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 |