« En faire plus, pour gagner plus » : la pratique de la césarienne dans trois contextes d'exemption des paiements au Sénégal

Abstract

In 2007, the number of caesarean sections performed in Senegal increased by 124% compared to the number of caesarean sections recorded before the introduction of a C-section funding initiative in 2006. The rate of increase varies in different regions and hospitals, with some hospitals performing caesarean sections in over 50% of deliveries. The purpose of this paper is to analyze the main reasons for high hospital caesarean section rates (i.e. above the national average) based on three cases of exemption from payment. The study is based on a qualitative method involving semi-structured interviews with healthcare and administrative staff and pregnant women in three healthcare institutions and interviews with central health authorities. Research indicates that high caesarean section rates are not directly linked to the C-section subsidy policy introduced in 2006. The perception of caesarean rates is more closely linked to the perception of population rates among healthcare professionals than to the perception of institutional (hospital) rates. Since population rates are very low, healthcare professionals tend to perform more caesarean sections. Among management staff, the financial returns of high caesarean section rates (in the three levels of exemption) represent a significant motivation for encouraging healthcare professionals to perform more C-sections. Despite these high rates, a normative discourse was found to be held by healthcare professionals, who tend to consider that their practices are aimed exclusively at saving the mother or the child. However, in the long term, high caesarean section rates may result in an increase of maternal deaths and go against MDG 5, aimed at reducing maternal mortality by 3/4 by 2015.

Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies

“…The studies investigated stakeholder views of different types of midwife staffing models [36,50,52–54]; financial strategies [28,29,43–44,48,58–60]; and organisational culture [27,40,42,46,47,49,51,55–57,61,62]. We also included two studies of social (doula) support during labour [39,41], with the decision for inclusion made by consensus, because of their positive effect on caesarean section rate reduction in the associated Cochrane review of effectiveness studies.…”

“…In one study from China insurance reform was not believed to be as influential on caesarean section rates as women’s preferences for caesareans. [48] From low- and middle-income countries there was evidence that financing structures, in the form of fee exemption policies [28,43,44,58–60] and insurance reform, [27,29,47,48] were mediators of access to both necessary caesarean section and unnecessary caesarean section. Whether financial interventions were successful or not was mediated by local philosophies of maternity care; inter-professional and inter-personal relationships; staff motivation to work with women or with the organisation, or simply for an income; and the expectations and demands of local women, families and communities.…”

“…In a highly telling interview, an administrator spoke of the increased revenue generated by this policy as the cash-cow for the hospital; the “ vaches laitières des hôpitaux . ” ( [28]:p216) It was seen as a source of pride for the obstetric department, providing them with power and influence in the hospital as a whole. In Iran, insurance policy change was met with scepticism by health professionals, amid concerns that women who need a caesarean section may no longer get one, or that there might be a paradoxical increase in the misreporting of indications for caesarean section to satisfy amended insurance criteria.…”

“…availability of equipment, theatre access) as powerful mediators of barriers or facilitators to reducing unnecessary caesarean section. [28,36,39,40–42,46,47,49,51,55–58,61,62] In high-income countries where “quick win” changes had been made to labour and delivery rooms to encourage normal labour and birth, the priority an organisation gave to maintaining them was fundamental to their effectiveness in reducing caesarean section rates. [56,61] This included changes to in-room facilities for labour and guaranteed access to operating theatres when necessary.…”

Exemption from Health Care Fees Influences Indications of Caesarean Section in a Urban Health District Hospital in Benin

“…However, vigilance needs to be observed as Mbaye et al, [18] reported in Senegal that the spirit of "doing more, to earn more" prevailed in hospitals where maternity is considered a dairy cow. Caesarean section is associated with short-and long-term risks that may persist for several years after delivery and affect child and women's health and next pregnancies [19].…”