Abstract
BackgroundThe increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness.MethodsThe sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software.ResultsNine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate.ConclusionsThe effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes.
Highlights
The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge
We identified seven related reviews published in the last 9 years [19,20,21,22,23,24,25], which addressed a range of non-clinical strategies intended to reduce CS births, including educational interventions [20, 21, 23, 25], organizational interventions [20, 21, 23, 24], regulatory interventions [21, 23], audits and feedback [19,20,21, 23], practice guidelines [20, 21, 23], and financial interventions [20, 21, 23]
We argue that it is urgent and critical to identify the effectiveness of various financial interventions in reducing CS rates, because financial incentives are a major driver in modern society irrespective of a country’s income level
Summary
The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness. That CS rate has increased from 19.5% (2000) to 27.2% (2014) in developed countries and from 13.1% (2000) to 20.9% (2014) in middle-income countries [2, 3]. Some less developed countries, such as Uganda and Kenya, are experiencing a CS rate increase trend, their growth rate is much slower than that of wealthier countries [4]. Unnecessary CS, or caesarean delivery on maternal request (CDMR) is the main cause of high CS rates [5]. High CS rates place a heavy burden on healthcare resources, which affects healthcare access equity [8, 9]
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