Insurance type does not affect cesarean rate

By Sarah Guy, MedWire Reporter

There is no significant disparity in the odds for US women undergoing cesarean section (c-section) delivery rather than vaginal delivery according to whether they are privately or publicly Medicaid-insured patients, show study results from Michigan, USA.

Critics have alleged that the increasing numbers of c-sections performed ‑ rates of the procedure increased by more than half in the 10 years between 1997 and 2007 ‑ could be a result of financial incentives for physicians, say Tammy Movsas (Michigan State University, East Lansing) and team.

However, their findings reveal that while the c-section rate was higher among privately insured than Medicaid patients, the difference was entirely accounted for by confounding factors including maternal age and maternal medical conditions.

"Positive disparity would have provided de facto evidence that financial incentives play a broader systemic role in physician decision-making regarding Caesarean delivery," suggest Movsas and colleagues. "Further studies are needed to support our findings and assess whether this null effect regarding insurance type holds true nationally," they add, in the Journal of Medical Ethics.

The team assessed rates of c-section by insurance type to address the question of whether any subpopulation of women in their state is at risk for undergoing one unnecessarily.

A total of 617,269 births between 2004 and 2008 were included in analysis, during which time the percentage of c-sections increased by 12%. The highest rate recorded was 33%, with a mean age of 28.6 years for women undergoing c-section.

Overall, the c-section rate was 33% for privately insured patients and 29% for Medicaid-insured patients, giving a significant probability for receiving one as a privately insured patient after univariate analysis.

However, after the researchers adjusted results for factors including maternal age and health status (diabetes, cardiovascular disease, hypertension), multiple births, prematurity, and low birth weight, the likelihood of undergoing a c-section was nonsignificant by insurance type, with an odds ratio of 1.01.

One of the main confounders in the analysis was maternal age, note Movsas et al, indicating that older mothers may be more likely to have private insurance. Indeed, the women who underwent c-section were a mean 18 months older than those who gave birth vaginally.

"Customary data collection surrounding deliveries should be interrogated in terms of its adequacy to evaluate both the role of physician financial incentives and the rising c-section rates," conclude the authors.

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