European Journal of Obstetrics & Gynecology and Reproductive Biology
Maternal request CS—Role of hospital teaching status and for-profit ownership
Introduction
Unprecedented cesarean section (CS) rates are being documented with parts of the developing world (Taiwan 32.5% [1], Chile 40% [2] and most other Latin American countries [2]) exceeding the rates of developed countries (US 24.4% [3] and England 22.0% [4]). Many authors report that maternal preference for cesarean delivery is an increasingly significant factor in rising CS rates [5], [6].
Studies on request CS can be classified into qualitative surveys of physicians and patients and data-driven studies using secondary data. A survey showed that 61.9% of obstetricians in the North Thames region of the United Kingdom felt that maternal request significantly contributed to increasing CS rates [7]. At the Watford General Hospital in UK maternal request was the reason for 38% of all elective CS in 1995–96 [8] and at Chelsea and Westminster Hospital, for 72% of elective CS in 1999 [9]. In Italy, maternal request CS as a percent of all CS jumped from 3.6% in 1997 to 9% in 2000 [10]. In Norway, maternal request accounted for 7.6% of all CSs [11].
Request CS in the absence of clinical need has drawn much discussion, driven by clinical, ethical and legal perspectives. Yet, little is known about the influence of physicians and the institutional setting, because of the delicate issues in isolating women's personal choice from their physicians’ or institutional preferences. Turnbull et al. reported that over a third of women were not consulted in the CS decision-making process [12]. Kirk et al. found that physicians’ attitudes toward vaginal birth after cesarean (VBAC) influences women's mode of delivery [13]. Hemminki observed that obstetricians’ preference for CS might facilitate increasing patient demands for abdominal delivery [14]. Collectively, these authors suggest that women's CS choice may be influenced by their physicians’ preferences.
One empirical approach would be to look for systematic variations in maternal request CS rates by institutional characteristics such as ownership and hospital level. This study examines these factors, using 4-year population-based data (1997–2000) from Taiwan's National Health Insurance (NHI) database. Over 98% of all 23 million plus citizens of Taiwan are covered by NHI, which is funded by employee, employer and government contributions. NHI provides comprehensive health coverage, requiring low co-payments that are waived for low-income individuals. For all others, the rate is fixed regardless of socio-economic status. Patients have full choice of providers, which could be public, not-for-profit (NFP) or for-profit hospitals (FP), or ob/gyn clinics (also FP), all geographically well dispersed throughout the country.
This study contributes to the international literature on the factors driving high CS rates in a universal-access health system, with a mix of public and private providers. Such studies can provide direction for public policies geared toward appropriate obstetric care, consistent with optimum maternal and fetal outcomes. Empirical studies have suggested that reductions in CS rates among high CS-rate populations do not adversely impact maternal or fetal outcomes and therefore may be cost-effective without concurrent loss of health benefits [6], [15]. Goer's exhaustive literature review (of 69 studies) indicates that elective cesarean delivery in the absence of clinical indications has no discernable benefit, while causing short-term and long-term adverse impacts in many cases [16]. Therefore, empirical studies on maternal request CS have policy implications. Our study also contributes to cross-country comparisons and is relevant to the international debate on maternal cesarean preferences and to the role of the private sector and market mechanisms in health care.
We hypothesize two institutional effects on request CS, ownership (FP, NFP and public) and hospital teaching status (large teaching hospitals versus small non-teaching hospitals). Our hypotheses are based on the tenets of the property rights theory, moderated by the educational mission of teaching hospitals. The property rights theory states that FP institutions strive to maximize profits, because managers and owners can gain from profits, unlike NFPs and public institutions [17]. Thus, FP hospital behavior may involve a selection process among alternative revenue generation opportunities, to choose revenue maximizing options that are consistent with other core objectives such as their teaching mission.
Teaching FP hospitals (medical centers and regional hospitals) possess superior diagnostic and treatment capabilities compared to district hospitals and clinics. These hospitals may prefer to use their core infrastructure of beds and personnel for diagnoses requiring hi-tech care, which would satisfy two core concerns, financial and teaching objectives. Because hi-tech care is more intensive and generates greater revenue per bed-day, FP teaching hospitals may prefer to admit cases requiring hi-tech care (rather than low-tech procedures, e.g. CS), to realize better returns on their core fixed costs. Further, their teaching mission obligates them to provide students and residents with clinical learning opportunities, which generates an explicit priority to admit complicated cases requiring detailed case work-up, investigations and complex treatments. In contrast, less equipped FP hospitals [18], [19], which lack hi-tech revenue-generation opportunities and a teaching mission, may opt to utilize their core infrastructure for low-tech, low-risk, revenue-maximizing procedures, such as elective CS. Therefore, although request CS may be a patient-initiated decision, physicians at lower levels of FP institutions may readily accede to patients’ CS requests, without much persistence to dissuade them through professional counseling. If this is the case, then the empirical evidence should show increased likelihood of maternal request CS at lower level FP hospitals. Higher CS rates among privately owned lower level institutions compared to higher level institutions is documented by Lallo et al. in Italy [20].
We use pooled, 4-year population-based data to test the following hypotheses:
- 1.
For-profit (FP) hospitals will show greater likelihood of request CS that yields higher revenues, relative to low-revenue procedures (vaginal delivery), compared to public and NFP institutions.
- 2.
Lower level (smaller, non-teaching) hospitals will be more likely to provide request CS relative to higher level (larger, teaching) hospitals.
Section snippets
Data sources
The data source for the study is the Bureau of NHI (BNHI) inpatient claims database, which includes detailed information on every medical encounter in Taiwan, except for the occasional consultation with physicians who are not contracted by NHI. There are very few practising physicians and hospitals that are not contracted by NHI. Each claim provides information on one primary and up to four secondary diagnoses, the procedure code, details of services and medications, institution type and some
Results
Table 2 shows the sample distribution (739,531 cases) by delivery mode, institution type and patient's age and Table 3 shows the bivariate distribution of institutions by ownership and level. Table 4 presents the results of multiple logistic regression analysis, showing that among teaching hospitals, FP RHs are slightly more likely than NFP and public teaching hospitals (MCs and RHs) to provide request CS. (The differences are statistically significant, all p < 0.001.) Overall, teaching
Discussion
Our findings empirically confirm that “maternal choice” of cesarean delivery is systematically associated with institutional setting. The pattern of odds ratios supports both our hypotheses. We believe that these findings have universal significance for policy makers concerned about increasing cesarean rates, because our findings come from national population-based data, covering every delivery, under stable reimbursement policies and a stable regulatory environment.
Our findings should readily
Acknowledgments
This study was partially supported by the Chein-Tien Hsu Women Health Care. This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health, Taiwan and managed by the National Health Research Institutes. The interpretations and conclusions contained herein do not represent those of the Bureau of National Health Insurance, Department of Health, or the National Health Research Institutes.
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