Publicly insured caesarean sections in private hospitals: a repeated cross-sectional analysis in Chile

Abstract

ObjectiveTo measure the likelihood of delivery by caesarean section (C-section) for publicly insured births as compared with privately insured births, across all hospitals and within private hospitals.DesignRepeated cross-sectional analysis.SettingThe universe of hospital births in 15 regions of Chile.Participants2 405 082 singleton births between 2001 and 2014.Outcome measuresC-section rates by type of hospital and type of insurance; contribution to overall C-section rates of subgroups by type of insurance and type of hospital; adjusted OR of privately insured births delivered by C-section compared with publicly insured births, across all hospitals and within private hospitals; percentage of discharges related to maternal morbidity and mortality across groups; length of stay after delivery.ResultsAn increasing percentage of publicly insured births occur in private facilities each year. Approximately three out of four publicly insured births in private hospitals are delivered by C-section. The adjusted odd of C-section delivery in a private maternity unit is lower for those privately insured than for those with public insurance: OR 0.6, 95% CI 0.56 to 0.64. There is no evidence that these women would have been more likely to have a C-section out of medical necessity.ConclusionsWe find an association between high C-section rates and publicly insured women delivering at private institutions in Chile, and show that this group is driving the overall high and growing rates. There is a need for a more informed surveillance on the part of the public insurance system of its private providers’ C-section practices.

Does Education Mitigate the Effect of Population Aging on Health Expenditure? A Panel Data Study of Latin American Countries

“…Interestingly, the mitigation effect of education seems to be present in private health expenditures rather than public ones. This finding is consistent with evidence at the micro level that shows education and income are positively related to individual-level private health expenditures (Borrescio-Higa and Valdés, 2019;Hoxha et al, 2017).…”

Introducing an anthropology of convenience

“…(Here, please note I refer only to planned C‐sections, not those determined and demonstrated to be medically necessary.) Many studies have noted that planned and medically unnecessary C‐sections tend to be scheduled on working days and not weekends or holidays, for reasons generally attributed to physician and even patient convenience, needs, or circumstances (Barros et al 2011; Bateman 2004; Borrescio‐Higa and Valdés 2019; Maharlouei et al 2013; Mossialos et al 2005). The idea of a doctor planning these procedures around a golfing schedule seems immoral, and indeed has been shown to be a problematic assumption, at least in North America and Western Europe (Allin et al 2015; Lefèvre 2014).…”

“…As this review suggests, this notion of convenience is very restricted and does not account for multidimensionality of convenience, including general scheduling convenience, that might structurally respond to physician scheduling needs without active input from the physicians themselves. There are other convenience incentives beyond physicians' scheduling convenience, including (a) procedural convenience, where noncomplicated and medically unnecessary C‐sections are more controlled and take less time and effort as they follow routinized medical procedures versus highly variable noninduced vaginal births (Borrescio‐Higa and Valdés 2019; Maharlouei et al 2013); (b) economic convenience, where C‐sections are usually more expensive than vaginal births and hence more cost‐effective for hospitals (Allin et al 2015; Bateman 2004); and (c) patient convenience, where patients can choose to schedule C‐sections based on their own schedules and medical, emotional, and/or aesthetic needs (Barros et al 2011; Morris 2016; Mossialos et al 2005).…”

“…There do seem to be two trends where medically unnecessary C‐sections are routinely performed at higher rates than country or even global norms: (a) for procedural convenience among resource‐poor patients in public and private (through public insurance; see Borrescio‐Higa and Valdés 2019) hospitals treated by doctors who are time/energy/resource stressed and (b) for economic/patient convenience among resource‐rich patients in private hospitals where scheduling and execution can suit the patients' needs and the profit‐gain motive of the hospital. Even so, we are hard‐pressed, except in the most egregious of observed cases, to place a moral judgment on convenience seeking in medical and health settings when we consider pressures on doctors' time and energy and even more on mothers' needs.…”

From public vs. private to public/private mix in healthcare: lessons from the Israeli and the Spanish cases

“…A systematic review of 21 studies [21] found that the odds of a Caesarean section (C-section) being performed was significantly higher in relation to women with private health insurance compared with women using public health insurance. In Chile, for example, three out of four publicly insured women who opt to give birth in a private hospital will have a C-section, while in public hospitals only one out of four women will undergo this procedure [22,23]. Mixed-methods studies suggest that private obstetricians have women undergo non-medical C-sections since this procedure is more lucrative for the private practitioner and allows the "programing" (scheduling) of births [23,24].…”