Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions

Abstract

Background: Caesarean sections (CS) are increasing worldwide. Financial incentives and related regulatory and legislative factors are important determinants of CS rates. This scoping review examines the evidence base of financial, regulatory and legislative interventions intended to reduce CS rates. Methods: We searched MEDLINE, EMBASE, CINAHL and two trials registers in June 2019. Both experimental and observational intervention studies were eligible for inclusion. Primary outcome measures were: CS, spontaneous vaginal and instrumental birth rates. We assessed quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. Results: We identified 9057 articles and assessed 65 full-texts. We included 16 observational studies. Most of the studies were conducted in high-income countries. Three studies assessed payment methods for health workers: equalising physician fees for vaginal and caesarean delivery reduced CS rates in one study; however, little or no difference in CS rates was found in the remaining two studies. Nine studies assessed payment methods for health organisations: There was no difference in CS rates between diagnosis-related group (DRG) payment system compared to fee-forservice system in one study. However, DRG system was associated with lower odds for CS in another study. There was little or no difference in CS rates following implementation of global budget payment (GBP) system in two studies. Vaginal birth after caesarean section (VBAC) increased after implementation of a case-based payment system in one study. Caesarean section increased while VBAC rates decreased following implementation of a cap-based payment system in another study. Financial incentive for providers to promote vaginal delivery combined with free vaginal delivery policy was found to reduce CS rates in one study. Studied regulatory and legislative interventions (comprising legislatively imposed practice guidelines for physicians in one study and multi-faceted strategy which included policies to control CS on maternal request in another

What is an appropriate caesarean delivery rate for China: a multicentre survey

“…A clearer message of the benefits of physiological birth and potential long‐term effects of CD on child health may help women in decision making. At the organisational level adjustments of the financial compensation may be useful, although their effectiveness must be investigated further 17 …”

“…At the organisational level adjustments of the financial compensation may be useful, although their effectiveness must be investigated further. 17 In contrast, scarred uterus is now far more common than any other CD indication in all regions, a result of the combination of a high primary CD rate in nulliparas and repeat CD rate in multiparas. This was a particular issue when the two-child policy was newly implemented.…”

Trends and projections of caesarean section rates: global and regional estimates

“… 24 26–28 Financial, regulatory and legislative interventions have emerged recently with focus on the reduction of unnecessary CS such as various payment methods for health workers or health organisations, financial incentive policies or legislatively imposed clinical guidelines. 29 However, the evidence is inconclusive with inconsistent effects and low-quality evidence.…”

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“…Several non-invasive techniques such as a Doppler ultrasound, tocodynamometer, cardiotocogram, fetal pulse oximetry, and fetal electrocardiograph have been suggested to address these concerns. However, the low accuracy and precision of these methods result in faulty analysis, impairing decision-making, as evidenced by the rising number of unnecessary C-sections in recent years [ 3 , 4 ]. Current non-invasive techniques are insufficient and require significant design enhancements to meet standard requirements.…”