title: Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis.
abstract: Financial incentives may encourage private for-profit providers to perform more caesarean section (CS) than non-profit hospitals. We therefore sought to determine the association of for-profit status of hospital and odds of CS.
  
  
  
  Systematic review and meta-analysis.
  
  
  
  MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the first year of records through February 2016.
  
  
  
  To be eligible, studies had to report data to allow the calculation of ORs of CS comparing private for-profit hospitals with public or private non-profit hospitals in a specific geographic area.
  
  
  
  The prespecified primary outcome was the adjusted OR of births delivered by CS in private for-profit hospitals as compared with public or private non-profit hospitals; the prespecified secondary outcome was the crude OR of CS in private for-profit hospitals as compared with public or private non-profit hospitals.
  
  
  
  15 articles describing 17 separate studies in 4.1 million women were included. In a meta-analysis of 11 studies, the adjusted odds of delivery by CS was 1.41 higher in for-profit hospitals as compared with non-profit hospitals (95% CI 1.24 to 1.60) with no relevant heterogeneity between studies (τ2≤0.037). Findings were robust across subgroups of studies in stratified analyses. The meta-analysis of crude estimates from 16 studies revealed a somewhat more pronounced association (pooled OR 1.84, 95% CI 1.49 to 2.27) with moderate-to-high heterogeneity between studies (τ2≥0.179).
  
  
  
  CS are more likely to be performed by for-profit hospitals as compared with non-profit hospitals. This holds true regardless of women's risk and contextual factors such as country, year or study design. Since financial incentives are likely to play an important role, we recommend examination of incentive structures of for-profit hospitals to identify strategies that encourage appropriate provision of CS.
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.|Institute of Primary Health Care, University of Bern, Bern, Switzerland.
authors.forename: Ilir
authors.identifier: 0000-0003-4262-1406
authors.initials: I
authors.lastname: Hoxha
authors.affiliation: Institute of Primary Health Care, University of Bern, Bern, Switzerland.
authors.forename: Lamprini
authors.initials: L
authors.lastname: Syrogiannouli
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
authors.forename: Xhyljeta
authors.initials: X
authors.lastname: Luta
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.|Institute of Primary Health Care, University of Bern, Bern, Switzerland.
authors.forename: Kali
authors.initials: K
authors.lastname: Tal
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.|The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.
authors.forename: David C
authors.initials: DC
authors.lastname: Goodman
authors.affiliation: Institute of Primary Health Care, University of Bern, Bern, Switzerland.
authors.forename: Bruno R
authors.initials: BR
authors.lastname: da Costa
authors.affiliation: Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Jüni
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data*; D006777:Hospitals, Proprietary / Q000706:statistics & numerical data*; D006779:Hospitals, Public / Q000706:statistics & numerical data*; D006788:Hospitals, Voluntary / Q000706:statistics & numerical data*; D006801:Humans
keywords: caesarean section; financial incentives; for-profit hospital; health services; medical practice variation; non-profit hospital