Caesarean sections and health financing: a global analysis

Systematic review and meta-analysis examining the effects of midwife care on cesarean birth

BACKGROUND

The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births.

METHODS

We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse-variance random-effects meta-analysis was used to generate overall odds ratios (ORs).

RESULTS

We observed a significantly lower likelihood of cesarean birth in midwife-led care, midwife-attended births, among those who received instruction pre-birth from midwives, and within institutions with a midwifery presence.

CONCLUSIONS

Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.

Fast Healthcare Interoperability Resources-Based Support System for Predicting Delivery Type: Model Development and Evaluation Study

BACKGROUND

The escalating prevalence of cesarean delivery globally poses significant health impacts on mothers and newborns. Despite this trend, the underlying reasons for increased cesarean delivery rates, which have risen to 36.3% in Portugal as of 2020, remain unclear. This study delves into these issues within the Portuguese health care context, where national efforts are underway to reduce cesarean delivery occurrences.

OBJECTIVE

This paper aims to introduce a machine learning, algorithm-based support system designed to assist clinical teams in identifying potentially unnecessary cesarean deliveries. Key objectives include developing clinical decision support systems for cesarean deliveries using interoperability standards, identifying predictive factors influencing delivery type, assessing the economic impact of implementing this tool, and comparing system outputs with clinicians' decisions.

METHODS

This study used retrospective data collected from 9 public Portuguese hospitals, encompassing maternal and fetal data and delivery methods from 2019 to 2020. We used various machine learning algorithms for model development, with light gradient-boosting machine (LightGBM) selected for deployment due to its efficiency. The model's performance was compared with clinician assessments through questionnaires. Additionally, an economic simulation was conducted to evaluate the financial impact on Portuguese public hospitals.

RESULTS

The deployed model, based on LightGBM, achieved an area under the receiver operating characteristic curve of 88%. In the trial deployment phase at a single hospital, 3.8% (123/3231) of cases triggered alarms for potentially unnecessary cesarean deliveries. Financial simulation results indicated potential benefits for 30% (15/48) of Portuguese public hospitals with the implementation of our tool. However, this study acknowledges biases in the model, such as combining different vaginal delivery types and focusing on potentially unwarranted cesarean deliveries.

CONCLUSIONS

This study presents a promising system capable of identifying potentially incorrect cesarean delivery decisions, with potentially positive implications for medical practice and health care economics. However, it also highlights the challenges and considerations necessary for real-world application, including further evaluation of clinical decision-making impacts and understanding the diverse reasons behind delivery type choices. This study underscores the need for careful implementation and further robust analysis to realize the full potential and real-world applicability of such clinical support systems.

Biomechanical Modeling of Cesarean Section Scars and Scar Defects

Uterine rupture is an intrinsically biomechanical process associated with high maternal and fetal mortality. A previous Cesarean section (C-section) is the main risk factor for uterine rupture in a subsequent pregnancy due to tissue failure at the scar region. Finite element modeling of the uterus and scar tissue presents a promising method to further understand and predict uterine ruptures. Using patient dimensions of an at-term uterus, a C-section scar was modeled with an applied intrauterine pressure to study how scars affect uterine stress. The scar positioning and uterine thickness were varied, and a defect was incorporated into the scar region. The modeled stress distributions confirmed clinical observations as the increased regions of stress due to scar positioning, thinning of the uterine walls, and the presence of a defect are consistent with clinical observations of features that increase the risk of uterine rupture.

Association between the stage of labour during caesarean delivery with adverse maternal and neonatal outcomes among referred mothers to tertiary centres in resource-limited settings

OBJECTIVE

Although the caesarean delivery (CD) rate has substantially increased, little is known about its impacts when performed in the first and second stages of labour on fetomaternal outcomes, especially among referred mothers. Thus, this study aimed to investigate the association between CDs performed during the first and second stages of labour and poor maternal and neonatal outcomes among mothers referred to tertiary centres.

SETTING

This retrospective cohort study analysed medical records of mother-infant pairs from September 2020 to May 2023 in Southern Ethiopia.

PARTICIPANTS

We retrospectively collected data from 848 participants who underwent emergency CD on a referral basis during the study period.

PRIMARY OUTCOME MEASURE

The primary outcomes of interest were adverse maternal and neonatal outcomes. Data were analysed using descriptive and inferential statistics.

RESULTS

Of the 848 CDs, 722 (85.2%) and 126 (14.8%) were performed at the first and second stages of labour, respectively. Caesarean sections performed at the second stage were higher with nulliparity, increased maternal age, and birth weight. Compared with the first-stage CD, the second-stage CD was associated with a significantly increased risk of adverse maternal (OR 3.7, 95% CI 2.4 to 5.7) and neonatal outcomes (OR 2.0; 95% CI 1.3 to 2.9), including neonatal death.

CONCLUSION

Second-stage CDs have an increased risk of adverse maternal and neonatal outcomes. Strengthening and improving obstetric emergency surgical services and intensive neonatal care for those populations would help decrease the maternal and fetal negative consequences.

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.

Factors contributing to socio-economic inequality in utilization of caesarean section delivery among women in Indonesia: Evidence from Demographic and Health Survey

BACKGROUND

Most of the existing literature in developing countries focused on either the rising trend of CS or its determinants. There is a paucity of population-based studies on existing socioeconomic inequalities in availing CS services by women in Indonesia. This study aimed to assess the factors associated with caesarian section (CS) delivery and explore the various factors contributing to inequalities in CS delivery rates in Indonesia.

METHODS

The study utilized nationally representative cross-sectional data from the Indonesia Demographic and Health Survey (IDHS), 2017. We conducted multivariable logistic regression to find the factors associated with CS delivery. Concentration index and Wagstaff's decomposition analysis were used to examine the socioeconomic inequalities in CS delivery among women and associated factors.

RESULTS

About 17% of women in Indonesia delivered babies through CS. A concentration index of 0.31 in CS delivery rate showed a higher CS delivery rate among women belonging to rich households. About 44.7% of socioeconomic status inequality in CS delivery was explained by educational status among women who went for CS delivery. Women's place of residence explained 30.1% of socioeconomic inequality, and women's age at first birth explained about 11.9% and reporting ANC visits explained 8.4% of the observed inequality. Highest socioeconomic inequality was witnessed in central Sulawesi (0.529), followed by Maluku (0.488) and West Kalimantan (0.457), whereas the lowest was recorded in Yogyakarta (0.021) followed by north Sulawesi (0.047) and east Kalimantan (0.171). Education (44.7%) followed by rural-urban place of residence (30.1%) and age of first birth (11.9%) contributed most to explain the gap in CS delivery among rich and poor women.

CONCLUSION

The study highlighted the higher CS delivery rates among women from higher socioeconomic groups and thus, it is important to frame policies after identifying the population subgroups with potential underuse or overuse of CS method of delivery.

Evolution of cesarean sections in Colombia and its association with the legal standing of the institutions where deliveries take place

Objectives

To describe how the frequency of cesarean section has evolved in Colombia since 1998, both in overall terms as well as discriminated according to the legal standing of the healthcare providers (IPSs) where delivery takes place, and to estimate the size of the association between the legal standing of the institutions and the performance of cesarean sections between 2015 and 2017.

Material and methods

A cross-sectional cohort study that describes the frequency of cesarean deliveries between 1998 and 2020, plus an analytical component to estimate the association between the legal nature and the route of delivery between 2015 and 2017, based on the birth records of the Colombian National Statistics Administrative Department (DANE). The prevalence ratio was used as an estimator of this association.

Results

In 1998, the proportion of cesarean deliveries was 25.7 %; it increased to 46.4 % by 2015 and then dropped to 44.6 % by 2020. After 1998, the proportion of cesarean sections in public hospitals increased from 26.2 % to 42.9 % by 2014, while in private providers it increased from 45.0 % to 57.7 % by 2013. The prevalence ratio of cesarean sections in private versus public institutions was 1.57 (95 % CI: 1.56-1.57).

Conclusions

After a long period of sustained growth, there is now a reduction in the proportion of cesarean sections in the country. In public health care institutions, these procedures increased in greater proportion during most of the study period, while in private healthcare providers they are carried out at a higher frequency in all subgroups of women. It will be necessary to evaluate in the future, using more robust methodologies, whether the decrease in the frequency of cesarean section is a real or secular trend.

Conflicting attitudes between clinicians and women regarding maternal requested caesarean section: a qualitative evidence synthesis

BACKGROUND

Caesarean section (CS) can be a life-saving operation but might also negatively affect the health of both the woman and the baby. The aim of this study was to synthesize and contrast women's and clinicians' attitudes toward maternal-requested CS, and their experiences of the decision-making process around CS.

METHODS

The databases of CINAHL, MEDLINE, PsycInfo and Scopus were screened. All qualitative studies that answered the study question and that were assessed to have minor or moderate methodological limitations were included. Synthesised findings were assessed using GRADE-CERQual.

RESULTS

The Qualitative Evidence Synthesis included 14 qualitative studies (published 2000-2022), involving 242 women and 141 clinicians. From the women's perspectives, two themes arose: women regarded CS as the safest mode of birth; and women's rights to receive support and acceptance for a CS request. From the clinicians' perspectives, four themes emerged: clinicians were concerned about health risks associated with CS; demanding experience to consult women with a CS request; conflicting attitudes about women's rights to choose a CS; and the importance of respectful and constructive dialogue about birthing options.

CONCLUSION

Women and clinicians often had different perceptions regarding the right of a woman to choose CS, the risks associated with CS, and the kind of support that should be part of the decision-making process. While women expected to receive acceptance for their CS request, clinicians perceived that their role was to support the woman in the decision-making process through consultation and discussion. While clinicians thought it was important to show respect for a woman's birth preferences, they also felt the need to resist a woman's request for CS and encourage her to give birth vaginally due to the associated increases in health risks.

Utilisation of private general practitioners to provide caesarean deliveries in five rural district public hospitals in South Africa: a mixed-methods study

OBJECTIVE

Researching how public-private engagements may promote universal access to safe obstetric care including caesarean delivery is essential. The aim of this research was to document the utilisation of private general practitioners (GPs) contracted to provide caesarean delivery services in five rural district hospitals in the Western Cape, the profile and outcomes of caesarean deliveries. We also describe stakeholder experiences of these arrangements in order to inform potential models of public-private contracting for obstetric services.

DESIGN

We used a mixed-methods study design to describe rural district hospitals' utilisation of private GP contracting for caesarean deliveries. Between April 2021 and March 2022, we collated routine data from delivery and theatre registers to capture the profile of deliveries and maternal outcomes. We conducted 23 semistructured qualitative interviews with district managers, hospital-employed doctors and private GPs to explore their experiences of the contracting arrangements.

SETTING

The study was conducted in five rural district hospitals in the Western Cape province, South Africa.

RESULTS

The use of private GPs as surgeon or anaesthetist for caesarean deliveries differed widely across the hospitals. Overall, the utilisation of private GPs for anaesthetics was similar (29% of all caesarean deliveries) to the utilisation of private GPs as surgeons (33% of all caesarean deliveries). The proportion of caesarean deliveries undertaken by private GPs as the primary surgeon was inversely related to size of hospital and mean monthly deliveries. Adverse outcomes following a caesarean delivery were rare. Qualitative data provided insights into contributions made by private GPs and the contracting models, which did not incentivise overservicing.

CONCLUSION

The findings of this study suggest that private GPs can play an important role in filling gaps and expanding quality care in rural public facilities that have insufficient obstetric skills and expertise. Different approaches to enable access to safe caesarean delivery are needed for different contexts, and contracting with experienced private GP's is one resource for rural district hospitals to consider.

Rates of instrumental vaginal birth and cesarean and quality of maternal and newborn health care in private versus public facilities: Results of the IMAgiNE EURO study in 16 countries

OBJECTIVE

To explore the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic by facility type among 16 European countries, comparing rates of instrumental vaginal birth and cesarean.

METHODS

Women who gave birth in the WHO European Region from March 1, 2020, to February 7, 2022, answered a validated online questionnaire. Rates of instrumental birth, instrumental vaginal birth, and cesarean, and a QMNC index were calculated for births in public versus private facilities.

RESULTS

Responses from 25 206 participants were analyzed. Women giving birth in private compared with public facilities reported significantly more frequent total cesarean (32.5% vs 19.0%; aOR 1.70; 95% CI 1.52-1.90), elective cesarean (17.3% vs 7.8%; aOR 1.90; 95% CI 1.65-2.19), and emergency cesarean before labor (7.4% vs 3.9%; aOR 1.39; 95% CI 1.14-1.70) (P < 0.001 for all comparisons), with analyses by country confirming these results. QMNC index results were heterogeneous across countries and regions in the same country and were largely affected by geographical distribution of regions rather than by type of facility alone.

CONCLUSION

The study confirms that births in private facilities have higher odds of cesarean. It also suggests that QMNC should be closely monitored in all facilities to achieve high-quality care, independent of facility type or geographical distribution.

CLINICALTRIALS

GOV IDENTIFIER

NCT04847336.

Office hours and caesarean section: systematic review and Meta-analysis

BACKGROUND

Unnecessary caesarean births may be affected by physician factors, such as preferences, incentives and convenience. Delivery during office hours can be a valuable proxy for measuring such effects.

OBJECTIVE

To determine the effect of office hours on the decision for caesarean delivery by assessing the odds of caesarean during office hours compared to out-of-office hours.

SEARCH STRATEGY

We searched CINAHL, ClinicalTrials.gov , The Cochrane Library, PubMed, Scopus and Web of Science from the beginning of records through August 2021.

DATA COLLECTION AND ANALYSIS

Search results were screened by three researchers. First, we selected studies that reported odds ratios of caesareans, or data allowing their calculation, for office and out-of-office hours. We extracted data on the study population, study design, data sources, setting, type of caesarean section, statistical analysis, and outcome measures. For groups reporting the same outcome, we performed a standard inverse-variance random-effects meta-analysis, which enabled us to calculate the overall odds ratios for each group. For groups reporting varying outcomes, we performed descriptive analysis.

MAIN RESULTS

Meta-analysis of weekday vs weekend for any caesarean section showed higher odds of caesarean during weekdays in adjusted analysis 1.40 (95%CI 1.13, 1.72 from 1,952,691 births). A similar effect was observed in the weekday vs Sunday comparison (1.39, 95%CI 1.10, 1.75, 150,932 births). A lower effect was observed for emergency CS, with a slight increase in adjusted analysis (1.06, 95%CI 0.90, 1.26, 2,622,772 births) and a slightly higher increase in unadjusted analysis (1.15, 95%CI 1.03, 1.29, 12,591,485 births). Similar trends were observed in subgroup analyses and descriptive synthesis of studies examining other office hours outcomes.

CONCLUSIONS

Delivery during office hours is associated with higher odds for overall caesarean sections and little to no effect for emergency caesarean. Non-clinical factors associated with office hours may influence the decision to deliver by caesarean section. Further detailed investigation of the "office hours effect" in delivery care is necessary and could lead to improvements in care systems.

FUNDING

The authors received no direct funding for this study.