ObjectiveFinancial 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.DesignSystematic review and meta-analysis.Data sourcesMEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the first year of records through February 2016.Eligibility criteriaTo 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.OutcomesThe 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.Results15 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).ConclusionsCS 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.

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.

ObjectiveTo investigate the association of caesarean section rates with the health system characteristics in the public hospitals of Kosovo.DesignCross-sectional survey.SettingFive largest public hospitals in Kosovo.Participants859 women with low-risk deliveries who delivered from April to May 2015 in five public hospitals in Kosovo.Outcome measuresThe prespecified outcomes were the crude and adjusted OR of births delivered with caesarean section by health system characteristics such as delivery by the physician who provided antenatal care, health insurance status and other. Additional prespecified outcomes were caesarean section rates and crude ORs for delivery with caesarean in each public hospital.ResultsWomen with personal monthly income had increased odds for caesarean (OR 1.55, 95% CI 1.06 to 2.27), as did women with private health insurance coverage (OR 3.44, 95% CI 1.20 to 9.85). Women instructed by a midwife on preparation for delivery had decreasing odds (OR 0.32, 95% CI 0.19 to 0.51) while women having preference for a caesarean had increasing odds for delivery with caesarean (OR 3.84, 95% CI 1.96 to 7.51). The odds for caesarean increased also in the case of delivery by a physician who provided antenatal care (OR 2.06, 95% CI 1.16 to 3.67) and delivery during office hours (OR 2.36, 95% CI 1.37 to 4.05), while delivery at the University Clinical Centre of Kosovo decreased the odds for caesarean (OR 0.46, 95% CI 0.24 to 0.90).ConclusionsWe found that several health system characteristics are associated with the increase of caesarean sections in a low-risk population of delivering women in public hospitals of Kosovo. These findings should be explored further and addressed via policy measures that would tackle provision of unnecessary caesareans. The study findings could assist Kosovo to develop corrective policies in addressing overuse of caesareans and may provide useful information for other middle-income countries.

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