Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study

Abstract

BackgroundArmenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.MethodsThis was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.ResultsThe mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government’s reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers’ concern.ConclusionThe study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

Why do pregnant women prefer cesarean delivery?: a qualitative study in a tertiary care center in Southern Thailand

“…Obstetricians' preference and hospital policies might have more influences on women's decisions. Some doctors prefer cesarean delivery to vaginal birth because it is faster, more convenient, and probably more profitable [8]. The limitation of our study was that it did not represent pregnant women in private sectors where cesarean delivery on demand is permitted.…”

Why do pregnant women prefer cesarean birth? : a qualitative study in a tertiary care center in Southern Thailand

“…Cesarean section rates in Thailand have been signi cantly increasing during the past three decades from 15.2% in 1990 to 32.5% in 2017 [3,4]. Factors contributing to this increase include delayed childbearing, policies promoting repeat cesarean section, refusal to offer vaginal birth after cesarean section, wide use of continuous electronic fetal monitoring, use of epidural analgesia, fear of malpractice liability, professional practice style, professional expectations for work-life balance, reimbursement system, nancial incentives, maternal request, and lack of regulations [5][6][7][8].…”

“…Cesarean section upon maternal request is a hotly debated issue, since it is one of the factors contributing to increase of cesarean section rates [6][7][8]. Rates for this indication are not known, but have been estimated to be 4 -18% [2].…”

Innervated adrenomedullary microphysiological system to model prenatal nicotine and opioid exposure

“…CATs approach their highest concentrations in life during vaginal delivery, but CAT concentrations are significantly reduced for newborns delivered by cesarean section (10). With the rise of cesarean sections in recent decades, this attenuated CAT surge has been proposed as a potential mechanism leading to perinatal cardiorespiratory concerns in this population (11)(12)(13)(14)(15). Prenatal exposure to nicotine and opioids also impairs the perinatal CAT surge in newborns independent of the route of delivery (16,17).…”