The analysis conducted suggests plenty of room for enhancing value in obstetric care and equity in women's access to such within the countries studied. The analysis of geographical variations in lower-value care can constitute a powerful screening tool.

Panel data are preferred over cross-section analysis because results are more robust. For all countries except Slovenia, beds and employees are relevant inputs for the production process.

Background Policymakers aim to reduce C-section (CS) rates, due to well documented overtreatment. However, little is known about how hospital characteristics relate to their c-section rates on low-risk deliveries (CSR-LRD). Methods CSR-LRD were computed using inpatient data from all Portuguese National Health Service hospitals (2002-2011). Linear and Fractional Response Models were estimated to quantify the relationship between CSR-LRD and a set of hospital characteristics: hospital size, type (exclusively obstetrics or not), Neonatal Intensive Care Unit (NICU) availability, obstetrician-to-obstetric bed ratio, and teaching status. Results CSR-LRD increased from 11.7% (2002) to 14.1% (2008), declining to 12.5% in 2011. While larger hospitals and hospitals with NICU had higher CSR-LRD rates, teaching status and obstetrician-to-obstetric bed ratio had no significant effect. Adjusted estimates, controlling for those four characteristics, indicate 91% of the variation in the CSR-LRD is left unexplained. Conclusion Hospital characteristics do not explain variation in CSR-LRD rates. Further studies considering medical practice, financial incentives to hospitals and/or physicians, and patient education are needed.