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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ObjectivesThe objective of this study is to explore the association of health financing indicators with the proportion of births by caesarean section (CS) across countries.DesignEcological cross-country study.SettingThis study examines CS proportions across 172 countries.Main outcome measuresThe primary outcome was the percentage excess of CS proportion, defined as CS proportions above the global target of 19%. We also analysed continuous CS proportions, as well as excess proportion with a more restrictive 9% global target. Multivariable linear regressions were performed to test the association of health financing factors with the percentage excess proportions of CS. The health financing factors considered were total available health system resources (as percentage of gross domestic product), total contributions from private households (out-of-pocket, compulsory and voluntary health insurance contributions) and total national income.ResultsWe estimate that in 2018 there were a total of 8.8 million unnecessary CS globally, roughly two-thirds of which occurred in upper middle-income countries. Private health financing was positively associated with percentage excess CS proportion. In models adjusted for income and total health resources as well as human resources, each 10 per cent increase in out-of-pocket expenditure was associated with a 0.7 per cent increase in excess CS proportions. A 10 per cent increase in voluntary health insurance was associated with a 4 per cent increase in excess CS proportions.ConclusionsWe have found that health system finance features are associated with CS use across countries. Further monitoring of these indicators, within countries and between countries will be needed to understand the effect of financial arrangements in the provision of CS.

ObjectiveThe aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.Study designSystematic review and meta-analysis.Data sourcesPubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.Eligibility criteriaWe included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.OutcomesThe prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.Results12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).ConclusionsCSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

OBJECTIVE: To assess the association of the gender of the delivering physician and the odds of performing cesarean delivery. DATA SOURCES: CINAHL, ClinicalTrials.gov, Cochrane Library, PubMed, Scopus and Web of Science from the first year of records through May 2020. METHODS OF STUDY SELECTION: We included studies that reported odds ratios (OR), or data allowing the calculation of ORs, for cesarean delivery performed by female and male delivering physicians. We also included studies that reported the preference of physicians for performing cesarean deliveries. TABULATION, INTEGRATION, AND RESULTS: Independent data extraction was carried out by at least two researchers. Standard inverse-variance random effects meta-analysis was used to generate overall ORs. Finally, in two separate meta-analyses, we analyzed 15 studies containing clinical data for 1,269,625 births, and 11 studies containing data for the preference for delivery mode of 4,911 obstetricians. Both the crude and adjusted odds of a cesarean delivery were lower for those performed by female physicians (crude OR 0.75, 95% CI 0.68–0.84, τ2=0.029, adjusted OR 0.74, 95% CI 0.65–0.85, τ2=0.031). We also found that female physicians had a lower preference for cesarean delivery in both crude and adjusted analysis (crude OR 0.59, 95% CI 0.36–0.96, I2=77%, adjusted OR 0.58, 95% CI 0.40–0.84, I2=67%). CONCLUSION: Female physicians are less likely to perform cesarean delivery and less likely to prefer it. This was observed across different health systems and populations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020158442.

Background Many studies examined the spread of SARS-CoV-2 within populations using seroprevalence. Healthcare workers are a high-risk population due to patient contact, and studies are needed to examine seroprevalence of SARS-CoV-2 antibodies among healthcare workers. Our study investigates the seroprevalence of anti-SARS-CoV-2 antibodies among staff at primary healthcare institutions in Prishtina, and factors associated with seroprevalence. Methods We carried out a cross-sectional survey including SARS-CoV-2 serological testing and questionnaires with primary healthcare workers from primary healthcare facilities in the Prishtina, the capital city of Kosovo. We calculated prevalence of anti-SARS-CoV-2 antibodies, and of self-reported positive PCR test among primary healthcare workers, as well as crude and adjusted ORs for explanatory factors. Results Eighty-three of the healthcare workers (17.47%) tested positive for SARS-CoV-2 antibodies IgG or IgM, while 231 (48.63%) either had antibodies or a previous positive PCR test. Odds of seropositivity were affected by male gender (OR 2.08, 95% CI 1.20, 3.61), and infected family members (OR 3.61, 95% CI 2.25, 5.79) of healthcare workers. Higher education, being part of larger families and having infected family members gave higher odds of positive PCR test and seropositivity. Other healthcare workers had lower odds of positive PCR test and seropositivity than physicians. Conclusion Over 17% of healthcare workers were seropositive for SARS-CoV-2 antibodies and close to half of them were either seropositive or PCR self-reported positive test. Several factors are associated with decreased and increased odds for such outcomes. These findings should be explored further and addressed to Kosovo policy makers, and assist them to intensify vaccination efforts, and maintain control measures until we achieve herd immunity.