Considerations before undertaking concerted action.

Abstract

Obstetricians in many countries have long been interested in reducing the number of cesarean sections (CS). We agree with the conclusions of Ayres-De-Campos et al. 1 that concerted action involving the education and training of healthcare professionals and an effective hospital funding policy are needed to reduce the number of deliveries by CS. In fact, similar measures were instituted in Korea as part of the government's healthcare policy. However, the desired reduction in the rate of CS has not been achieved. The Republic of Korea introduced a medical insurance system in 1960, and today this covers almost all forms of disease, which means that about 70–90% of total medical fees are covered by the government insurance system. Pregnant women receive a “mother's card”, worth almost US $500, for antenatal care. The Health Insurance Review & Assessment Service (HIRA) of the Republic of Korea began to assess the CS rate in 2000. We believe that HIRA's assessment is a similar pattern of concerted action to reduce the CS rate. HIRA identified maternal and infant factors associated with CS and other factors and defined risk levels by scores. HIRA defined factors that make it reasonable to perform a CS, including emergency or elective sections. If an obstetrician performs a CS, HIRA scores the CS as reasonable or not, providing scores and ranks by hospital. HIRA assessed delivery cases at 808 institutions that performed 30 or more deliveries during 1 year. HIRA also calculated monitoring indicators (rate of CS in primipara/rate of vaginal birth after CS). The scores were divided into three grades after adjusting for clinical risk factors that affected the rate of CS. HIRA's calculations were based on logistic regression analysis and assessed risk factors on the mother's side, in the fetus, and “others”. For example, risk factors in the mother were hypertensive disorders, diabetes mellitus, maternal age, venereal disease, issues with reproductive organs, placenta previa, placental abruption, and anatomical factors. Risk factors in the fetus were excessive size, multiple pregnancy, umbilical cord prolapse, vasa previa, fetal anomalies, and breech presentation. “Other” factors included a history of uterine surgery (such as myomectomy) and preterm birth 2. HIRA ranked institutions in three grades based on their monitoring methods. The rate of CS decreased to 40.5% in 2001 2 and has fallen by 36.0% since 2010 2. HIRA did not consider how many obstetricians, midwives, and other assistants took care of deliveries in the hospital, the burden of potential legal problems following obstetric complications, or the low cost of a CS. Indeed, these three factors discourage vaginal delivery and do not decrease the rate of CS rapidly, i.e. the burden of potential legal problems following obstetric complications, the low cost of a CS (our CS average medical fee is US $1769, which is the lowest among all Organization for Economic Cooperation and Development countries) 3, and no consideration for decision-making input of obstetricians, midwives, and other healthcare staff. HIRA did not include fetal distress as a risk factor in its assessment program 2. Fetal distress is sometimes subjective. If an obstetrician insists on a vaginal delivery and the neonate develops unexpected problems, such as shoulder dystocia or cerebral palsy, the obstetrician receives no legal assistance from the government. Obstetricians must address these two problems by themselves: the CS rate should be reduced without any complications involving the fetus or the pregnant woman. Obstetricians are therefore very concerned about the legal burden. In July 2013, CS diagnosis-related groups were scheduled for implementation at all healthcare institutions, including tertiary hospitals. In May 2014, the Korean Society of Obstetrics and Gynecology reported that CS rates had increased after diagnosis-related group implementation because obstetricians received no additional fee, even after post-term induction admission. For example, if a post-term pregnant woman is induced but the induction fails, a CS is then performed. Obstetricians cannot receive an additional fee, such as an induction admission fee. As another example, if a preterm pregnant woman is admitted to a hospital and undergoes a CS within 6 days of admission, the obstetrician cannot receive any additional fee, such as a tocolytic management fee. Korean obstetricians know about the low CS rates and diagnosis-related groups in Europe. However, we have many other unsolved factors, as mentioned above, such as the low cost, diagnosis-related groups including all admission fees, and legal issues.