The effect of increasing Women's autonomy on primary and repeated caesarean sections in Brazil.
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ABSTRACT:
SUBMITTER: de Oliveira VH
PROVIDER: S-EPMC9545260 | biostudies-literature | 2022 Aug
REPOSITORIES: biostudies-literature
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The effect of increasing Women's autonomy on primary and repeated caesarean sections in Brazil.
de Oliveira Victor Hugo VH Lee Ines I Quintana-Domeque Climent C
Health economics 20220523 8
Caesarean section (C-section) rates continue to rise globally. Yet, there is little consensus about the key determinants of rising C-section rates and the sources of variation in C-section rates across the world. While C-sections can save lives when medically justified, unnecessary surgical procedures can be harmful for women and babies. We show that a state-wide law passed in São Paulo (Brazil), which increased women's autonomy to choose to deliver via C-section even when not medically necessar ...[more]
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Project description:ObjectiveTo measure the likelihood of delivery by caesarean section (C-section) for publicly insured births as compared with privately insured births, across all hospitals and within private hospitals.DesignRepeated cross-sectional analysis.SettingThe universe of hospital births in 15 regions of Chile.Participants2 405 082 singleton births between 2001 and 2014.Outcome measuresC-section rates by type of hospital and type of insurance; contribution to overall C-section rates of subgroups by type of insurance and type of hospital; adjusted OR of privately insured births delivered by C-section compared with publicly insured births, across all hospitals and within private hospitals; percentage of discharges related to maternal morbidity and mortality across groups; length of stay after delivery.ResultsAn increasing percentage of publicly insured births occur in private facilities each year. Approximately three out of four publicly insured births in private hospitals are delivered by C-section. The adjusted odd of C-section delivery in a private maternity unit is lower for those privately insured than for those with public insurance: OR 0.6, 95% CI 0.56 to 0.64. There is no evidence that these women would have been more likely to have a C-section out of medical necessity.ConclusionsWe find an association between high C-section rates and publicly insured women delivering at private institutions in Chile, and show that this group is driving the overall high and growing rates. There is a need for a more informed surveillance on the part of the public insurance system of its private providers' C-section practices.
| S-EPMC6500210 | biostudies-literature
Project description:ObjectivesTo investigate whether the high rates of caesarean sections (CSs) in Brazil have impacted on the prevalence of preterm and early-term births.DesignIndividual-level, cross-sectional analyses of a national database.SettingAll hospital births occurring in the country in 2015.Participants2 903 716 hospital-delivered singletons in 3157 municipalities, representing >96% of the country's births.Primary and secondary outcome measuresCS rates and gestational age distribution (<37, 37-38, 39-41 and 42 or more weeks' gestation). Outcomes were analysed according to maternal education, measured in years of schooling and municipal CS rates. Analyses were also adjusted for maternal age, marital status and parity.ResultsPrevalence of CS was 55.5%, preterm prevalence (<37 weeks' gestation) was 10.1% and early-term births (37-38 weeks of gestation) represented 29.8% of all births, ranging from 24.9% among women with <4 years of schooling to 39.8% among those with >12 years of education. The adjusted prevalence ratios of preterm and early-term birth were, respectively, 1.215 (1.174-1.257) and 1.643 (1.616-1.671) higher in municipalities with?80%?CS compared with those <30%.ConclusionsBrazil faces three inter-related epidemics: a CS epidemic; an epidemic of early-term births, associated with the high CS rates; and an epidemic of preterm birth, also associated with CS but mostly linked to poverty-related risk factors. The high rates of preterm and early-term births produce an excess of newborns at higher risk of short-term morbidity and mortality, as well as long-term developmental problems. Compared with high-income countries, there is an annual excess of 354?000 preterm and early-term births in Brazil.
| S-EPMC6078248 | biostudies-literature
Project description:BACKGROUND:Antenatal care and correctly indicated caesarean section can positively impact on health outcomes of the mother and newborn. Our objective was to describe how coverage and inequalities for these interventions changed from 1982 to 2015 in Pelotas, Brazil. METHODS:Using perinatal data from the 1982, 1993, 2004 and 2015 Pelotas birth cohorts, we assessed antenatal care coverage and caesarean section rates over time. Antenatal care indicators included the median number of visits, the prevalence of mothers attending at least six visits and the proportion who started antenatal care in the first trimester of pregnancy and attended at least six visits. We described these outcomes according to income quintiles and maternal skin colour, to identify inequalities. We described overall, private sector and public sector caesarean section rates. Differences in prevalence were tested using chi-square testing and median differences using Kruskal-Wallis testing. RESULTS:From 1982 to 2015, the median number of antenatal care visits and the prevalence of mothers attending at least six visits increased in all income quintiles and skin colour groups. Inequalities were reduced, but not eliminated. The overall proportion of caesarean births increased from 27.6% in 1982 to 65.1% in 2015, when 93.9% of the births in the private sector were by caesarean section. Absolute income-related inequalities in caesarean sections increased over time. CONCLUSIONS:Special attention should be given to the antenatal care of poor and Black women in order to reduce inequalities. The explosive increase in caesarean sections requires radical changes in delivery care policies, in order to reverse the current trend.
| S-EPMC6422067 | biostudies-literature
Project description:ObjectivesThe objective of this study is to explore the association of health financing indicators with the proportion of births by caesarean section (CS) across countries.DesignEcological cross-country study.SettingThis study examines CS proportions across 172 countries.Main outcome measuresThe primary outcome was the percentage excess of CS proportion, defined as CS proportions above the global target of 19%. We also analysed continuous CS proportions, as well as excess proportion with a more restrictive 9% global target. Multivariable linear regressions were performed to test the association of health financing factors with the percentage excess proportions of CS. The health financing factors considered were total available health system resources (as percentage of gross domestic product), total contributions from private households (out-of-pocket, compulsory and voluntary health insurance contributions) and total national income.ResultsWe estimate that in 2018 there were a total of 8.8 million unnecessary CS globally, roughly two-thirds of which occurred in upper middle-income countries. Private health financing was positively associated with percentage excess CS proportion. In models adjusted for income and total health resources as well as human resources, each 10 per cent increase in out-of-pocket expenditure was associated with a 0.7 per cent increase in excess CS proportions. A 10 per cent increase in voluntary health insurance was associated with a 4 per cent increase in excess CS proportions.ConclusionsWe have found that health system finance features are associated with CS use across countries. Further monitoring of these indicators, within countries and between countries will be needed to understand the effect of financial arrangements in the provision of CS.
| S-EPMC8149434 | biostudies-literature
Project description:INTRODUCTION:Improvement of women's knowledge and attitude toward vaginal birth is recognized as an important strategy to control caesarean sections (CS) on maternal request. This study aimed to evaluate the effectiveness of a mass-media campaign in improving knowledge, attitude and intention of women for vaginal birth. METHODS:This was a population-based study carried out in Tehran, Iran. A national 'No to unnecessary caesarean sections' campaign was launched in April 2016 and was televised for ten days. A random sample of pregnant women from all defined geographical areas of Tehran were recruited and assessed for knowledge about the benefits of vaginal birth and the risk of CS, attitude and intention toward mode of delivery at two points in time: before and after the campaign. A comparison was made to evaluate outcome measures among those who had seen the campaign and those who had not. RESULTS:In all, 37 public and private maternity care centers were selected randomly and 702 eligible pregnant women attending these centers were entered in the study. Pre- and post-intervention data for 466 women were available for analysis. Of these, 194 women indicated that they had seen the campaign and the remaining 272 women said that they had not. A comparison of the outcome measures between the two study groups showed that there were significant differences between those who had seen the campaign and those who had not. Those who had seen the campaign reported increased knowledge, had a more positive attitude and indicated increased behavioral intention toward vaginal birth. CONCLUSIONS:In general, the findings indicated that the mass-media campaign improved pregnant women's knowledge, attitude and intention towards vaginal birth. However, the long-term effects of such campaigns need further investigation.
| S-EPMC7418979 | biostudies-literature
Project description:The consequences for women "left behind" by virtue of temporary male migration are mixed. On the one hand, concomitant changes in fertility, participation in the labor force, and social norms are often associated with increased independence for women. On the other hand, women left behind can be vulnerable to increased dependency on members of their husbands' family or face limited access to social institutions. These shifts in women's capacity for decision making can have important implications for their health and well-being. Focusing on the state of Kerala in southern India, we examine the conditions under which the remittances that migrants send home have an impact on the health of women left behind. Specifically, we assess the extent to which the timing of remittance sending can support women's autonomy and improve their ability to make autonomous healthcare decisions. We use evidence from migrant households in Kerala, a region deeply engrained in the world labor migration system for more than five decades. Analysis is conducted with data from the 2016 wave of the Kerala Migration Survey (KMS), a representative household survey, and paired with in-depth qualitative interviews with women in Kerala whose husbands and other family members have migrated to the Gulf. We show that the positive effect of remittances on women's autonomy manifests primarily through the timing of remittance receipt, not the amount of money remitted. Regular remittances are associated with higher levels of autonomy than remittances received at irregular intervals, net of amount remitted. This finding challenges the usual emphasis on remittance volume as the driving factor of social and behavioral change in sending communities. Analytical efforts should be refocused on the social-interactional component of remittance sending and how these interactions can impact women's health and autonomy.
| S-EPMC6978472 | biostudies-literature
Project description:An analysis of births by caesarean sections for ten years at a service hospital was carried out to identify the benefit in terms of reduction in perinatal mortality over the period without increase in maternal mortality and morbidity. An increase of 43.25 per cent in caesarean section rate was observed. Since 1986 there had been no significant change in the indications for caesarean sections or obstetrical care in terms of man and machine modernisation at this hospital. New born's care in this hospital is supervised by obstetrician and medical specialist. However, a definite reduction in perinatal mortality rate by 59.68 per cent was noted with no maternal mortality in caesarean cases. This retrospective study showed that the judicious increase of caesarean sections could improve perinatal outcome.
| S-EPMC5531570 | biostudies-other
Project description:ObjectiveOur objective was to describe trends in caesarean section (CS) rates, characteristics of women delivering by CS, reasons for CS and impact of CS on perinatal mortality, in a rural Indian population.DesignSecondary data analysis using a prospective population-based registry.SettingFour districts in Eastern Maharashtra, India, 2010 to 2013.Participants39 026 pregnant women undergoing labour and delivery.Main outcomesCS, single most likely reason, perinatal mortality.ResultsOverall, 20% of the women delivered by CS. Rates increased from 17.4% in 2010 to 22.7% in 2013 (p<0.001) with an absolute risk increase from 1% to 5% during this time-period. Women aged 25+ years old, being nulliparous, having at least a secondary school education, a body mass index 25+ and a multiple gestation pregnancy were more likely to deliver by CS. Perinatal mortality was higher among babies delivered vaginally than those delivered by CS (4.5% vs 2.7%, p<0.001). Prolonged and obstructed labour as the reported reason for CS increased over time for both nulliparous and multiparous women (p<0.001), and 6% to 10% women had no clear reason for CS. Perinatal mortality was higher among babies born vaginally than those delivered by CS (adjusted OR: 0.65, 95% CI 0.56 to 0.76, p<0.001).ConclusionRates of CS increased over time in rural Maharashtra, exceeding WHO recommendations. Characteristics associated with CS and outcomes of CS were similar to previous reports. Further studies are needed to ensure accuracy of reported reasons for CS, why obstructed and prolonged labour leading to CS is increasing in this population and what leads to CS without a clear indication. Such information may be helpful for implementing the Indian Government mandate that no CS be performed without strict medical indications, while ensuring that the overall CS rates are appropriate.Trial registration numberNCT01073475.
| S-EPMC6687025 | biostudies-literature
Project description:ObjectiveFinancial incentives associated with private insurance may encourage healthcare providers to perform more caesarean sections. We therefore sought to determine the association of private insurance and odds of caesarean section.DesignSystematic review and meta-analysis.Data sourcesMEDLINE, Embase and The Cochrane Library from the first year of records through August 2016.Eligibility criteriaWe included studies that reported data to allow the calculation of OR of caesarean section of privately insured as compared with publicly insured women.OutcomesThe prespecified primary outcome was the adjusted OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance. The prespecified secondary outcome was the crude OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance.ResultsEighteen articles describing 21 separate studies in 12.9 million women were included in this study. In a meta-analysis of 13 studies, the adjusted odds of delivery by caesarean section was 1.13 higher among privately insured women as compared with women with public insurance coverage (95% CI 1.07 to 1.18) with no relevant heterogeneity between studies (τ2=0.006). The meta-analysis of crude estimates from 12 studies revealed a somewhat more pronounced association (pooled OR 1.35, 95% CI 1.27 to 1.44) with no relevant heterogeneity between studies (τ2=0.011).ConclusionsCaesarean sections are more likely to be performed in privately insured women as compared with women using public health insurance coverage. Although this effect is small on average and variable in its magnitude, it is present in all analyses we performed.
| S-EPMC5629699 | biostudies-literature
Project description:BackgroundCaesarean sections (CS) are increasing worldwide. Financial incentives and related regulatory and legislative factors are important determinants of CS rates. This scoping review examines the evidence base of financial, regulatory and legislative interventions intended to reduce CS rates.MethodsWe searched MEDLINE, EMBASE, CINAHL and two trials registers in June 2019. Both experimental and observational intervention studies were eligible for inclusion. Primary outcome measures were: CS, spontaneous vaginal and instrumental birth rates. We assessed quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method.ResultsWe identified 9057 articles and assessed 65 full-texts. We included 16 observational studies. Most of the studies were conducted in high-income countries. Three studies assessed payment methods for health workers: equalising physician fees for vaginal and caesarean delivery reduced CS rates in one study; however, little or no difference in CS rates was found in the remaining two studies. Nine studies assessed payment methods for health organisations: There was no difference in CS rates between diagnosis-related group (DRG) payment system compared to fee-for-service system in one study. However, DRG system was associated with lower odds for CS in another study. There was little or no difference in CS rates following implementation of global budget payment (GBP) system in two studies. Vaginal birth after caesarean section (VBAC) increased after implementation of a case-based payment system in one study. Caesarean section increased while VBAC rates decreased following implementation of a cap-based payment system in another study. Financial incentive for providers to promote vaginal delivery combined with free vaginal delivery policy was found to reduce CS rates in one study. Studied regulatory and legislative interventions (comprising legislatively imposed practice guidelines for physicians in one study and multi-faceted strategy which included policies to control CS on maternal request in another study) were found to reduce CS rates. The GRADE quality of evidence varied from very low to low.ConclusionsAvailable evidence on the effects of financial and regulatory strategies intended to reduce unnecessary CS is inconclusive given inconsistency in effects and low quality of the available evidence. More rigorous studies are needed.
| S-EPMC7457477 | biostudies-literature