Caesarean section in uninsured women in the USA: systematic review and meta-analysis

Abstract

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.

Too Posh to Push: Determinants of Planned C-Section Delivery Among Indonesian Women

“…Our findings confirm the studies by Hoxha and colleagues [18][19][20] where they argue that women with private health insurance are more likely to undergo CS than those with public insurance or no insurance at all. Women with private/employer insurance have higher probability to have CS compared to those with no insurance cover (aRRR = 1.6064).…”

“…As for the potential explanatory variables, we selected them based on previous literature [11,[17][18][19][20][21][22][23][24][25][26][27]. We categorized them into several groups, namely spatial variables, maternal variables, demographic variables, access to information, and socio-economic variables.…”

Prevalence and determinants of the use of caesarean section (CS) in the dichotomy of ‘public’ and ‘private’ health facilities in West Bengal. India

“…These plausibly happen in the private hospitals because, in many cases, the obstetricians are pressurized to perform caesarean delivery by hospital authority, or women themselves may choose for the caesarean delivery out of fear of labour pain and anxiety. 23 Haxha et al (2019) 24 showed that opting for a health insurance policy increases the likelihood of women to undergo of caesarean delivery in the private health facility. These high rates of CS deliveries have further economic consequences at the household and individual levels.…”

Caesarean sections in teaching hospitals: systematic review and meta-analysis of hospitals in 22 countries

“…Recent meta-analyses examining the effect of hospitals and financial factors 22 33 34 have found that CS was 1.41 times as likely in for-profit hospitals as compared with non-profit hospitals (95% CI 1.24 to 1.60), 22 1.13 for privately insured women compared with women covered with public insurance (95% CI 1.07 to 1.18) 34 and 0.70 in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72). 33 …”