I was also surprised by the assertion in the editorial that Béhague,
et al, "contradict" studies that indicate most cesareans are unwanted.
The way that I interpret Béhague, et al, is quite consistent with the
other studies.
Béhague, et al, show that in a social context in which rich woman
overwhelmingly have cesareans, poor women interpret cesareans as "better
medical care" and therefore actively seek it out. But this doesn't answer
why the prevalence of Cesarean sections is there in the first place.
Financial incentives are the most logical explanation for huge gaps
between private hospitals (with generally wealthier lower risk mothers)
and public hospitals (who admit mothers with less income and are
reimbursed less for Cesareans). Once patterns are established for the
wealthy, it is not surprising to see a shift in preferences in the rest of
the population.
Most of the literature on how financial incentives (and doctor's
convenience) affect cesarean rates comes from the United States and
Brazil. However, a recent study in Peru confirms that after controlling
for a variety of risk factors, hospital ownership and payment mechanisms
have a statistically significant impact on the decision to do a cesarean.
See Lorena Alcázar and Raúl Andrade "Induced Demand and Absenteeism in
Peruvian Hospitals", Ch. 5 in R. Di Tella and W. Savedoff, *Diagnosis
Corruption: Fraud in Latin America's Public Hospitals*, Inter-American
Development Bank, Washington, DC, 2002.
Rapid Response:
Financial and Non-Financial Reasons
I was also surprised by the assertion in the editorial that Béhague,
et al, "contradict" studies that indicate most cesareans are unwanted.
The way that I interpret Béhague, et al, is quite consistent with the
other studies.
Béhague, et al, show that in a social context in which rich woman
overwhelmingly have cesareans, poor women interpret cesareans as "better
medical care" and therefore actively seek it out. But this doesn't answer
why the prevalence of Cesarean sections is there in the first place.
Financial incentives are the most logical explanation for huge gaps
between private hospitals (with generally wealthier lower risk mothers)
and public hospitals (who admit mothers with less income and are
reimbursed less for Cesareans). Once patterns are established for the
wealthy, it is not surprising to see a shift in preferences in the rest of
the population.
Most of the literature on how financial incentives (and doctor's
convenience) affect cesarean rates comes from the United States and
Brazil. However, a recent study in Peru confirms that after controlling
for a variety of risk factors, hospital ownership and payment mechanisms
have a statistically significant impact on the decision to do a cesarean.
See Lorena Alcázar and Raúl Andrade "Induced Demand and Absenteeism in
Peruvian Hospitals", Ch. 5 in R. Di Tella and W. Savedoff, *Diagnosis
Corruption: Fraud in Latin America's Public Hospitals*, Inter-American
Development Bank, Washington, DC, 2002.
Competing interests: No competing interests