Economic Incentives in the Choice between Vaginal Delivery and Cesarean Section

Keeler, Emmett B.; Brodie, Mollyann

doi:10.2307/3350407

Cited by 95 publications

(64 citation statements)

References 70 publications

(64 reference statements)

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“…27 Financial incentives for cesarean delivery may affect cesarean rates in certain systems. 28 At the LaFarge Birthing Center, there was no fi nancial incentive for operative delivery. Additionally, malpractice concerns may increase non-Amish cesarean rates.…”

Section: Cesarean Ratementioning

confidence: 99%

Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center

Deline¹,

Varnes-Epstein²,

Dresang

et al. 2012

The Annals of Family Medicine

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PURPOSE Recent national guidelines encourage a trial of labor after cesarean (TOLAC) as a means of increasing vaginal births after cesarean (VBACs) and decreasing the high US cesarean birth rate and its consequences (2010 National Institute of Health Consensus Statement and American College of Obstetricians and Gynecologists revised guideline). A birthing center serving Amish women in Southwestern Wisconsin offered an opportunity to look at the effects of local culture and practices that support vaginal birth and TOLAC. This study describes childbirth and perinatal outcomes during a 17-year period in LaFarge, Wisconsin. METHODSWe undertook a retrospective analysis of the records of all women admitted to the birth center in labor. Main outcome measures include rates of cesarean deliveries, TOLAC and VBAC deliveries, and perinatal outcomes for 927 deliveries between 1993 and 2010. RESULTSThe cesarean rate was 4% (35 of 927), the TOLAC rate was 100%, and the VBAC rate was 95% (88 of 92). There were no cases of uterine rupture and no maternal deaths. The neonatal death rate of 5.4 of 1,000 was comparable to that of Wisconsin (4.6 of 1,000) and the United States (4.5 of 1,000).CONCLUSIONS Both the culture of the population served and a number of factors relating to the management of labor at the birthing center have affected the rates of cesarean delivery and TOLAC. The results of the LaFarge Amish study support a low-technology approach to delivery where good outcomes are achieved with low cesarean and high VBAC rates. Ann Fam Med 2012;10:530-537. doi:10.1370/afm.1403. INTRODUCTIONT he cesarean rate in the United States has risen from 5.5% in 1970 to 16.5% in 1980 1 to 21% in 1996 to 32.9% in 2009. 2,3 A 2011 study calculates that if trends continue, the 2020 cesarean rate will be 56.2%. 4 The 2007 primary cesarean rate was 23.4%. 5 The vaginal birth after cesarean (VBAC) rate-the percentage of pregnant women who give birth vaginally after a previous cesarean-has fallen from a high of 28.3% in 1996 1 to 8.5% in 2006. 6 The World Health Organization (WHO) and Healthy People 2020 have suggested the ideal cesarean rate should be around 15%. 7,8 The 2010 National Institutes of Health consensus conference on VBAC highlighted high-grade evidence that maternal mortality risk is decreased by VBAC compared with a repeat cesarean (3.8 vs 13.4 of 100,000).2 Data suggest decreasing the primary cesarean delivery rate and increasing the VBAC rate as key strategies to decrease the US cesarean rate. 9Amish communities ascribe religious and cultural value to childbearing. 10,11 Contraception, including sterilization, may be prohibited. 10Advanced maternal age and grand multiparity are common. Amish women of Southwest Wisconsin generally give birth at home attended by an unlicensed birth attendant, mother, mother-in-law, or neighbor. Formal education for men and women is through 8th grade, and women do not work outside the home. Amish culture prohibits electricity, telephone service, and car ownership, leading to delays ...

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Section: Cesarean Ratementioning

confidence: 99%

Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center

Deline¹,

Varnes-Epstein²,

Dresang

et al. 2012

The Annals of Family Medicine

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“…From a policy perspective, one concern about the rise in the caesarean rate is the additional healthcare costs that it involves. Keeler and Brodie (1993) found that in 1989, the physician's charge alone was on average $500 more to perform a C-section than a vaginal birth. Gruber et al (1999) find that this difference depends on the patient's insurance status, with physicians receiving $561 more to perform a C-section for patients with private insurance and only $127 more for patients with Medicaid.…”

Section: Vbacs In the Usmentioning

confidence: 99%

Patient education and the impact of new medical research

Price

Simon

2009

Journal of Health Economics

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We examine the impact that medical research published in peer-reviewed journals has on the practice of medicine. We exploit the release of a recent New England Journal of Medicine article which demonstrated that the risks of attempting a vaginal birth after having a previous C-section birth (VBAC) were higher than previously thought. We find that immediately following this article, the national VBAC rate dropped by 16% and this change was largest among more educated mothers, particularly those with a graduate degree.

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“…Similarly, Stafford (1990) found that women with private insurance in California are more likely than HMO enrollees to receive a cesarean delivery. Keeler and Brodie (1993) suggest that economic incentives may play a role in cesarean deliveries. Women with private fee-for-service insurance have the greatest likelihood of cesarean deliveries due to a combination of the higher provider reimbursements and the low financial cost to women.…”

Section: Literaturementioning

confidence: 99%

“…They claim that physicians overused cesarean delivery relative to what would be chosen by a financially disinterested provider. In addition, Keeler and Brodie (1993) argue that women also have economic incentives to demand too many cesarean deliveries.…”

Section: Cesarean Deliverymentioning

confidence: 99%

Medical interventions among pregnant women in fee-for-service and managed care insurance: a propensity score analysis

2006

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Standard-Nutzungsbedingungen:Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden.Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen.Sofern die Verfasser die Dokumente unter Open-Content-Lizenzen (insbesondere CC-Lizenzen) zur Verfügung gestellt haben sollten, gelten abweichend von diesen Nutzungsbedingungen die in der dort genannten Lizenz gewährten Nutzungsrechte. The Institute for the Study of Labor (IZA) in Bonn is a local and virtual international research center and a place of communication between science, politics and business. IZA is an independent nonprofit company supported by Deutsche Post World Net. The center is associated with the University of Bonn and offers a stimulating research environment through its research networks, research support, and visitors and doctoral programs. IZA engages in (i) original and internationally competitive research in all fields of labor economics, (ii) development of policy concepts, and (iii) dissemination of research results and concepts to the interested public. Terms of use: Documents in D I S C U S S I O N P A P E R S E R I E SIZA Discussion Papers often represent preliminary work and are circulated to encourage discussion. Citation of such a paper should account for its provisional character. A revised version may be available directly from the author. We extend prior research on the effect of managed care on the receipt of four medical interventions for pregnant women: ultrasound, induction/stimulation of birth, electronic fetal monitor, and cesarean delivery. Propensity score methods are used to account for sample selection issues regarding insurance choice. Managed care enrollees are more likely to receive an ultrasound, which may be indicative of receiving better prenatal care. Managed care plans reduce the rate of cesarean deliveries, but such limitations may be beneficial given the substantial medical evidence that cesarean deliveries are over utilized. The results indicate that insurance coverage does influence treatment intensity, but that utilization controls and provider financial incentives do not adversely affect care for pregnant women.JEL Classification: I71

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Economic Incentives in the Choice between Vaginal Delivery and Cesarean Section

Cited by 95 publications

References 70 publications

Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center

Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing Center

Patient education and the impact of new medical research

Medical interventions among pregnant women in fee-for-service and managed care insurance: a propensity score analysis

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