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Trends in hospital-based childbirth care: the role of health insurance.

ABSTRACT: OBJECTIVES:Childbirth is the leading reason for hospitalization in the United States, and maternity related expenditures are substantial for many health insurance programs, including Medicaid. We studied the relationship between primary payer and trends in hospital-based childbirth care. STUDY DESIGNS:Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project, a 20% stratified sample of US hospitals. METHODS:Data on 6,717,486 hospital-based births for the years 2002 through 2009 came from the NIS. We used generalized estimating equations to measure associations over time between primary payer (Medicaid, private insurance, or self) and cesarean delivery, vaginal birth after cesarean (VBAC), labor induction, and episiotomy. RESULTS:Controlling for clinical, demographic, and hospital factors, births covered by Medicaid had lower odds of cesarean delivery (adjusted odds ratio [AOR], 0.91), labor induction (AOR, 0.73), and episiotomy (AOR, 0.62) and higher odds of VBAC (AOR, 1.20; P <.001 for all AORs) compared with privately insured births. Cesarean rates increased 6% annually among births paid by private insurance (AOR, 1.06; P <.001) and less rapidly (5% annually) among those covered by Medicaid. CONCLUSIONS:US hospital-based births covered by private insurance were associated with higher rates of obstetric intervention than births paid for by Medicaid. After controlling for clinical, demographic, and hospital factors, cesarean delivery rates increased more rapidly among births covered by private insurance, compared with Medicaid. Changes in insurance coverage associated with healthcare reform may impact costs and quality of care for women giving birth in US hospitals.

SUBMITTER: Kozhimannil KB

PROVIDER: S-EPMC3671492 | biostudies-other | 2013 Apr

REPOSITORIES: biostudies-other

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Trends in hospital-based childbirth care: the role of health insurance.

Kozhimannil Katy B KB Shippee Tetyana P TP Adegoke Olusola O Vemig Beth A BA

The American journal of managed care 20130401 4

<h4>Objectives</h4>Childbirth is the leading reason for hospitalization in the United States, and maternity related expenditures are substantial for many health insurance programs, including Medicaid. We studied the relationship between primary payer and trends in hospital-based childbirth care.<h4>Study designs</h4>Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project, a 20% stratified sample of US hospitals.< ...[more]

PMID: 23725450

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Project description:Introduction:Hospital utilization varies across socioeconomic and demographic strata in Canada, a country with a universal health care system. Rates of adverse birth outcomes are known to differ among women of high and low socioeconomic status (SES), but less is known of the excess hospital burden related to SES over the course of childbirth across Canadian provinces. Objective:To examine length of stay and risk of hospitalization surrounding delivery, relative to women's socio-demographic characteristics. Methods:A population-based record linkage between the Canadian Community Health Survey (CCHS) years 2005-2011 and the Discharge Abstract Database (DAD) allowed the tracking of hospital utilization for linked survey respondents between 2005 and 2011. Hourly length of stay for delivery, risk of readmission, and risk of admission prior to delivery was modeled by socio-demographic factors, controlling for other clinical and individual-level characteristics. Results:There were 21,914 complete delivery records from 15,458 female CCHS respondents who agreed to link and share their information. Average length of stay (for both vaginal and Caesarian deliveries) dropped over the study period from 67.86 hours in 2005 to 59.37 hours in 2011. In multivariate analyses, women with the lowest income had on average, two-hour longer stays for vaginal delivery as compared to high-income women (IRR 1.04, 95% CI 1.00-1.08) and higher risk of admission prior to delivery (OR 1.43, CI 1.13-1.81). Low-income women, Aboriginal women and women living in rural areas were also at elevated risk for longer hospital stays and for hospital admission prior to delivery. There was no consistent socioeconomic patterning of hospital burden for Caesarian deliveries. Conclusion:The length of hospital stays for childbirth has declined in Canada. Length of stay remains modestly longer, and risk of hospitalization in the perinatal period higher, for low income women, Aboriginal women and rural women. The absence of egregious income-related differences in hospital burden related to childbirth is reassuring for the equity goals of the Canadian health care system. The persistence of marginally longer, and in turn, costlier visits for low-income and Aboriginal women before and during delivery is, however, suggestive that resources targeted to the prenatal period might be highly cost-effective if they achieve population-wide reductions in length of stay and hospitalization in the perinatal period.

Project description:Proportions of facility births are increasing throughout sub-Saharan Africa, but obstetric services vary within the health system. In Tanzania, advanced management of childbirth complications (comprehensive emergency obstetric care) is offered in hospitals, while in frontline, primary health care (PHC) facilities (health centres and dispensaries) mostly only routine childbirth care is available. With over half (54%) of rural births in facilities, we hypothesized the presence of socio-economic inequity in hospital-based childbirth uptake in rural Tanzania and explored whether this relationship was modified by parity. This inequity may compound the burden of greater mortality among the poorest women and their babies. Records for 4456 rural women from the 2015-16 Tanzania Demographic and Health Survey with a live birth in the preceding 5 years were examined. Proportions of births at each location (home/PHC/hospital) were calculated by demographic and obstetric characteristics. Multinomial logistic regression was used to obtain crude and adjusted odds ratios of home/PHC and hospital/PHC births based on household wealth, including interaction between wealth and parity. Post-estimation margins analysis was applied to estimate childbirth location by wealth and parity. Hospital-based childbirth uptake was inequitable. The gap between poorest and richest was less pronounced at first birth. Hospital-based care utilization was lowest (around 10%) among the poorest multiparous women, with no increase at high parity (≥5) despite higher risk. PHC-based childbirth care was used by a consistent proportion of women after the first birth (range 30-51%). The poorest women utilized it at intermediate parity, but at parity ≥5 mostly gave birth at home. In an effort to provide effective childbirth care to all women, context-specific strategies are required to improve hospital-based care use, and poor, rural, high parity women are a particularly vulnerable group that requires specific attention. Improving childbirth care in PHC and strengthening referral linkages would benefit a considerable proportion of women.

Project description:BACKGROUND:According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe. METHODS:We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income. RESULTS:Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05). CONCLUSION:This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care. TRIAL REGISTRATION:Registered at www.clinical trials.gov identifier NCT03604458.

Project description:BackgroundAfrica, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa.MethodsWe used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population.ResultsThe percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest.ConclusionsThe growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

Dataset Information

Trends in hospital-based childbirth care: the role of health insurance.

Publications

Trends in hospital-based childbirth care: the role of health insurance.

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