Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 458
Filtrar
1.
BMC Health Serv Res ; 19(1): 645, 2019 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-31492134

RESUMO

BACKGROUND: Maternal and perinatal mortality is a major public health concern across the globe and more so in low and middle-income countries. In Kenya, more than 6000 maternal deaths, and 35,000 stillbirths occur each year. The Government of Kenya abolished user fee for maternity care under the Free Maternity Service policy, in June of 2013 in all public health facilities, a move to make maternity services accessible and affordable, and to reduce maternal and perinatal mortality. METHOD: An observational retrospective study was carried out in 3 counties in Kenya. Six maternal health output indicators were observed monthly, 2 years pre and 2 years post- policy implementation. Data was collected from daily maternity registers in 90 public health facilities across the 3 counties all serving an estimated population of 3 million people. Interrupted Time Series Analysis (ITSA) with a single group was used to assess the effects of the policy. Standard linear regression using generalized least squares (gls) model, was used to run the results for each of the six variables of interest. Absolute and relative changes were calculated using the gls model coefficients. RESULTS: Significant sustained increase of 89, 97, and 98% was observed in the antenatal care visits, health facility deliveries, and live births respectively, after the policy implementation. An immediate and significant increase of 27% was also noted for those women who received Emergency Obstetric Care (EmONC) services in either the level 5, 4 and 3 health facilities. No significant changes were observed in the stillbirth rate and caesarean section rate following policy implementation. CONCLUSION: After 2 years of implementing the Free Maternity Service policy in Kenya, immediate and sustained increase in the use of skilled care during pregnancy and childbirth was observed. The study suggest that hospital cost is a major expense incurred by most women and their families whilst seeking maternity care services and a barrier to maternity care utilization. Overall, Free Maternity Service policy, as a health financing strategy, has exhibited the potential of realizing the full beneficial effects of maternal morbidity and mortality reduction by increasing access to skilled care.


Assuntos
Serviços de Saúde Materna/economia , Cesárea/economia , Cesárea/estatística & dados numéricos , Parto Obstétrico/economia , Parto Obstétrico/estatística & dados numéricos , Serviços Médicos de Emergência/economia , Serviços Médicos de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Instalações de Saúde/economia , Instalações de Saúde/estatística & dados numéricos , Humanos , Análise de Séries Temporais Interrompida , Quênia/epidemiologia , Saúde Materna/economia , Saúde Materna/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Mortalidade Perinatal , Gravidez , Cuidado Pré-Natal/economia , Cuidado Pré-Natal/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Natimorto/epidemiologia
2.
BMC Public Health ; 19(1): 1080, 2019 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-31399068

RESUMO

BACKGROUND: 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. METHODS: The 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. RESULTS: Nine 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. CONCLUSIONS: The 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.


Assuntos
Cesárea/economia , Cesárea/estatística & dados numéricos , Ensaios Clínicos Controlados como Assunto , Feminino , Humanos , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
3.
Am J Obstet Gynecol ; 221(3): 265.e1-265.e9, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31229430

RESUMO

BACKGROUND: Routine cesarean delivery has been shown to decrease mother-to-child-transmission of HIV in women with high viral load greater than 1000 copies/mL; however, women presenting late in pregnancy may not have viral load results before delivery. OBJECTIVE: Our study investigated the costs and outcomes of using a point-of-care HIV RNA viral load test to guide delivery compared with routine cesarean delivery for all in the setting of unknown viral load. STUDY DESIGN: A decision-analytic model was constructed using TreeAge software to compare HIV RNA viral load testing vs routine cesarean delivery for all in a theoretical cohort of 1275 HIV-positive women without prenatal care who presented at term for delivery, the estimated population of HIV-positive women without prenatal care in the United States annually. TreeAge Pro software is used to build decision trees modeling clinical problems and perform cost-effectiveness, sensitivity, and simulation analysis to identify the optimal outcome. The average cost per test was $15.22. To examine the downstream impact of a cesarean delivery and because most childbearing women in the United States will deliver 2 children, we incorporated a second pregnancy and delivery in the model. Primary outcomes were mother-to-child transmission, delivery mode, cesarean delivery-related complications, cost, and quality-adjusted life years. Model inputs were derived from the literature and varied in sensitivity analyses. The cost-effectiveness threshold was $100,000/quality-adjusted life year. RESULTS: Measuring viral load resulted in more HIV-infected neonates than routine cesarean delivery for all due to viral exposure during more frequent vaginal births in this strategy. There were no observed maternal deaths or differences in cesarean delivery-related complications. Quantifying viral load increased cost by $3,883,371 and decreased quality-adjusted life years by 63 compared with routine cesarean delivery for all. With the threshold set at $100,000/quality-adjusted life year, the viral load test is cost-effective only when the vertical transmission rate in women with high viral load was below 0.68% (baseline: 16.8%) and when the odds ratio of vertical transmission with routine cesarean delivery for all compared with vaginal delivery was above 0.885 (baseline: 0.3). CONCLUSIONS: For HIV-infected pregnant women without prenatal care, quantifying viral load to guide mode of delivery using a point-of-care test resulted in increased costs and decreased effectiveness when compared with routine cesarean delivery for all, even after including downstream complications of cesarean delivery.


Assuntos
Parto Obstétrico/métodos , Infecções por HIV/diagnóstico , HIV-1/isolamento & purificação , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Sistemas Automatizados de Assistência Junto ao Leito , Complicações Infecciosas na Gravidez/diagnóstico , Carga Viral , Adulto , Cesárea/economia , Análise Custo-Benefício , Árvores de Decisões , Parto Obstétrico/economia , Feminino , Infecções por HIV/economia , Infecções por HIV/transmissão , Infecções por HIV/virologia , HIV-1/genética , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Recém-Nascido , Transmissão Vertical de Doença Infecciosa/economia , Sistemas Automatizados de Assistência Junto ao Leito/economia , Gravidez , Complicações Infecciosas na Gravidez/economia , Complicações Infecciosas na Gravidez/virologia , Anos de Vida Ajustados por Qualidade de Vida , RNA Viral/análise , Estados Unidos , Carga Viral/economia
4.
PLoS One ; 14(6): e0219020, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31247013

RESUMO

BACKGROUND: Monitoring Caesarean Section (CS) rates is essential to ensure optimal use of the procedure. Information on CS rates in the South African private sector is limited and information from this study will assist in planning for the proposed NHI in South Africa. OBJECTIVES: The objectives of this paper are to assess mode of delivery patterns and to determine CS rates amongst South African private health insurance scheme members; and to assess the extent to which CS rates are influenced by age and health status of the mother. METHODS: The 2015 claims for members of 10 health insurance schemes were analysed to assess delivery type patterns. Mode of delivery patterns were assessed by 6 delivery types: emergency, elective and "other" for caesarean deliveries; and non-assisted, assisted and "other" for vaginal deliveries; as well as by age and health condition of the mother. RESULTS: Of a total of 6,542 births analysed, 4,815 were CS giving a CS rate of 73·6% (95% CI 72·5%;74·7%). Emergency CS were the most common mode of delivery (39·7%), followed by elective CS (39·5%). CS rates increased with increasing maternal age and were higher for women with a medical condition. CONCLUSIONS: CS rates for the South African private sector are considerably higher than the safe rates recommended by the WHO. The high CS rates is a cause for concern for the health system under the proposed NHI. To support initiatives encouraging evidence based practice, further research is required to understand the drivers for the high CS rates.


Assuntos
Cesárea , Parto Obstétrico/métodos , Adolescente , Adulto , Cesárea/economia , Cesárea/estatística & dados numéricos , Estudos Transversais , Parto Obstétrico/economia , Parto Obstétrico/estatística & dados numéricos , Honorários e Preços , Feminino , Nível de Saúde , Humanos , Recém-Nascido , Seguro Saúde , Idade Materna , Saúde Materna , Pessoa de Meia-Idade , Gravidez , Setor Privado , África do Sul , Adulto Jovem
5.
East Mediterr Health J ; 25(4): 254-261, 2019 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-31210346

RESUMO

Background: In recent decades, the rate of caesarian section (C-section) has increased in the Islamic Republic of Iran. A reform in the Iranian health system - the Health Transformation Plan (HTP) - was launched in 2014 in which one of the objectives of HTP is decreasing the rate of C-section. Aims: This study aimed to assess the effects of the Health Transformation Plan (HTP) on the C-section rate in the Islamic Republic of Iran. Methods: This study was an interrupted time series analysis that used segmented regression analysis to assess the immediate and long-term effects of the HTP on C-section rate in two groups of hospitals affiliated and not affiliated to the Ministry of Health and Medical Education (MoHME) in Kurdistan province. Study samples were selected using the data on monthly C-section rate collected over a period of four years. Results: We observed significant decreases in C-section rate immediately after the HTP in both groups of hospitals by 0.0629 and 0.0013, respectively (P < 0.05). In the long run, we observed no significant decrease in the regression slope of C-section rate in both groups. Conclusions: The implementation of HTP decreased the C-section rate. However, the reduction does not meet expectations.


Assuntos
Cesárea/estatística & dados numéricos , Reforma dos Serviços de Saúde/estatística & dados numéricos , Cesárea/economia , Humanos , Análise de Séries Temporais Interrompida , Irã (Geográfico)
6.
BMC Public Health ; 19(1): 557, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31088443

RESUMO

BACKGROUND: In the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong'an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS. METHODS: Data from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong'an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method. RESULTS: The EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates. CONCLUSIONS: These results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.


Assuntos
Cesárea/economia , Gastos em Saúde/estatística & dados numéricos , Implementação de Plano de Saúde/economia , Política de Saúde/economia , Readmissão do Paciente/economia , Adulto , China/epidemiologia , Compensação e Reparação , Bases de Dados Factuais , Feminino , Hospitalização , Humanos , Pacientes Internados/estatística & dados numéricos , Gravidez , População Rural/estatística & dados numéricos
7.
Cien Saude Colet ; 24(4): 1527-1536, 2019 Apr.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31066854

RESUMO

This study estimated the costs of vaginal delivery and elective cesarean section without clinical indication, for usual risk pregnant women from the perspective of the Brazilian Unified Health System. Data was collected from three public maternity hospitals located in the southeast region of Brazil through visits and interviews with professionals. The cost components were human resources, hospital supplies, capital cost and overhead, which were identified, quantified and valued through the micro-costing method. The costs with vaginal delivery, elective cesarean section and daily hospital charge in rooming for the three maternity hospitals were identified. The mean cost of a vaginal delivery procedure was R$ 808.16 and ranged from R$ 585.74 to R$ 916.14 between hospitals. The mean cost of elective cesarean section was R$ 1,113.70, ranging from R$ 652.69 to R$ 1,516.02. The main cost component was human resources for both procedures. When stay in rooming was included, the mean costs of vaginal delivery and cesarean were R$ 1,397.91 (R$ 1,287.50 - R$ 1,437.87) and R$ 1,843.87 (R$ 1,521.54 - R$ 2,161.98), respectively. Cost analyses of perinatal care contribute to the management of health services and are essential for cost-effectiveness analysis.


Assuntos
Cesárea/economia , Parto Obstétrico/economia , Custos Hospitalares/estatística & dados numéricos , Programas Nacionais de Saúde/economia , Brasil , Cesárea/estatística & dados numéricos , Parto Obstétrico/métodos , Feminino , Maternidades/economia , Humanos , Gravidez , Gravidez de Alto Risco , Alojamento Conjunto/economia , Alojamento Conjunto/estatística & dados numéricos
8.
PLoS One ; 14(3): e0213352, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30840678

RESUMO

BACKGROUND: Caesarean section rates are increasing worldwide, and since the 2000s, several researchers have investigated women's demand for caesarean sections. QUESTION: The aim of this article was to review and summarise published studies investigating caesarean section demand and to describe the methodologies, outcomes, country characteristics and country income levels in these studies. METHODS: This is a systematic review of studies published between 2000 and 2017 in French and English that quantitatively measured women's demand for caesarean sections. We carried out a systematic search using the Medline database in PubMed. FINDINGS: The search strategy identified 390 studies, 41 of which met the final inclusion criteria, representing a total sample of 3 774 458 women. We identified two different study designs, i.e., cross-sectional studies and prospective cohort studies, that are commonly used to measure social demand for caesarean sections. Two different types of outcomes were reported, i.e., the preferences of pregnant or non-pregnant women regarding the method of childbirth in the future and caesarean delivery following maternal request. No study measured demand for caesarean section during the childbirth process. All included studies were conducted in middle- (n = 24) and high-income countries (n = 17), and no study performed in a low-income country was found. DISCUSSION: Measuring caesarean section demand is challenging, and the structural violence leading to demand for caesarean section during childbirth while in the labour ward remains invisible. In addition, the caesarean section demand in low-income countries remains unclear due to the lack of studies conducted in these countries. CONCLUSION: We recommend conducting prospective cohort studies to describe the social construction of caesarean section demand. We also recommend conducting studies in low-income countries because demand for caesarean sections in these countries is rarely investigated.


Assuntos
Cesárea , Cesárea/economia , Cesárea/estatística & dados numéricos , Cesárea/tendências , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Preferência do Paciente/estatística & dados numéricos , Pobreza , Gravidez , Estudos Prospectivos , Meio Social , Fatores Socioeconômicos
9.
Am J Obstet Gynecol ; 220(6): 590.e1-590.e10, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30768934

RESUMO

BACKGROUND: A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes. OBJECTIVE: We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States. STUDY DESIGN: A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years. RESULTS: In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time. CONCLUSION: In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences. KEY WORDS: cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes.


Assuntos
Cesárea/economia , Macrossomia Fetal/economia , Hipertensão Induzida pela Gravidez/economia , Trabalho de Parto Induzido/economia , Paralisia do Plexo Braquial Neonatal/economia , Natimorto/economia , Adulto , Cesárea/estatística & dados numéricos , Análise Custo-Benefício , Parto Obstétrico/economia , Parto Obstétrico/métodos , Feminino , Macrossomia Fetal/epidemiologia , Custos de Cuidados de Saúde , Humanos , Hipertensão Induzida pela Gravidez/epidemiologia , Trabalho de Parto Induzido/métodos , Paralisia do Plexo Braquial Neonatal/epidemiologia , Paridade , Morte Perinatal , Gravidez , Anos de Vida Ajustados por Qualidade de Vida , Natimorto/epidemiologia , Conduta Expectante/economia
10.
Matern Child Health J ; 23(5): 613-622, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30600515

RESUMO

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.


Assuntos
Cesárea/economia , Financiamento da Assistência à Saúde , Hospitais Rurais/economia , Adulto , Cesárea/métodos , Análise Custo-Benefício , Feminino , Instalações de Saúde/economia , Instalações de Saúde/tendências , Hospitais Rurais/tendências , Humanos , Gravidez , Resultado da Gravidez/economia , Ruanda , Fatores de Tempo
11.
Rev Assoc Med Bras (1992) ; 64(11): 1045-1049, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30570059

RESUMO

OBJECTIVE: To describe the number of funds made by the Brazilian National Health System to normal delivery and cesarean procedures, according to the Brazilian regions in 2015, and estimate the cost cutting if the recommendation concerning the prevalence of cesarean deliveries by the World Health Organization (10 to 15%) were respected. METHODS: Secondary analysis of data from the Hospital Information System of the Brazilian National Health System. The variables considered were the type of delivery (cesarean section and normal), geographic region of admission, length of stay and amount paid for admission in 2015. RESULTS: In the year 2015, there were 984,307 admissions to perform labor in the five Brazilian regions, of which 36.2% were cesarean section. The Northeast and Southeast regions were the two regions that had the highest number of normal deliveries and cesarean sections. The overall average hospital stay for delivery was 3.2 days. About R$ 650 million (US$ 208,5 million) were paid, 45% of the total in cesarean deliveries. If the maximum prevalence proposed by the World Health Organization (WHO) were considered, there would be a potential reduction in spending in the order of R$ 57.7 million (US$ 18,5 million). CONCLUSIONS: Cesarean sections are above the parameter recommended by the WHO in all Brazilian regions. The Northeast and Southeast had the highest total number of normal and cesarean deliveries and thus the greatest potential reduction in estimated costs (69.6% of all considered reduction).


Assuntos
Cesárea/economia , Cesárea/estatística & dados numéricos , Parto Obstétrico/economia , Parto Normal/economia , Parto Normal/estatística & dados numéricos , Adolescente , Adulto , Brasil , Criança , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Gravidez , Características de Residência , Adulto Jovem
12.
Rev Saude Publica ; 52: 91, 2018 Nov 23.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30484479

RESUMO

OBJECTIVE: To conduct a cost-effectiveness analysis of natural childbirth and elective C-section for normal risk pregnant women. METHODS: The study was conducted from the perspective of supplemental health, a health subsystem that finances private obstetric care, represented in Brazil by health plan operators. The reference populations were normal risk pregnant women, who could undergo natural childbirth or elective C-section, subdivided into primiparous and multiparous women with previous uterine scar. A decision analysis model was constructed including choice of delivery types and health consequences for mother and newborn, from admission for delivery to maternity hospital discharge. Effectiveness measures were identified from the scientific literature, and cost data obtained by consultation with health professionals, health plan operators' pricing tables, and pricing reference publications of health resources. RESULTS: Natural childbirth was dominant compared with elective C-section for primiparous normal risk pregnant women, presenting lower cost (R$5,210.96 versus R$5,753.54) and better or equal effectiveness for all evaluated outcomes. For multiparous women with previous uterine scar, C-section presented lower cost (R$5,364.07) than natural childbirth (R$5,632.24), and better or equal effectiveness; therefore, C-section is more efficient for this population. CONCLUSIONS: It is necessary to control and audit C-sections without clinical indication, especially with regard to primiparous women, contributing to the management of perinatal care.


Assuntos
Cesárea/economia , Análise Custo-Benefício , Parto , Brasil , Cesárea/estatística & dados numéricos , Feminino , Sistemas Pré-Pagos de Saúde , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal
13.
PLoS One ; 13(10): e0205082, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30304060

RESUMO

OBJECTIVE: In the Democratic Republic of the Congo, insufficient state financing of the health system produced weak progress toward targets of Millennium Development Goals 4 and 5. In Lubumbashi, almost all women pay out-of-pocket for obstetric and neonatal care. As no standard pricing system has been implemented, there is great variation in payments related to childbirth between health facilities and even within the same facility. This work investigates the determinants of this variation. METHODS: We conducted a cross-sectional study including women from admission through discharge at 92 maternity wards in Lubumbashi in March 2014. The women's payments were collected and validated by triangulating interviews of new mothers and nurses with document review. We studied payments related to delivery from the perspective of women delivering. The total was the sum of the payments linked to seeking and accessing care and transport of the woman and companion. The determinants were assessed by multilevel regression. RESULTS: Median payments for delivery varied by type: for an uncomplicated vaginal delivery, US$45 (range, US$17-260); for a complicated vaginal delivery US$60 (US$16-304); and for a Cesarean section, US$338 (US$163-782). Vaginal delivery was more expensive at health centers than in general referral hospitals or polyclinics. Cesarean sections done in corporate polyclinics and hospitals were more expensive than those done in the general referral hospitals. Referral of delivering women, use of more highly trained personnel, and a longer stay in the maternity unit contributed to higher expenses. A vaginal delivery in the private sector was more cost-effective than in the public sector. CONCLUSION: To guarantee universal coverage of high-quality care, we suggest that the government and funders in DRC support health insurance and risk pool initiatives, and introduce and institutionalize free mother and infant care.


Assuntos
Gastos em Saúde , Cuidado do Lactente/economia , Serviços de Saúde Materna/economia , Adolescente , Adulto , Cesárea/economia , Estudos Transversais , Parto Obstétrico/economia , República Democrática do Congo , Honorários e Preços , Feminino , Instalações de Saúde/economia , Humanos , Recém-Nascido , Seguro Saúde/economia , Entrevistas como Assunto , Tempo de Internação/economia , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Gravidez , Qualidade da Assistência à Saúde/economia , Adulto Jovem
16.
Int J Equity Health ; 17(1): 71, 2018 06 05.
Artigo em Inglês | MEDLINE | ID: mdl-29871645

RESUMO

BACKGROUND: Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced. METHODS: We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries. RESULTS: We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present. CONCLUSIONS: Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.


Assuntos
Cesárea/economia , Gastos em Saúde , Política de Saúde/economia , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Pobreza , Classe Social , Adolescente , Adulto , Benin , Parto Obstétrico , Escolaridade , Honorários e Preços , Feminino , Humanos , Mali , Pessoa de Meia-Idade , Parto , Gravidez , População Rural , Fatores Socioeconômicos , População Urbana , Adulto Jovem
17.
Med Care ; 56(8): 658-664, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29912840

RESUMO

BACKGROUND: Nearly half of US births are financed by Medicaid, and one-third of births occur by cesarean delivery, at double the cost of vaginal delivery. With the goal of reducing unnecessary cesarean use and improving value, in 2009 Minnesota's Medicaid program introduced a blended payment rate for uncomplicated births (ie, a single facility or professional services payment regardless of delivery mode). OBJECTIVE: We evaluated the effect of the blended payment policy on cesarean use and costs for Medicaid fee-for-service births. METHODS: We identified births in Medicaid Analytic Extract files from 3 years before and after the 2009 payment change in Minnesota and in 6 control states. We used a quarterly interrupted time series approach to assess policy-related changes in study outcomes, comparing Minnesota to control states. Outcomes included cesarean delivery, childbirth hospitalization costs, and maternal morbidity. RESULTS: Minnesota's prepolicy cesarean rate (22.8%) decreased 0.27 percentage points per quarter after the policy for a total decrease of 3.24 percentage points, compared with control states (P=0.01). The cost of childbirth hospitalizations in Minnesota dropped by $425.80 at the time of the policy. Postpolicy, childbirth hospitalization costs continued to decrease in Minnesota relative to prepolicy by $95.04 per quarter, and declined more than control states (P<0.001). There were no significant policy effects on maternal morbidity. CONCLUSIONS: Implementation of a single, blended payment to facilities and clinicians for uncomplicated births mitigated trends toward greater use of cesarean and rising costs of childbirth hospitalization, without adverse effects on maternal morbidity.


Assuntos
Cesárea/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Medicaid/economia , Cesárea/estatística & dados numéricos , Feminino , Humanos , Análise de Séries Temporais Interrompida , Medicaid/estatística & dados numéricos , Minnesota , Gravidez , Cuidado Pré-Natal/economia , Estados Unidos
18.
Yonsei Med J ; 59(4): 539-545, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29749137

RESUMO

PURPOSE: To examine changes in clinical practice patterns following the introduction of diagnosis-related groups (DRGs) under the fee-for-service payment system in July 2013 among Korean tertiary hospitals and to evaluate its effect on the quality of hospital care. MATERIALS AND METHODS: Using the 2012-2014 administrative database from National Health Insurance Service claim data, we reviewed medical information for 160400 patients who underwent cesarean sections (C-secs), hysterectomies, or adnexectomies at 43 tertiary hospitals. We compared changes in several variables, including length of stay, spillover, readmission rate, and the number of simultaneous and emergency operations, from before to after introduction of the DRGs. RESULTS: DRGs significantly reduced the length of stay of patients undergoing C-secs, hysterectomies, and adnexectomies (8.0±6.9 vs. 6.0±2.3 days, 7.4±3.5 vs. 6.4±2.7 days, 6.3±3.6 vs. 6.2±4.0 days, respectively, all p<0.001). Readmission rates decreased after introduction of DRGs (2.13% vs. 1.19% for C-secs, 4.51% vs. 3.05% for hysterectomies, 4.77% vs. 2.65% for adnexectomies, all p<0.001). Spillover rates did not change. Simultaneous surgeries, such as colpopexy and transobturator-tape procedures, during hysterectomies decreased, while colporrhaphy during hysterectomies and adnexectomies or myomectomies during C-secs did not change. The number of emergency operations for hysterectomies and adnexectomies decreased. CONCLUSION: Implementation of DRGs in the field of obstetrics and gynecology among Korean tertiary hospitals led to reductions in the length of stay without increasing outpatient visits and readmission rates. The number of simultaneous surgeries requiring expensive operative instruments and emergency operations decreased after introduction of the DRGs.


Assuntos
Doenças dos Anexos , Cesárea , Grupos Diagnósticos Relacionados/economia , Planos de Pagamento por Serviço Prestado , Histerectomia , Qualidade da Assistência à Saúde/estatística & dados numéricos , Doenças dos Anexos/economia , Doenças dos Anexos/cirurgia , Cesárea/economia , Cesárea/estatística & dados numéricos , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Feminino , Administração Financeira de Hospitais , Ginecologia , Custos de Cuidados de Saúde , Gastos em Saúde , Política de Saúde , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Programas Nacionais de Saúde/estatística & dados numéricos , Obstetrícia , Readmissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/tendências , Gravidez , Reembolso de Incentivo , República da Coreia , Centros de Atenção Terciária
19.
Cad Saude Publica ; 34(5): e00022517, 2018 05 10.
Artigo em Português | MEDLINE | ID: mdl-29768579

RESUMO

The purpose of this study was to conduct a cost-effectiveness analysis of spontaneous vaginal delivery and elective cesarean (with no clinical indication) for normal risk pregnant women, from the perspective of the Brazilian Unified National Health System. An analytical decision model was developed and included the choice of delivery mode and clinical consequences for mothers and newborns, from admission for delivery to hospital discharge. The reference population consisted of normal risk pregnant women with singleton, at-term gestations in cephalic position, subdivided into primiparas and multiparas with prior uterine scar. Cost data were obtained from three public maternity hospitals (two in Rio de Janeiro, one in Belo Horizonte, Minas Gerais State, Brazil). Direct costs were identified with human resources, hospital inputs, and capital and administrative costs. Effectiveness measures were identified, based on the scientific literature. The study showed that vaginal delivery was more efficient for primiparas, at lower cost (BRL 1,709.58; USD 518.05) than cesarean (BRL 2,245.86; USD 680.56) and greater effectiveness for three of the four target outcomes. For multiparas with prior uterine scar, repeat cesarean was cost-effective for the outcomes averted maternal morbidity, averted uterine rupture, averted neonatal ICU, and averted neonatal death, but the result was not supported by probabilistic sensitivity analysis. For maternal death as the outcome, there was no difference in effectiveness, and labor showed the lowest cost. This study can contribute to the management of perinatal care, expanding measures that encourage adequate delivery according to the population's characteristics.


Assuntos
Cesárea/economia , Análise Custo-Benefício/economia , Parto Obstétrico/economia , Procedimentos Cirúrgicos Eletivos/economia , Brasil , Cesárea/efeitos adversos , Parto Obstétrico/efeitos adversos , Feminino , Humanos , Recém-Nascido , Morte Materna , Programas Nacionais de Saúde/economia , Paridade , Período Pós-Parto , Gravidez , Resultado da Gravidez , Medição de Risco/estatística & dados numéricos
20.
BMC Pregnancy Childbirth ; 18(1): 66, 2018 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-29523121

RESUMO

BACKGROUND: In China, increases in both the caesarean section (CS) rates and delivery costs have raised questions regarding the reform of the medical insurance payment system. Case payment is useful for regulating the behaviour of health providers and for controlling the CS rates and excessive increases in medical expenses. New Cooperative Medical Scheme (NCMS) agencies in Xi County in Henan Province piloted a case payment reform (CPR) in delivery for inpatients. We aimed to observe the changes in the CS rates, compare the changes in delivery-related variables, and identify variables related to delivery costs before and after the CPR in Xi County. METHODS: Overall, 28,314 cases were selected from the Xi County NCMS agency from 2009 to 2010 and from 2014 to 2015. One-way ANOVA and chi-square tests were used to compare the distributions of CS and vaginal delivery (VD) before and after the CPR under different indicators. We applied multivariate linear regressions for the total medical cost of the VD and CS groups and total samples to identify the relationships between medical expenses and variables. RESULTS: The CS rates in Xi County increased from 26.1% to 32.5% after the CPR. The length of stay (LOS), total medical cost, and proportion of county hospitals increased in the CS and VD groups after the CPR, which had significant differences. The total medical cost in the CS and VD groups as well as the total samples was significantly influenced by inpatient age, LOS, and hospital type, and had a significant correlation with the CPR in the VD group and the total samples. CONCLUSION: The CPR might fail to control the growth of unreasonable medical expenses and regulate the behaviour of providers, which possibly resulted from the unreasonable compensation standard of case payments, prolonged LOS, and the increasing proportion of county hospitals. The NCMS should modify the case payment standard of delivery to inhibit providers' motivation to render CS services. The LOS should be controlled by implementing clinical guidelines, and a reference system should be established to guide patients in choosing reasonable hospitals.


Assuntos
Cesárea/economia , Parto Obstétrico/economia , Custos de Cuidados de Saúde/legislação & jurisprudência , Seguro Saúde/economia , Análise de Variância , Distribuição de Qui-Quadrado , China , Compensação e Reparação/legislação & jurisprudência , Controle de Custos , Análise Custo-Benefício , Parto Obstétrico/legislação & jurisprudência , Parto Obstétrico/métodos , Feminino , Órgãos Governamentais , Política de Saúde/economia , Política de Saúde/legislação & jurisprudência , Mau Uso de Serviços de Saúde/economia , Mau Uso de Serviços de Saúde/legislação & jurisprudência , Hospitalização/economia , Hospitais de Condado/estatística & dados numéricos , Humanos , Seguro Saúde/legislação & jurisprudência , Tempo de Internação , Governo Local , Modelos Logísticos , Análise Multivariada , Gravidez
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA