies that measure the cost of continuity of midwifery care for women with complex pregnancy across the childbearing continuum are limited and apply inconsistent methods of economic evaluation. The cost and outcomes of implementing continuity of midwifery care for women with complex pregnancy is an important issue that requires further investigation. Robust cost-effectiveness evidence is essential to inform decision makers, to implement sustainable systems change in comparative maternity models for pregnant women at risk and to address health inequity.

Mode of birth and postnatal health-related quality of life after one previous cesarean in three European countries

BACKGROUND

How a woman gives birth can affect her health-related quality of life (HRQoL). This study explored HRQoL at 3 months postpartum in women with a history of one previous cesarean in three European countries.

METHODS

A prospective longitudinal survey, embedded within a cluster randomized trial in three countries, exploring women's postnatal HRQoL up to 3 months postpartum. The Short-Form Six-Dimensions (SF-6D) was used to measure HRQoL, and multivariate analyses were used to examine the relationship with mode of birth.

RESULTS

Complete data were available from 880 women. Women with a spontaneous vaginal birth had the highest HRQoL scores, whereas women with an emergency repeat cesarean (P = .01) had the lowest. Postnatal readmission of the mother (P = .03), having public health insurance (P = .04), and a low antenatal HRQoL score (P < .01) contributes to poorer HRQoL scores. More specifically, women with a spontaneous vaginal birth had significantly higher HRQoL scores on the vitality dimension compared with women with an emergency repeat cesarean (P = .04).

CONCLUSIONS

In women with low-risk factors, repeat cesareans result in a poorer HRQoL compared with vaginal birth. When there are no contraindications for vaginal birth, women with a history of one previous cesarean should be encouraged to give birth vaginally rather than have an elective repeat cesarean.

Caesarean section rate and cost control effectiveness of case payment reform in the new cooperative medical scheme for delivery: evidence from Xi County, China

BACKGROUND

In China, increases in both the caesarean section (CS) rates and delivery costs have raised questions regarding the reform of the medical insurance payment system. Case payment is useful for regulating the behaviour of health providers and for controlling the CS rates and excessive increases in medical expenses. New Cooperative Medical Scheme (NCMS) agencies in Xi County in Henan Province piloted a case payment reform (CPR) in delivery for inpatients. We aimed to observe the changes in the CS rates, compare the changes in delivery-related variables, and identify variables related to delivery costs before and after the CPR in Xi County.

METHODS

Overall, 28,314 cases were selected from the Xi County NCMS agency from 2009 to 2010 and from 2014 to 2015. One-way ANOVA and chi-square tests were used to compare the distributions of CS and vaginal delivery (VD) before and after the CPR under different indicators. We applied multivariate linear regressions for the total medical cost of the VD and CS groups and total samples to identify the relationships between medical expenses and variables.

RESULTS

The CS rates in Xi County increased from 26.1% to 32.5% after the CPR. The length of stay (LOS), total medical cost, and proportion of county hospitals increased in the CS and VD groups after the CPR, which had significant differences. The total medical cost in the CS and VD groups as well as the total samples was significantly influenced by inpatient age, LOS, and hospital type, and had a significant correlation with the CPR in the VD group and the total samples.

CONCLUSION

The CPR might fail to control the growth of unreasonable medical expenses and regulate the behaviour of providers, which possibly resulted from the unreasonable compensation standard of case payments, prolonged LOS, and the increasing proportion of county hospitals. The NCMS should modify the case payment standard of delivery to inhibit providers' motivation to render CS services. The LOS should be controlled by implementing clinical guidelines, and a reference system should be established to guide patients in choosing reasonable hospitals.

Cost analysis of the CTLB Study, a multitherapy antenatal education programme to reduce routine interventions in labour

OBJECTIVE

To assess whether the multitherapy antenatal education 'CTLB' (Complementary Therapies for Labour and Birth) Study programme leads to net cost savings.

DESIGN

Cost analysis of the CTLB Study, using analysis of outcomes and hospital funding data.

METHODS

We take a payer perspective and use Australian Refined Diagnosis-Related Group (AR-DRG) cost data to estimate the potential savings per woman to the payer (government or private insurer). We consider scenarios in which the intervention cost is either borne by the woman or by the payer. Savings are computed as the difference in total cost between the control group and the study group.

RESULTS

If the cost of the intervention is not borne by the payer, the average saving to the payer was calculated to be $A808 per woman. If the payer covers the cost of the programme, this figure reduces to $A659 since the average cost of delivering the programme was $A149 per woman. All these findings are significant at the 95% confidence level. Significantly more women in the study group experienced a normal vaginal birth, and significantly fewer women in the study group experienced a caesarean section. The main cost saving resulted from the reduced rate of caesarean section in the study group.

CONCLUSION

The CTLB antenatal education programme leads to significant savings to payers that come from reduced use of hospital resources. Depending on which perspective is considered, and who is responsible for covering the cost of the programme, the net savings vary from $A659 to $A808 per woman. Compared with the average cost of birth in the control group, we conclude that the programme could lead to a reduction in birth-related healthcare costs of approximately 9%.

TRIAL REGISTRATION NUMBER

ACTRN12611001126909.

The Costs and Their Determinant of Cesarean Section and Vaginal Delivery: An Exploratory Study in Chongqing Municipality, China

Objectives. This study aims to analyze the cesarean section (CS) rates and vaginal delivery rates in tertiary hospitals of China, explore the costs of two different deliveries, and examine the relative influencing factors of the costs in both CS and vaginal deliveries. Methods. 30,168 anonymized obstetric medical cases were selected from three sample tertiary hospitals in Chongqing Municipality from 2011 to 2013. Chi-square test was used to compare the distributions of CS and vaginal deliveries under different indicators. Mann–Whitney test and Kruskal-Wallis test were adopted to analyze the differences under different items. Multiple linear regression was used to determine the influencing factors of the costs of different delivery modes. Results. (1) The rates of CS were 69%, 65.5%, and 59.2% in the three sample tertiary hospitals in Chongqing from 2011 to 2013. (2) The costs and the length of stay of CS were greater than those of vaginal delivery, which had significant differences (P < 0.005). (3) The areas, length of stay, age, medical insurance, and modes of delivery were the influencing factors of both CS and vaginal delivery costs. Discussion. The high CS rates in China must be paid significant attention. The indicators of two modes of delivery should be regulated strictly. CS rate reduction and saving medical resources will be the benefits if vaginal delivery is chosen by pregnant women.

Induction of labor using prostaglandin vaginal gel: cost analysis comparing early amniotomy with repeat prostaglandin gel

BACKGROUND

In a randomized controlled trial of two policies for induction of labor (IOL) using Prostaglandin E2 (PGE2) vaginal gel, women who had an earlier amniotomy experienced a shorter IOL-to-birth time.

OBJECTIVE

To report the cost analysis of this trial and determine if there are differences in healthcare costs when an early amniotomy is performed as opposed to giving more PGE2 vaginal gel, for women undergoing IOL at term.

STUDY DESIGN

Following an evening dose of PGE2 vaginal gel, 245 women with live singleton pregnancies, ≥37+0 weeks, were randomized into an amniotomy or repeat-PGE2 group. Healthcare costs were a secondary outcome measure, sourced from hospital finance systems and included staff costs, equipment and consumables, pharmacy, pathology, hotel services and business overheads. A decision analytic model, specifically a Markov chain, was developed to further investigate costs, and a Monte Carlo simulation was performed to confirm the robustness of these findings. Mean and median costs and cost differences between the two groups are reported, from the hospital perspective.

RESULTS

The healthcare costs associated with IOL were available for all 245 trial participants. A 1000-patient cohort simulation demonstrated that performing an early amniotomy was associated with a cost-saving of $AUD289 ($AUD7094 vs $AUD7338) per woman induced, compared with administering more PGE2. Propagating the uncertainty through the model 10,000 times, early amniotomy was associated with a median cost savings of $AUD487 (IQR -$AUD573, +$AUD1498).

CONCLUSIONS

After an initial dose of PGE2 vaginal gel, a policy of administering more PGE2 when the Modified Bishop's score is <7 was associated with increased healthcare costs compared with a policy of performing an amniotomy, if technically possible. Length of stay was the main driver of healthcare costs.

Practice audits to reduce caesareans in a tertiary referral hospital in south-western China

OBJECTIVE

To assess the effectiveness of a three-stage intervention to reduce caesarean deliveries in a Chinese tertiary hospital.

METHODS

A retrospective study was conducted to assess whether educating staff, educating patients and auditing surgeon practices (introduced in 2005) had reduced caesarean delivery rates. Multiple logistic regression was used to check for a potential association between caesarean rates and rates of admission to the neonatal intensive care unit (NICU).

FINDINGS

The caesarean delivery rate ranged from 53.5% to 56.1% in 2001-2004 and from 43.9% to 36.1% in 2005-2011. When 2001-2004 and 2005-2011 were treated as "before" and "after" periods to evaluate the intervention's impact on the mean caesarean section rate, a significant reduction was noted: from 54.8% to 40.3% (odds ratio, OR: 0.56; 95% confidence interval, CI: 0.52-0.59; χ(2) test: P < 0.001). The overall drop in the caesarean section rate was significant (χ(2) test: P < 0.001) and inversely correlated with the years (Spearman's ρ: -0.096; P < 0.001). Although complicated pregnancies increased after 2004, the primary caesarean section rate decreased annually by 20% on average in 2005-2011, after practice audits were implemented. Multiple logistic regression showed a positive association between the caesarean delivery rate and the rate of admission to the NICU (adjusted OR: 1.26; 95% CI: 1.14-1.40).

CONCLUSION

Patient and staff education and practice audits reduced the Caesarean section rate in a tertiary referral hospital without an increase in admissions to the NICU.

Caesarean section in the absence of need: a pathologising paradox for public health?

Caesarean section in the absence of need: a pathologising paradox for public health? This qualitative study explored the discourses constructing women's choice for a caesarean section, in the absence of clinical indication. The research was informed from the theoretical ideas of poststructuralism that presumes people's reality is shaped discursively through the discourses they encounter. A Foucauldian discourse analysis was undertaken of the transcripts of participant's interviews and the texts of both professional and popular media before inductively discerning the prevailing discourses that influence the choice of caesarean in the absence of need. In shaping women's choice in childbirth the discourses of autonomy, convenience and desire alongside fear and risk were identified in the talk and texts of women, childbirth professionals and popular culture. For the purposes of this article we have confined our focus to the findings related to how caesarean is represented in both professional and popular discourse and include feminist discussions around childbirth as an embodied practice. We contend that the discourses of autonomy, desire and risk unite with broader societal discourses to expose a pathologising paradox in which normal bodily performance emerges as abnormal and the abnormal as normal. The trend has implications for both future healthy populations and the equitable distribution of maternity resources.

Trinidadian women's knowledge, perceptions, and preferences regarding cesarean section: How do they make choices?

Objectives

The objective of this study is to determine the awareness of perception and attitude toward cesarean section (CS) in a high-user setting.

Design and methods

A cross-sectional design using multistage sampling methods was used to select participants from antenatal and postnatal clinics in a primary health care setting in north Trinidad. A multi-item structured questionnaire was designed and administered by in-depth interviews. Sociodemographic data and data about history of previous pregnancies and outcomes and about knowledge and perceptions of CSs were collected from women aged 16 years and older.

Results

Of the women who were eligible for entry into the study, 368 participated. However, participants chose not to respond to some questions. The majority of women (46.2%) were found to have very little information from which to make informed decisions about selecting CS as the preferred choice of delivery. Their preference was significantly associated with the perception of safety (maternal or fetal death, P = 0.001), difficulty (complications to mother and baby, P = 0.001), and pain (P = 0.001). Notwithstanding, persons who received information from health care professionals (odds ratio [OR], 1.9; confidence interval, 1.50–2.33) were more likely to have high or adequate levels of information about CSs. Data were analyzed using SPSS software, and ORs were calculated using logistic regression.

Conclusion

The majority of women attending antenatal and postnatal clinics in north Trinidad were not sufficiently knowledgeable about CS to enable them to make informed choices. In addition, the information obtained was from an unreliable source, emphasizing the need for information on CS to form a component of a structured antenatal education program.

Why is the Rate of Cesarean Section in Urban China so High? Is the Price Transparency Policy Working?

The caesarean section (CS) rate and non-clinically-indicated CS (NCS) rate in urban China are extremely high. On the demand side the assumed reason is China's one-child policy. We also assume that the supply side induces the CS demand, thus resulting in a continued rise in delivery expenditure. Therefore, so-called ‘price transparency policy’ was adopted to control costs. This study aims to prove that demand and supply factors may cause the high NCS rate, thus affecting the consequences of this policy, and causing a waste of resources and increased delivery expenditure. We conducted a multinomial logistic regression analysis to identify factors related to the high NCS rate, ANOVA and ANCOVA to compare the resource waste among the different delivery modes or hospitals. It was confirmed that the high NCS rate (37.7 per cent) in urban China might be predicted based not only on the demand factors (region of residence, parity, maternal age and weight gain), but also supply factors (hospital dummy). The price transparency policy requiring providers to disclose hospital charges information has thus led to inaccurate average CS charges, which confuse consumers, thus contributing to the overuse of NCS. Our study indicates that this policy could not effectively control costs.

Short-term maternal and neonatal outcomes by mode of delivery

OBJECTIVE

Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery.

STUDY DESIGN

Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4).

CONCLUSIONS

In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.

Vacuum assisted delivery in Ecuador for prolonged second stage of labor: maternal-neonatal outcome

BACKGROUND

In South America, and particularly Ecuador, cesarean section rates have risen markedly over the past five years. The associated increases in maternal morbidity and healthcare costs indicate the need for alternative strategies. Operative vaginal delivery is minimally utilized in Ecuador, as neither vacuum nor forceps have been available.

OBJECTIVE

As vacuum delivery was recently introduced to our clinical service, we sought to examine our initial experiences (i.e., maternal and neonatal outcome) with operative vaginal delivery for prolonged second stage of labor.

METHODS

Following an initial educational program at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, vacuum extraction cups (Mityvac, Cooper Surgical) were offered to laboring women with term singleton gestations and cephalic presentations no higher than +3 station. Maternal and neonatal data were analyzed.

RESULTS

During the study period, 100 vacuum applications were performed on laboring women complicated with prolonged second stage of labor. Mean maternal age was 23.8 +/- 6.4 years (range 14-41 years) with 57% of patients nulliparous. Left anterior and right posterior fetal positions were the most frequent (85% and 11%, respectively). Maternal complications included need for blood transfusion (1%), shoulder dystocia (1%) and perineal tears (first degree 6%, second degree 5%). Vaginal delivery was successful in 97% of cases. Among neonates, the average weight was 3149 +/- 410 g, with 10% neonates small for gestational age and 5% large for gestational age. Only 1% of infants presented an Apgar score <7 at 5 min. There were no scalp lacerations, cephalohematomas, or subgaleal bleeds.

CONCLUSIONS

In this initial observational study, vacuum extraction for prolonged second stage was safe and effective. We propose that the introduction of operative vaginal delivery to developing countries will mitigate rising cesarean section rates.

Factors related to the high cesarean section rate and their effects on the "price transparency policy" in Beijing, China

In urban China, many non-clinically indicated cesarean sections (NCSs) are performed, resulting in an unnaturally high cesarean section (CS) rate. NCSs represent CSs without any specific medical indications. The demand for NCS may be due to women's preference for CS and their belief in its safety and comfortableness. In addition, CS is more profitable for the supply side than vaginal delivery, which results in a continued rise in delivery expenditures. As a result, the so-called "price transparency policy", which forces hospitals to declare their average hospital charges, was adopted to control the delivery expenditures in the ongoing Chinese healthcare reform policy. The purpose of this study is to prove that the supply and demand factors affect the choice of delivery modes and more resources are consumed in NCS. The data of 680 live deliveries were collected from three hospitals in Beijing. Multinomial logistic regression analyses were conducted to identify the factors related to choosing NCS, and ANOVA and ANCOVA were used to compare the charges, proxy for resource utilization, among the delivery modes or hospitals. The results showed that the high NCS rate (37.7%) might be predicted not only based on the demand factors (region of residence, parity, maternal age and weight gain) but also on the supply factors (hospital dummy, revenue-staff ratio, bed turnover rate and obstetric medical staffs-delivery ratio), suggesting that such induced NCSs result in an unnecessarily high resource consumption. These data suggest that the present Chinese policy fails to control delivery expenditures.

Public Health Implications of Cesarean on Demand

Cesarean rates have been rising in the United States. Recently, there has been an upsurge of interest in "cesarean on maternal request" in the absence of any medical indication, a phenomenon that will further increase the cesarean rate. This trend may not be benign on a population basis, and reliable data are lacking. This article reviews reasons for the increasing cesarean rate, describes maternal and neonatal consequences likely to accrue with a policy of cesarean on demand, and explores larger implications for public health.

Economic implications of method of delivery

OBJECTIVE

This study was undertaken to examine the costs of hospital care associated with different methods of delivery.

STUDY DESIGN

An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared outcomes in nulliparous women at term undergoing spontaneous or induced labor for planned vaginal delivery, or undergoing cesarean delivery without labor. Costs that were assessed included physician fees, nursing hours in the labor and delivery, postpartum and neonatal intensive care units, epidural use, induction of labor agents, and consumables.

RESULTS

A total of 27,614 pregnancies satisfied inclusion and exclusion criteria, 5233 of which had labor induced. A comparison of mean costs per mother/infant pair demonstrated that cesarean delivery in labor ($2137) was increased compared with spontaneous vaginal delivery ($1340, P=.01), assisted vaginal delivery ($1594, P=.01), and cesarean delivery without labor ($1532, P=.01). The cost of delivery after induction of labor ($1715) was increased compared with spontaneous onset of labor ($1474, P<.001).

CONCLUSION

Cesarean delivery in labor occurs more frequently with labor induction and is associated with increased costs compared with other methods of delivery.

Association between method of delivery, puerperal complication rate and postpartum hysterectomy

OBJECTIVES

The aim of this study was to assess current maternal obstetrical risk associated with different modes of delivery concerning puerperal complications, especially postpartum hysterectomy.

MATERIALS AND METHODS

We studied the perinatal survey data 1998-2001 of the German state of Baden-Wurttemberg, comparing complication rates associated with method of delivery of different groups of pregnant women. For statistical analysis chi2-test, Fisher's exact test, Mantel-Haenzel statistics and relative risks (RR) were used to describe the risk to those exposed to the likelihood of undergoing a caesarean section.

RESULTS

Surgical delivery is associated with a significantly higher total puerperal complication rate and risk of postpartum hysterectomy (p < 0.0001, sample size = 354,160). If primary caesarean section for a singleton in cephalic presentation and more than 37 weeks' gestation is tested separately versus spontaneous vaginal delivery of a singleton in cephalic presentation and more than 37 weeks' gestation, the RR for puerperal complications is 3.38 (95% confidence interval [CI] 2.94-3.77), and the RR for postpartum hysterectomy is 7.96 (95% CI 3.96-16.00).

CONCLUSIONS

Surgical method of delivery is also subject to a propensity towards puerperal complications when primary caesarean sections are considered separately. The results support the concept that reducing caesarean delivery likelihood is a correct approach to providing primary prevention of caesarean-related maternal morbidity.

Unnecessary cesarean delivery in Louisiana: an analysis of birth certificate data

OBJECTIVE

The purpose of this study was to explore the temporal trends and factors that are associated with cesarean deliveries and potentially unnecessary cesarean deliveries.

STUDY DESIGN

The Louisiana birth certificate database was evaluated to identify a total of 57 potential indications/risk factors and maternal demographic factors that are associated with methods of delivery over the period from January 1993 to December 2000. A cesarean delivery without any potential indications/risk factors in the birth certificate was classified as unnecessary.

RESULTS

The primary cesarean delivery rate decreased and the repeat cesarean delivery rate increased significantly during the study period. But neither the absence nor the presence of potential indications/risk factors accounted for these changes. The average potentially unnecessary primary and repeat cesarean deliveries in Louisiana were 17 and 43, respectively, per 100 cesarean deliveries over the years 1993 through 2000.

CONCLUSION

The proportions of potentially unnecessary cesarean deliveries are relatively high in Louisiana. It is important to explore the influence of nonclinical factors on unnecessary cesarean delivery to reduce the cesarean rates.

Cesarean section on demand

The safety of cesarean section has improved dramatically over the past 50 years. During the past 20 years a greater awareness of and discussion about the symptomatic morbidity that can result for women following vaginal delivery has occurred and women's expectations for the outcome of pregnancy for them and their babies has increased. A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by cesarean section rather than the reverse. With the balance in favor of benefit for the baby from delivery by cesarean section, it is now difficult to sustain the argument favoring vaginal delivery rather than planned cesarean section, using maternal morbidity and mortality statistics. A critical evaluation of the costs indicates that there are probably few grounds for denying women their request for cesarean section for economic reasons. It seems likely, therefore, that in the near future those advising women on the options for delivery will need to ensure that the risks of vaginal delivery are explained as well as those for planned cesarean section.

Cesarean section on request: a case for common sense

Considering the patient's right to autonomy and the trend towards more involvement of the patient in the decision making, it is our belief that obstetricians should consider the woman's request for cesarean section without medical indication. The procedure can only be carried out after obtaining proper consent of the patient with careful information including a detailed description of the possible risks and benefits of both modes of delivery. In order to decrease the risk of respiratory distress syndrome, cesarean section under these circumstances should not be performed prior to 39 weeks' gestation. Debating over whether or not to charge women who request a cesarean section that is not medically indicated is fruitless, since rigorous cost studies are lacking and since any implementation of such a system would be extremely difficult.

[Cesarean section on demand--an equivalent alternative to spontaneous delivery?]

Due to advances in perioperative management, surgical techniques as well as anaesthesia, caesarean section has become a very safe intervention for mother and child. In certain high-risk situations, an early delivery by caesarean section can prevent serous morbidity and mortality of the fetus and newborn. It has been postulated that a planned caesarean section is a true alternative to vaginal birth, and in the absence of a specific medical reason the woman's demand may be an indication for the operation. A critical review of studies based on large regional perinatal datasets shows that the risk for minor as well as serious complications in the mother and the newborn is increased after planned caesarean section. Serious consequences for subsequent pregnancies like uterine rupture or placenta praevia, which may be associated with accreta or abruptio of the placenta, are of major concern. On the other hand, trauma to the pelvic floor with urinary or anal incontinence is more frequent after vaginal birth. The balance of these risks including the very rare cases of severe intrapartal asphyxia, which might be prevented by a planned caesarean section, must be carefully evaluated together with the patient on an individual basis. These risks must be carefully balanced and the final decision about the type of delivery requires a detailed informed consent.critical review of studies based on large regional perinatal datasets shows that the risk for minor as well as serious complications in the mother and the newborn is increased after planned caesarean section. Serious consequences for subsequent pregnancies like uterine rupture or placenta praevia, which may be associated with accreta or abruptio of the placenta, are of major concern. On the other hand, trauma to the pelvic floor with urinary or anal incontinence is more frequent after vaginal birth. The balance of these risks including the very rare cases of severe intrapartal asphyxia, which might be prevented by a planned caesarean section, must be carefully evaluated together with the patient on an individual basis. These risks must be carefully balanced and the final decision about the type of delivery requires a detailed informed consent.