Table 5.
Effects of interventions
| Study Intervention |
Quality assessment | Effects of interventions | Effect on CS | Certainty (GRADE) | ||||
|---|---|---|---|---|---|---|---|---|
| Risk of bias | Inconsistency | Indirectness | Imprecision | Other aspects | ||||
| a) Financial interventions | ||||||||
| Health worker payment methods | ||||||||
|
Lo 2008 [22] Increase physician fees for vaginal birth after caesarean (VBAC) fee to the same level as caesarean section Increase in vaginal birth physician fees to that of caesarean section |
Seriousd | Single study | Not serious | Not serious | None |
The change in the level of total CS rates following the rise in VBAC fees was −1.68 (95% CI −2.3 to −1.07); the change in slope was −0.004 (95% CI −0.05 to 0.04)e The change in the level of total CS rates (for all indications and order of birth) following the rise in vaginal birth fees was 1.19 (95% CI − 0.01 to 2.40) and the change in slope was − 0.43 (95% CI − 0.78 to − 0.09)e |
CS decreased |
⊕⊖⊖⊖ VERY LOWd |
|
Keeler 1996 [23] Equalising physician fees for vaginal and caesarean delivery |
Seriousd | Single study | Not serious | Not serious | None | CS rates for non-breech deliveries decreased by 1.2% (22.5% before reform versus 21.3% after reform) | Effect on CS unclear |
⊕⊖⊖⊖ VERY LOWd |
|
Liu 2007 [24] National Health Insurance (NHI) which equalized price for CS and vaginal delivery |
Not serious | Single study | Not serious | Not serious | None | The percentage of pregnant women who received cesarean sections increased by 6.3% after NHI, from 24.2 to 30.5%, but after controlling for other variables NHI was not found to have a significant impact on the rate. | No change in CS |
⊕⊕⊖⊖ LOW |
| Health organization payment methods | ||||||||
| Diagnosis-related group (DRG) payment systems | ||||||||
|
Kim 2016 [25] Diagnosis-related Group (DRG) payment system |
Not serious | Single study | Not serious | Not serious | None |
Longer DRG adoption period was associated with a lower odds of CS (OR 0.997, 95% CI: 0.996 to 0.998). Hospitals that underwent mandatory adoption of the DRG system performed 216,633 (37.3%) deliveries by CSs, whereas hospitals that underwent voluntary adoption of the DRG system performed 260,676 (36.8%) deliveries by CSs |
CS decreased |
⊕⊕⊖⊖ LOW |
|
Lee 2007 [26] Diagnosis-Related Group (DRG) payment system |
Not serious | Single study | Not serious | Not serious | None | No significant differences in CS rates between providers in DRG and fee-for-system (control) groups after controlling for organizational variables. | No change in CS |
⊕⊕⊖⊖ LOW |
| Global budget payment (GBP) system | ||||||||
|
Chen 2014 [27] Global fee for obstetric services, increasing reimbursement for VD to be equal to CS, co-payment when CS not indicated |
Not serious | Single study | Not serious | Not serious | None |
For women under 30 and over 45, the overall caesarean section rate increased following implementation of the global fee (18.8 to 19.4% for women aged 20, 27.6 to 28.3% for women aged 25, and 9.0 to 11.8% for women aged 45). The elective caesarean rate decreased for women under 30 (1.4 to 1.1% for 20-year-olds, and 2.1 to 1.7% for 25-year-olds) following the global fee intervention. Following the copayment intervention, elective caesarean sections increased for all age groups; mothers aged 20 had the highest odds (1.51) of electing for cesarean after the intervention (as compared to before the intervention). There was no statistically significant effect of either policy change on the elective caesarean rate for women over 40 |
Mixed-effects |
⊕⊕⊖⊖ LOW |
|
Kozhimannil 2018 [28] Global fee for uncomplicated deliveries (regardless of mode) |
Not serious | Single study | Not serious | Not serious | None |
Overall CS decreased 3.2 percentage points, with a 0.27 percentage points decrease per quarter (p = 0.01). The cost of childbirth hospitalizations decreased by $425.8 and continued to drop $95.0 per quarter (p < 0.001). No significant effects on maternal morbidity. |
CS decreased |
⊕⊕⊖⊖ LOW |
|
Liu 2013 [29] Global Budget System (GBS) Hospital-based Self-Management (HBSM) |
Not serious | Single study | Not serious | Not serious | None | No significant change in total CS rate. Primary CS rate increased from 23.6 to 26.9% post-GBS (from 2001 to 2002), but repeat CS decreased from 95.3 to 87.8%. VBAC increased from 4.8 to 12.2% in the same period. There were no significant changes after HBSM was introduced. | No change in CS |
⊕⊕⊖⊖ LOW |
| Case-based payment system | ||||||||
|
Tsai 2006 [30] Vaginal birth after cesarean section (VBAC) case payment program |
Seriousb | Single study | Not serious | Not serious | None | After implementation of VBAC case payments, the VBAC rates at the sampled hospitals increased 6.06% (p < 0.001). | VBAC increased |
⊕⊖⊖⊖ VERY LOWb |
| Cap-based payment systems | ||||||||
|
Misra 2008 [31] Cap-based payment system (HealthChoice managed care program with risk-adjusted capitation rates designed to individualize care and reduce unnecessary CS rates) |
Not serious | Single study | Not serious | Not serious | None | Caesarean section increased as a proportion of all births (from 21.1 to 24.0%) and VBAC decreased from 4.7 to 3.6% during the same period. |
CS increased VBAC decreased |
⊕⊕⊖⊖ LOW |
|
Chen 2016 [32] Cap-based maternity insurance scheme |
Seriousd | Single study | Not serious | Not serious | None |
While all medical expenditures increased over time, the rate of expenditure on CS decreased as compared to other patient services in the hospital. The average annual growth rate for CS medical expenditures was significantly lower than that of inpatient and outpatient expenditures (3.8% vs. 8.3 and 13.0%). |
Changes in CS not reported |
⊕⊖⊖⊖ VERY LOWd |
| Other financial interventions | ||||||||
|
Karami 2018 [33] Financial incentive and free vaginal delivery policy (financial incentives for providers to promote vaginal delivery rather than CS; free-of-charge inpatient services for VD) |
Not serious | Single study | Not serious | Not serious | None | The proportion of caesarean sections decreased dramatically (−11.0%, p = 0.044) in the first month post-intervention, but overall the rate of caesarean sections increased by 0.0017% per month in the post-intervention period. Hospitalizations increased following the intervention (0.70 per 10,000, p < 0.01). | CS increased |
⊕⊕⊖⊖ LOW |
| b) Regulatory and legislative interventions | ||||||||
|
Studnicki 1997 [34] Legislatively imposed practice guidelines |
Not serious | Single study | Not serious | Not serious | None | Caesarean sections decreased as a whole, but this trend was apparent prior to implementation of the guidelines. Repeat caesarean sections decreased by a greater magnitude (5.7%) following the intervention, suggesting that the guideline program may have a greater impact on repeat caesarean sections. | CS decreased |
⊕⊕⊖⊖ LOW |
|
Yu 2017 [35] Multifaceted institutional and policy interventions.c |
Not serious | Single study | Not serious | Not serious | None |
After institutional interventions were introduced, the overall CDMR rate increased from 15.8 to 16.3% (p = 0.053), but the average annual growth rate (AAGR) of the overall CDMR rate quickly declined from 20.1% to −4.3%. The overall CS rate declined by 1.29% from 2006 to 2008 and 2009–2010. The AAGR decreased from 0.29% to −6.73% over the same period. The overall CS rate decreased from 54.42 to 46.16% (p < 0.001). The AAGR of the CDMR rate decreased from − 4.30% to − 14.77% after policy interventions were applied. Post-intervention the CDMR, AAGR, the probability of performing CS, and the probability of a woman electing for CS decreased. |
CS decreased |
⊕⊕⊖⊖ LOW |
| c) Other interventions | ||||||||
|
Snowden 2016 [36] “Hard-stop” policy limiting elective inductions and cesarean deliveries before 39 weeks of gestation |
Not serious | Single study | Not serious | Not serious | None |
The odds of overall elective caesarean section remained the same in the post-policy period compared with the pre-policy period (OR 1.00, 95% CI, 0.97 to 1.03). The odds of chorioamnionitis (OR 1.94, 95% CI 1.80 to 2.09) and blood transfusion (OR 1.42, 95% CI 1.20 to 1.67 were elevated in the post-policy period compared with the pre-policy period. The odds of stillbirth (OR 1.20, 95% CI 0.88 to 1.63) and neonatal death (OR 1.34, 95% CI 0.87 to 2.07) remained the same in the post-policy period compared with the pre-policy period. |
No change in CS |
⊕⊕⊖⊖ LOW |
|
Borem 2020 [37] Quality Improvement Initiative (“Appropriate Birth”) |
Not serious | Single study | Not serious | Not serious | None |
Quality improvement initiative was associated with a 62% increase in the rate of vaginal deliveries (vaginal deliveries increased from 21.5% (95% CI 15.8 to 29.2%) in 2014 to 34.8% (95% CI 28.9 to 41.9%) in 2016, a relative increase of 1.62 (95% CI 1.27 to 2.07, p < 0.001), equivalent to a 62% increase in VD). Rates of adverse eventsa (IRR 1.13, 95% CI 0.88 to 1.46) and NICU admissions (IRR 1.13, 95% CI 0.91 to 1.4). |
Vaginal births decreased |
⊕⊕⊖⊖ LOW |
Abbreviations: ITS interrupted time series study, OR odds ratio, CI confidence interval, VBAC vaginal birth after cesarean section, CS caesarean section, VD vaginal deliveries, NICU neonatal intensive care unit, IRR incidence rate ratio
aMaternal death, intrapartum or neonatal death > 2.5 kg, uterine rupture, maternal admission to intensive care unit, birth trauma (neonatal), return to operating room, admission to NICU > 2.5 kg for > 24 h, Apgar score < 7 at 5 min, blood transfusion, 3rd or 4th degree perineal tear
bDowngraded one level for serious risk of bias due to possible confounding (lack of concurrent control group)
cInstitutional interventions (face-to-face weekly educational meetings between patients and hospital staff, training for obstetricians and midwives, introduction of painless delivery, doula care) and policy interventions (policies to decrease high CS rate by controlling caesarean delivery on maternal request (CDMR) rate, requirement for health providers to encourage vaginal delivery and rigorously control indications for CS, inclusion of CS rate among patient safety indicators)
dDowngraded one level for serious risk of bias (due to possible confounding of outcome, unclear whether the intervention occurred independently of other changes over time)
eTwo standardised effect sizes are obtained from ITS analysis: a change in level (also called ‘step change’) and a change in trend (also called ‘change in slope’) before and after the intervention. Change in level = difference between the observed level at the first intervention time point and that predicted by the pre-intervention time trend; change in trend = difference between post- and pre-intervention slopes. A negative change in level and slope indicates a reduction in CS rate