An investigation of Caesarean sections in three Greek hospitals: the impact of financial incentives and convenience.
BACKGROUND
Caesarean section (CS) rates have been increasing dramatically in the past decades around the world. The objective of our study was to investigate the factors increasing the likelihood of undergoing CS in two public hospitals and one private hospital in Athens, Greece. Specifically, the purpose was primarily to assess the impact of non-medical factors such as private health insurance, potential for making informal payments, physician convenience and socio-economic status on the rate of CS deliveries.


METHODS
All available demographic, socio-economic and medical information from the medical records of all deliveries in the three hospitals in January 2002 were analysed. The relative importance of the variables in predicting delivery with CS rather than normal vaginal delivery was calculated in multiple logistic regression models to generate odds ratios (OR).


RESULTS
The CS rate in the public hospitals was 41.6% (52.5% for Greeks and 26% for immigrants), while the CS rate in the private hospital was 53% (65.2% for women with private insurance and 23.9% for women who paid directly). In the public hospitals, after controlling for demographic and medical factors, Greek ethnic background, delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, and on Monday, Wednesday and Friday were found to increase the likelihood of CS delivery. In the private hospital, having private health insurance is the strongest predictor of CS delivery, followed by delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, delivery on a Saturday and being a housewife.


CONCLUSIONS
The results of this study lend support to the hypothesis that physicians are motivated to perform CS for financial and convenience incentives. The recent commercialization of gynaecology services in Greece is discussed, along with its implications on physicians' decisions to perform CS.
Mossialos
E
E
LSE Health and Social Care, Cowdray House, London School of Economics and Political Science, London, UK. e.a.mossialos@lse.ac.uk
Allin
S
S
Karras
K
K
Davaki
K
K
D000293:Adolescent; D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D005260:Female; D006115:Greece; D016304:Hospitals, Private; D006779:Hospitals, Public; D006801:Humans; D009313:National Health Programs; D009775:Obstetrics and Gynecology Department, Hospital; D016017:Odds Ratio; D010816:Physician Incentive Plans; D011247:Pregnancy; D011248:Pregnancy Complications; D012923:Social Class