Why it’s not necessarily about you

We know that many of the caesarean sections that are carried out today aren’t medically warranted. A related concern is that a proportion of these may be being carried out in the interests of profit rather than for the benefit of women and babies, so I was interested to see the publication of a systematic review and meta-analysis which looked at the relationship between the caesarean section rate and the for-profit status of the hospital.

Sadly, the results of this analysis are clear, compelling and unequivocal. Caesarean sections are more likely to be performed by for-profit hospitals as compared to non-profit hospitals. This finding holds true even when we take into account the health (or risk status) of women and across different contexts, countries and years. It doesn’t seem to vary in relation to how the individual research studies are designed, either. The authors conclude that, “since financial incentives are likely to play an important role, we recommend examination of incentive structures of for-profit hospitals to identify strategies that encourage appropriate provision of CS.” (Hoxha 2017)

I don’t know how likely that is. Far better, in my humble opinion, to work on helping more women understand that the decision of place of birth and care provider is theirs to make, and that these decisions may have far greater impact upon their outcomes and experience than they realise.

Hoxha I, Syrogiannouli L, Luta X et al (2017). Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis. BMJ Open, 7(2).

 

The Research

Objective Financial incentives may encourage private for-profit providers to perform more caesarean section (CS) than non-profit hospitals. We therefore sought to determine the association of for-profit status of hospital and odds of CS.

Design Systematic review and meta-analysis.

Data sources MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the first year of records through February 2016.

Eligibility criteria To be eligible, studies had to report data to allow the calculation of ORs of CS comparing private for-profit hospitals with public or private non-profit hospitals in a specific geographic area.

Outcomes The prespecified primary outcome was the adjusted OR of births delivered by CS in private for-profit hospitals as compared with public or private non-profit hospitals; the prespecified secondary outcome was the crude OR of CS in private for-profit hospitals as compared with public or private non-profit hospitals.

Results 15 articles describing 17 separate studies in 4.1 million women were included. In a meta-analysis of 11 studies, the adjusted odds of delivery by CS was 1.41 higher in for-profit hospitals as compared with non-profit hospitals (95% CI 1.24 to 1.60) with no relevant heterogeneity between studies (τ2≤0.037). Findings were robust across subgroups of studies in stratified analyses. The meta-analysis of crude estimates from 16 studies revealed a somewhat more pronounced association (pooled OR 1.84, 95% CI 1.49 to 2.27) with moderate-to-high heterogeneity between studies (τ2≥0.179).

Conclusions CS are more likely to be performed by for-profit hospitals as compared with non-profit hospitals. This holds true regardless of women’s risk and contextual factors such as country, year or study design. Since financial incentives are likely to play an important role, we recommend examination of incentive structures of for-profit hospitals to identify strategies that encourage appropriate provision of CS.

photo credit: Alexander Rentsch KEH Berlin via photopin (license)

 

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