Do physicians and their relatives have a decreased rate of cesarean section? A 4-year population-based study in Taiwan

Comparison of Labor and Delivery Complications and Delivery Methods Between Physicians and White-Collar Workers

To evaluate labor and delivery complications and delivery modes between physicians and white-collar workers in Taiwan, this retrospective population-based study used data from Taiwan’s National Health Insurance Research Database. We compared 1530 physicians aged 25 to 50 years old who worked and had singleton births between 2007 and 2013 with 3060 white-collar workers matched by age groups, groups of monthly insured payroll-related premiums, previous cesarean delivery, perinatal history anemia, and gestational diabetes mellitus. The logistic regression models were used to assess the labor and delivery complications between the two groups. Multivariate analysis revealed that physicians had a significantly higher risk of placenta previa (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.08–1.69) and other malpresentation (OR 1.86, 95% CI 1.45–2.39) than white-collar workers, whereas they had a significantly lower risk of placental abruption (OR 0.53, 95% CI 0.40–0.71), preterm delivery (OR 0.75, 95% CI 0.61–0.92), and premature rupture of membranes (OR 0.72, 95% CI 0.59–0.88). Increased risks of some adverse labor and delivery complications were observed among physicians, when compared to white-collar workers. These findings suggest that working women should take preventative action to manage occupational risks during pregnancy.

Do informed consumers in Taiwan favour larger hospitals? A 10-year population-based study on differences in the selection of healthcare providers among medical professionals, their relatives and the general population

OBJECTIVES

Exploring whether medical professionals, who are considered to be 'informed consumers' in the healthcare system, favour large providers for elective treatments. In this study, we compare the inclination of medical professionals and their relatives undergoing treatment for childbirth and cataract surgery at medical centres, against those of the general population.

DESIGN

Retrospective study using a population-based matched cohort data.

PARTICIPANTS

Patients who underwent childbirth or cataract surgery between 1 January 2004 and 31 December 2013.

PRIMARY AND SECONDARY OUTCOMES MEASURES

We used multiple logistic regression to compare the ORs of medical professionals and their relatives undergoing treatment at medical centres, against those of the general population. We also compared the rate of 14-day re-admission (childbirth) and 14-day reoperation (cataract surgery) after discharge between these groups.

RESULTS

Multivariate analysis showed that physicians were more likely than patients with no familial connection to the medical profession to undergo childbirth at medical centres (OR 5.26, 95% CI 3.96 to 6.97, p<0.001), followed by physicians' relatives (OR 2.68, 95% CI 2.20 to 3.25, p<0.001). Similarly, physicians (OR 1.63, 95% CI 1.21 to 2.19, p<0.01) and their relatives (OR 1.43, 95% CI 1.13 to 1.81, p<0.01) were also more likely to undergo cataract surgery at medical centres. Physicians also tended to select healthcare providers who were at the same level or above the institution at which they worked. We observed no significant difference in 14-day re-admission rates after childbirth and no significant difference in 14-day reoperation rates after cataract surgery across patient groups.

CONCLUSIONS

Medical professionals and their relatives are more likely than the general population to opt for service at medical centres. Understanding the reasons that medical professionals and general populations both have a preferential bias for larger medical institutions could help improve the efficiency of healthcare delivery.

Understanding the relationship between cesarean birth and stress, anxiety, and depression after childbirth: A nationwide cohort study

BACKGROUND

Women who undergo cesarean birth might have an increased risk for poor mental health after childbirth, possibly because of maternal and neonatal physical problems, low parental confidence, and decreased levels of oxytocin. However, this relationship remains controversial and requires further examination. The study aimed to examine the effect of cesarean birth on postpartum stress, anxiety, and depression.

METHODS

This nationwide population-based cohort study was conducted using the Taiwan National Health Insurance Database. A total of 12 619 women who underwent cesarean birth and 12 619 control women who underwent vaginal birth were matched by propensity score based on age, socioeconomic status, residential urbanicity, antepartum comorbidity, and index year of delivery. We compared the incidence of stress, anxiety, and depression during the first postpartum year between cesarean and comparison groups by calculating incidence rate ratios (IRRs).

RESULTS

The cesarean group showed a significantly higher risk for stress symptoms (IRR 1.4 [95% confidence interval {CI} 1.02-1.92]), but not anxiety (IRR 1.14 [95% CI 0.95-1.38]) or depression (IRR 1.32 [95% CI 0.94-1.87]), although the IRRs were also greater than one. The cesarean group had a significantly higher risk of any of the above-listed three disorders than the comparison group (incidence 27.6 vs 23.4 per 1000 person-years; IRR 1.18 [95% CI 1.01-1.38]).

CONCLUSIONS

Cesarean birth was associated with an increased risk of postpartum stress symptoms. Health professionals should avoid unnecessary cesarean birth, pay attention to women who deliver by cesarean, and intervene appropriately in an attempt to improve mental health among postpartum women.

Does Pay-For-Performance Program Increase Providers Adherence to Guidelines for Managing Hepatitis B and Hepatitis C Virus Infection in Taiwan?

Background

Many people are concerned about that the quality of preventive care for patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is suboptimal. Taiwan, a hyperendemic area of chronic HBV and HCV infection, implemented a nationwide pay-for-performance (P4P) program in 2010, which aimed to improve the preventive care provided to HBV and HCV patients by increasing physicians’ adherence to guidelines through financial incentives. The objective of this study was to evaluate the early effects of the P4P program on utilization of preventive services by HBV and HCV patients.

Methods

Using a quasi-experimental design with propensity score matching method, we matched the HBV and HCV patients enrolled in the P4P program with non-enrollees in 2010, resulting in 21,643 patients in each group. Generalized estimating equations was applied to examine the difference-in-difference effects of P4P program enrollment on the utilization of three guideline-recommended preventive services (regular outpatient follow-up visits, abdominal ultrasonography (US) examinations, and aspartate aminotransferase and alanine aminotransferase (AST/ALT) tests by HBV and HCV patients.

Results

The P4P program enrollees were significantly more likely to attend twice-annual follow-up visits, to receive recommended US examinations and AST/ALT tests, than non-enrollees.

Conclusions

The results of our preliminary assessment indicate that financial incentives offered by the P4P program was associated with a modest improvement in adherence to guidelines for better chronic HBV and HBC management.

The Effects of Anti-Dementia and Nootropic Treatments on the Mortality of Patients with Dementia: A Population-Based Cohort Study in Taiwan

Background

Few studies have examined the contribution of treatment on the mortality of dementia based on a population-based study.

Objective

To investigate the effects of anti-dementia and nootropic treatments on the mortality of dementia using a population-based cohort study.

Methods

12,193 incident dementia patients were found from 2000 to 2010. Their data were compared with 12,193 age- and sex-matched non-dementia controls that were randomly selected from the same database. Dementia was classified into vascular (VaD) and degenerative dementia. Mortality incidence and hazard ratios (HRs) were calculated.

Results

The median survival time was 3.39 years (95% confidence interval [CI]: 2.88–3.79) for VaD without medication, 6.62 years (95% CI: 6.24–7.21) for VaD with nootropics, 3.01 years (95% CI: 2.85–3.21) for degenerative dementia without medication, 8.11 years (95% CI: 6.30–8.55) for degenerative dementia with anti-dementia medication, 6.00 years (95% CI: 5.73–6.17) for degenerative dementia with nootropics, and 9.03 years (95% CI: 8.02–9.87) for degenerative dementia with both anti-dementia and nootropic medications. Compared to the non-dementia group, the HRs among individuals with degenerative dementia were 2.69 (95% CI: 2.55–2.83) without medication, 1.46 (95% CI: 1.39–1.54) with nootropics, 1.05 (95% CI: 0.82–1.34) with anti-dementia medication, and 0.92 (95% CI: 0.80–1.05) with both nootropic and anti-dementia medications. VaD with nootropics had a lower mortality (HR: 1.25, 95% CI: 1.15–1.37) than VaD without medication (HR: 2.46, 95% CI: 2.22–2.72).

Conclusion

Pharmacological treatments have beneficial effects for patients with dementia in prolonging their survival.

Caesarean delivery before 39 weeks associated with selecting an auspicious time for birth in Taiwan

BACKGROUND

Caesarean delivery before 39 weeks of gestation increases the risk of morbidity among infants. Taiwan has one of the highest caesarean rates in the world, but little attention has been paid to this issue. This study aimed to describe the rate of caesarean delivery before 39 weeks gestation among women who did not have labour signs and had a non-emergency caesarean delivery in Taiwan and to examine whether the phenomenon was associated with the Chinese cultural practice of selecting an auspicious time for birth.

METHODS

We recruited women at 15-28 weeks of pregnancy at 5 hospitals in northern Taiwan and followed them at 4 or 5 weeks after delivery using structured questionnaires. This analysis included 150 primiparous mothers with a singleton pregnancy who had a non-emergency caesarean delivery without the presence of labour signs.

RESULTS

Ninety-three of these women (62.0%) had caesarean deliveries before 39 weeks of gestation. Logistic regression analysis showed that women who had selected an auspicious time for delivery (OR=2.82, 95% CI: 1.15-6.95) and delivered in medical centres (OR=5.26, 95% CI: 2.25-12.26) were more likely to deliver before 39 weeks of gestation.

CONCLUSION

Non-emergency caesarean delivery before 39 weeks of gestation was common among the study women, and was related to the Chinese cultural practice of selecting an auspicious time for birth. Further studies are needed to examine the risks and benefits associated with timing of caesarean delivery in Taiwan in order to generate a consensus among obstetricians and give pregnant women appropriate information.

Do physicians with diabetes have differences in dialysis use and survival than other patients with diabetes

AIMS

To assess whether the increased knowledge and resources available to physicians led to differences in dialysis and survival rates between physicians and non-physician patients with diabetes.

METHODS

All newly diagnosed (1997-2009) type 2 diabetes patients aged ≥35 years from the National Health Insurance Program of Taiwan database were included. After propensity score matching (1:10), we estimated the relative risk of dialysis and death using Cox proportional hazards model adjusted for demographic characteristics and comorbidities.

RESULTS

Physicians with diabetes were more likely to start dialysis than general patients, with a 48% increased hazard risk (HR) (P=0.006). Physicians with diabetes had significantly lower risk of death (HR: 0.88; P=0.025). However, those requiring dialysis had a non-significant increased risk of death (HR: 1.19). There was an increased HR for death in older physicians (HR: 1.81; P<0.001) and those with cancer or catastrophic illness. The HR of dialysis (7.89; P<0.0001) increased dramatically with increasing Charlson Comorbidity Index scores.

CONCLUSIONS

Physicians with DM survived longer than other patients with diabetes, likely benefiting from their professional resources in disease control and prevention. Nonetheless, they displayed no advantage from their medical backgrounds compared with the general patients if they developed end stage renal disease.

Do nurses have worse pregnancy outcomes than non-nurses?

BACKGROUND

Nurses encounter multiple occupational exposures at work which may harm their reproductive health. The purpose of the study was to compare pregnancy complications and outcomes including cesarean deliveries, tocolysis, miscarriage, and preterm labor between female nurses and comparable women who were not nurses in Taiwan.

METHODS

This nationwide population-based study was performed using the National Health Insurance Research Database from 1997 to 2008. We identified 3,656 pregnancies among 2,326 nurses and 111,889 pregnancies among 74,919 non-nurses. A generalized estimating equation was used to compare risks between the two groups.

RESULTS

The rates of tocolysis (28.6 vs 22.3%), miscarriage (6.0 vs 5.3%), and preterm labor (8.1 vs 4.4%) were significantly higher among nurses than non-nurses. After adjustment for background differences, nurses had significantly higher risks for cesarean section (adjusted OR 1.12 [95% confidence interval (CI) 1.03-1.22]), tocolysis (OR 1.18 [95% CI 1.09-1.29]), and preterm labor (OR 1.46 [95% CI 1.28-1.67]) than non-nurses.

CONCLUSIONS

Nurses are at higher risk for cesarean section, tocolysis, and preterm labor than non-nurses. Occupational exposure related to these adverse pregnancy outcomes should be examined. Strategies to decrease the risks should be developed to improve reproductive health among nurses.

Mind the information gap: fertility rate and use of cesarean delivery and tocolytic hospitalizations in Taiwan

BACKGROUND

Physician-induced demand (PID) is an important theory to test given the longstanding controversy surrounding it. Empirical health economists have been challenged to find natural experiments to test the theory because PID is tantamount to strong income effects. The data requirements are both a strong exogenous change in income and two types of treatment that are substitutes but have different net revenues. The theory implies that an exogenous fall in income would lead physicians to recoup their income by substituting a more expensive treatment for a less expensive treatment. This study takes advantages of the dramatic decline in the Taiwanese fertility rate to examine whether an exogenous and negative income shock to obstetricians and gynecologists (ob/gyns) affected the use of c-sections, which has a higher reimbursement rate than vaginal delivery under Taiwan's National Health Insurance system during the study period, and tocolytic hospitalizations.

METHODS

The primary data were obtained from the 1996 to 2004 National Health Insurance Research Database in Taiwan. We hypothesized that a negative income shock to ob/gyns would cause them to provide more c-sections and tocolytic hospitalizations to less medically-informed pregnant women. Multinomial probit and probit models were estimated and the marginal effects of the interaction term were conducted to estimate the impacts of ob/gyn to birth ratio and the information gap.

RESULTS

Our results showed that a decline in fertility did not lead ob/gyns to supply more c-sections to less medically-informed pregnant women, and that during fertility decline ob/gyns may supply more tocolytic hospitalizations to compensate their income loss, regardless of pregnant women's access to health information.

CONCLUSION

The exogenous decline in the Taiwanese fertility rate and the use of detailed medical information and demographic attributes of pregnant women allowed us to avoid the endogeneity problem that threatened the validity of prior research. They also provide more accurate estimates of PID.JEL Classification: I10, I19, C23, C25.

Women's preference for cesarean delivery and differences between Taiwanese women undergoing different modes of delivery

BACKGROUND

The rate of cesarean delivery was 35% in 2007 in Taiwan. It is unclear how many of the cesarean deliveries were without medical indications. Women's preference for cesarean delivery during their course of pregnancy has rarely been studied and therefore our objectives were to examine rate of cesarean deliveries without medical indications, to explore women's preference for cesarean delivery as their gestation advances, and to compare background and perinatal factors among women who underwent different modes of delivery in Taiwan.

METHODS

This prospective study applied a longitudinal design. The study participants were 473 women who received prenatal care at four hospitals in Taipei and answered structured questionnaires at 20 to 24 weeks of pregnancy, 34 to 36 weeks of pregnancy, and 5 to 7 weeks after delivery.

RESULTS

Of the 151 women (31.9%) who had cesarean deliveries, 19.9% were without medical indication. Three indications: malpresentation, prior cesarean section, and dysfunctional labor together accounted for 82.6% of cesarean section with medical indications. The prevalence of maternal preference for cesarean delivery was found to be 12.5% and 17.5% during the second and third trimester, respectively. Of the women who preferred cesarean delivery during the second trimester, 93.2% eventually had a cesarean delivery. Women who were older, with older spouses, and who had health problems before or during pregnancy were more likely to have cesarean deliveries.

CONCLUSIONS

About 20% of cesarean deliveries were without medical indications. Women's preference for cesarean delivery during the second trimester predicts subsequent cesarean delivery. Counseling regarding mode of delivery should be offered early in pregnancy, especially for women who are older or with older spouses, have health problems, or had a prior cesarean section.

Pregnancy outcomes among native and foreign-born women in Taiwan: maternal health utilization

BACKGROUND

As immigrant populations increase rapidly around the world and with most immigrant women being of childbearing age, their use of pregnancy-related healthcare has become an important health issue. However, there has been only limited research available on maternal health use by foreign immigrants in Asia. This study aims to compare inpatient use for pregnancy complications and type of delivery among foreign and native-born women of different socioeconomic status in Taiwan.

METHODS

Using the 2001 National Health Insurance (NHI) database, 232,828 deliveries were identified, of which 222,852 were to native-born mothers and 9,976 were to foreign-born mothers. Univariate and multivariate logistic regression models were used to determine the likelihood of using inpatient services for any pregnancy complication and for cesarean section.

RESULTS

Our results indicate that after adjusting for other factors, foreign-born women were less likely than native-born women to use inpatient services for complicated pregnancies across all socioeconomic status (SES) levels. On the other hand, a pattern emerged among the higher SES groups showing a similar likelihood of cesarean section when foreign-born and native-born mothers were compared. This was not the case for the lower SES groups, however, where native-born mothers were significantly more likely to undergo a cesarean section than foreign-born mothers.

CONCLUSIONS

Foreign-born mothers tended to use fewer inpatient services for complicated pregnancies than native-born mothers and were less likely to undergo cesarean section. As immigrants increase across the world as a result of globalization and with half of them being female, pregnancy-related health service use among this group needs our attention.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

OBJECTIVE

To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery.

DESIGN

Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health.

SETTING

410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data

PARTICIPANTS

106,546 deliveries reported during the three month study period, with data available for 97,095 (91% coverage).

MAIN OUTCOME MEASURES

Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics.

RESULTS

Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective.

CONCLUSIONS

Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.

Factors affecting Taiwanese women's choice of Cesarean section

The rising rate of cesarean section (CS) is a subject of concern, intensive discussion, and investigation. However, few, if any, systematic studies of this trend have been recorded among the oriental populations. This study examines factors that may contribute to the high incidence of CS in Taiwan, where the rate of CS is among the highest in the world. Multiple logistic regression and stratified analyses were used to determine the association between CS and various factors, including provider and patient parameters. Our study sample of 2,497 cases was drawn from a total of 10,654 in-patient deliveries in Chang Gung Memorial Hospital of Taiwan. A number of factors associated with the use of CS were explored, including maternal age, occupation, education and marital status of the mother, sex and body weight of the infant at birth, parity, insurance status, source of admission, and time of birth. Our study also shows that CS in Taiwan is affected by the folk belief of Pe-Ji, which influences the preference of some patients for delivery at a specific time. Such a preference reflects a unique right of choice by women in Taiwan.