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. 2019 Jan 3;19(1):2.
doi: 10.1186/s12884-018-2158-6.

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study

Meri Tadevosyan  1 , Anna Ghazaryan  2 , Arusyak Harutyunyan  2 , Varduhi Petrosyan  2 , Adam Atherly  3 , Kim Hekimian  4
Affiliations

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study

Meri Tadevosyan et al. BMC Pregnancy Childbirth. .

Abstract

Background: Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.

Methods: This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.

Results: The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government's reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers' concern.

Conclusion: The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

Keywords: Cesarean section; Financial reimbursement; Vaginal birth.

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Conflict of interest statement

Ethics approval and consent to participate

The Institutional Review Board of the American University of Armenia reviewed the protocols and gave approval. Oral informed consent was obtained from all participants prior to their participation in this research. Moreover, the research team obtained permission from the administration of participating health facilities before starting data collection.

Consent for publication

“Not applicable”

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Cesarean section rates in Armenia (2000–2017)
See this image and copyright information in PMC

References

    1. Althabe F, Belizán JM. Caesarean section: the paradox. Lancet. 2006;368(9546):1472–1473. doi: 10.1016/S0140-6736(06)69616-5. - DOI - PubMed
    1. Shamshad B. Factors leading to increased cesarean section rate. Gomal J Med Sci. 2008;6(1):1–5.
    1. Mikki N, Abu-Rmeileh N, Wick L, Abu-Asab N, Hassan-Bitar S. Caesarean delivery rates, determinants and indications in Makassed hospital, Jerusalem 1993 and 2002. East Mediterr Health J. 2009;15(4):869. doi: 10.26719/2009.15.4.868. - DOI - PubMed
    1. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007;176(4):455–460. doi: 10.1503/cmaj.060870. - DOI - PMC - PubMed
    1. Festin MR, Laopaiboon M, Pattanittum P, Ewens MR, Henderson-Smart DJ, Crowther CA. Caesarean section in four south east Asian countries: reasons for, rates, associated care practices and health outcomes. BMC pregnancy childbirth. 2009;9(1):1. doi: 10.1186/1471-2393-9-17. - DOI - PMC - PubMed