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Table 3 Characteristics of included studies

From: Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions

Study ID

Study design

Study period

Participants

Sample size

Notes

a) Financial interventions

Health worker payment methods

Lo 2008 [22]

ITS

Study period: 2001 to 2005

Country: Taiwan

Pregnant women

Baseline (control group) CS rate: 29%

Outcomes assessed: CS

Keeler 1996 [23]

ITS

Study period: Data set used – 12 months before and 12 months after May 1993

Country: USA

11,767 deliveries (5255 cases for the 12 months before and 6515 cases for the 12 months afterwards)

Baseline (control group) CS rate: 25.3%

Outcomes assessed: CS

Liu 2007 [24]

Interrupted time series analysis

Study Period:

Stage 1: May 1989; February 1996

Stage 2: 2001 to 2003

Country: Taiwan

Participants:

Stage 1: All women who gave birth between May 15 and 17, 1989 (1610) and February 12–16, 1996 (3546).

Stage 2: All women who gave birth between 2001 and 2003

Baseline CS rate: 33 to 35%

Outcomes assessed: overall CS

Health organization payment methods

Diagnosis-related group (DRG) payment systems

Kim 2016 [25]

Controlled before-after study

Study period: 2011 to 2014

Country: South Korea

Participants: 1,289,989 delivery cases in 674 hospitals

Baseline CS rate: 37%

Outcomes assessed: CS

Lee 2007 [26]

Retrospective cohort study

Study period: January –

September 2003

Country: South Korea

Participants: 179,222 patients (106,406 Diagnosis-Related Group (DRG) patients)

Baseline CS rate in Korea: 40.5%

Outcomes assessed: overall CS

Global budget payment (GBP) systems

Chen 2014 [27]

Retrospective pre-post reform case study

Study period: May 2003 to April 2008.

Country: Taiwan

Participants: 1,003,412 hospital admissions of women (18 to 45 years) for delivery, of which 1/3 were caesarean sections (5.6% of which were elective)

Baseline CS rate: 30.6%

Outcomes assessed: overall CS, elective CS

Kozhimannil 2018 [28]

ITS

Study period: 2006 to 2012

Country: USA

Participants: 671,177 total maternal birth records (N = 25,080 in policy group, and N = 646,097 in control group)

Baseline CS rate: 22.8%

Outcomes assessed: overall CS, childbirth hospitalization costs, maternal morbidity

Liu 2013 [29]

Interrupted time series analysis

Study period: June 2001 to August 2010

Country: Taiwan

Participants: 35,616 deliveries, including 12,831 CS. All pregnant women who delivered babies between June 2001 and August 2010 at Chang Gung Memorial Hospital in Linkou, Taiwan.

Baseline CS rate: 35.1%

Outcomes assessed: overall CS, primary CS, repeat CS, VBAC

Case-based payment system

Tsai 2006 [30]

Uncontrolled Before-after study

Study period: “Vaginal Birth after Caesarean Section” (VBAC) case payment program implemented on April 1, 2003.

Country: Taiwan

Physicians practicing VBAC.

The data used in the study were derived from the health care system in Taiwan, including four of the system’s hospitals, 30 obstetric attendings, and 2246 gravidas with a previous caesarean section delivery under the attending physician’s care.

Baseline CS rate: unclear (full text article not available)

Outcomes assessed: VBAC

Cap-based payment system

Misra 2008 [31]

Design: Pre-post study using a comparison group with Maryland State inpatient databases.

Pregnant women enrolled in Medicaid managed care were compared pre-implementation and post implementation with pregnant women delivering babies under private insurance.

Study period: 1995 and 2000

Country: USA

Participants: 128,743 births identified through Maryland State inpatient databases. 63,570 and 65,173 births in 1995 and 2000, respectively.

Baseline CS rate: 21.7%

Outcomes assessed: primary CS, repeat CS, VBAC

Chen 2016 [32]

Retrospective pre/post reform case study

Study period: January 2004 to December 2013. Reform instituted in 2009.

Country: China

Participants: 6547 Caesarean delivery case records from a tertiary level hospital in Wuxi. 3240 cases were pre-reform and 3307 were post-reform.

The cap system does not reimburse hospitals for costs above the threshold (per capita) which disincentivizes doctors from prescribing unnecessary procedures.

Baseline CS rate: 54%

Outcomes assessed: rate of expenditure on CS compared to other patient services

Other financial interventions

Karami 2018 [33]

ITS

Study period: Intervention implemented in April 2014 (Monthly data C-section rate collected for a period of 53

Months – 25 months before and 28 months after the implementation of the HSEP from the information system of all 15 hospitals)

Country: Iran

Participants: Fifteen hospitals affiliated to Ministry of Health and Medical Education (MoHME) in Kermanshah province.

Baseline CS rate: 43.4%

Outcomes assessed: CS, hospitalization

b) Regulatory and legislative interventions

Studnicki 1997 [34]

ITS

Study period: Implemented fall 1992

Preintervention period: 1990–1992

Postintervention period: 1993

Country: USA

Participants: Retrospective analysis of 366,246 total live births occurring in Florida hospitals during 1992 and 1993, before and after formal hospital certification of the implementation of the guidelines.

Provider hospitals: were defined in the law as facilities in which 30 or more deliveries occurred annually that either were fully paid by state or federal funds administered by the state.

Baseline CS rate: 25.2%

Outcomes assessed: primary CS, repeat CS

Yu 2017 [35]

Pre-post intervention study

Study period: 2006 to 2014

Country: China

Participants: 131,312 deliveries in 3 tertiary public hospitals between 2006 and 2014.

Baseline CS rate: 54.9% in China; 55.7% in the sample population

Outcomes assessed: overall CS, caesarean delivery on maternal request (CDMR), Average annual growth rate (AAGR) of the overall CDMR.

c) Other interventions

Snowden 2016 [36]

Retrospective cohort study

Study period: 2008–2013

Country: USA

Participants: 181,034 women who delivered in Oregon hospitals between 2008 and 2013, excluding 2011. 111,292 women delivered in the period before the hard-stop policy (2008–2010), and 69,742 women delivered after the rollout of the policy (2012–2013).

Baseline total CS rate: 26%

Baseline early CS rate: 4%

Outcomes assessed: CS, maternal morbidity, neonatal morbidity and mortality

Borem 2020 [37]

Interrupted time series (ITS) study

Study period: 2014 to 2016

Baseline period: January to December 2014 to the year following the set-up period of Projeto Parto Adequado (PPA) or “Appropriate Birth” project;

Full implementation period: January to December 2016

Country: Brazil

Low risk women (nulliparous, term, singleton, vertex) in Brazilian hospitals.

Twenty-eight hospitals enrolled in a 20-month quality improvement (QI) Collaborative that targeted low-risk pregnancies.

119,378 targeted deliveries in 13 intervention hospitals.

The primary aim of PPA was to increase vaginal delivery from a baseline of around 21.5 to 40% in the target population of 28 Brazilian hospitals over a 20-month intervention period, without worsening outcomes for mothers or infants.

This flexible approach allowed adaptation to local priorities.

Multiple strategies implemented simultaneously that are anchored in a learning system that constantly reassesses progress and makes modifications to the design.

Baseline CS rate: range 21.5 to 40%.

Outcomes assessed: vaginal deliveries, maternal and neonatal adverse events, NICU admissions

  1. CS caesarean section, NICU neonatal intensive care admission, CDMR caesarean delivery on maternal request, AAGR average annual growth rate (AAGR), VBAC vaginal birth after caesarean section