Is Money Motivating More C-sections?

04 May 2020

The cord might be around her neck, so we will need to schedule a C-section. How does next Wednesday sound?” My obstetrician smiled reassuringly. It was 1992 in Brazil. My first C-section. Not medically necessary I’ve come to learn. Brazil offers a cautionary tale of C-section rates over 50% of all births, well above the suggested 15%. Similar increasing trends are already emerging in some other low and middle-income countries (LMICs) as they make welcome strides to improve access to basic and emergency obstetric care.

C-sections can save lives. This is especially true in LMICs where C-section rates are low (below 5%). But at the same time, unnecessary C-sections are bad. The World Health Organization has warned, “Rising C-section rates have not been accompanied by significant maternal or perinatal benefits. On the contrary, there is evidence that, beyond a certain threshold, increasing caesarean section rates may be associated with increased maternal and perinatal morbidity…[and] substantial health-care costs.” As a surgical procedure, a C-section exposes the mother and baby to risk of complications, injury, and infection.

In Kenya, there are urban settings where we are doing too many C-sections, yet in the rural areas we don’t have enough to save women’s lives.– Marleen Temmerman, Professor of Obstetrics and Gynaecology, Aga Khan University

LMICs may face the dual dilemma of:

  • Too little, too late for poor and/or rural women who cannot access safe C-sections when medically necessary because the surgical facilities and staff are lacking or because they cannot afford the hospitals that offer safe C-sections
  • Too much, too soon for wealthier urban women who opt for a C-section that is not medically necessary for a variety of reasons, such as doctor recommendation, convenience, fear of pain, or to be “modern”

Both contribute to poor outcomes, including disproportionally high C-section deaths in LMICs, especially in sub-Saharan Africa.

Source: Soha Sobhy et al. 2019

The drivers of C-sections are varied and complex. High and middle-income countries are trying to address the problem with mixed results. What can LMICs learn from these countries? Can they save lives and money in the process? Stakeholders from around the world convened for a two-day workshop in December that was titled, “Averting an Impending Cesarean Section Disaster in LMICs.” I was honored to join more than 30 experts who shared the evidence on C-sections, necessary and unnecessary, in LMICs and their heroic efforts to address a growing crisis.

I joined the workshop to share information on how financial incentives for C-section provision influence the health care provider. Paying providers a higher fee for a C-section compared to a normal delivery does contribute to higher C-section rates. Yet this is common practice in many countries. National health insurers in Kenya, Indonesia, and Philippines are alarmed at rising C-section rates among their beneficiaries. All three pay more for C-sections.

Country Payer Rate by type of delivery C-section incentive
Kenya National Hospital Insurance Fund Normal         KES 10,000

C-section      KES 30,000

3 times more
Indonesia National Health Insurance JKN Normal        Rp 1.5M-4.7M

C-section     Rp 5.2M – 14.5M

3 to 3.5 times more
Philippines PhilHealth Normal             P 9,700

C-section        P 19,000

2 times more

While financial incentives are just one driver of rising C-section rates, they may represent one lever to prevent or contain the impending disaster. Countries need financial incentives to be working with, not against, the other efforts to promote cost-effective, quality maternal and neonatal care. ThinkWell is supporting these three countries and others to align financial incentives for improved primary health care through Strategic Purchasing for Primary Health Care (SP4PHC), a project funded by a grant from the Bill & Melinda Gates Foundation.

A few months ago, my husband and I received the joyous news that we would be grandparents. My Brazilian husband asked if it would be a normal delivery. He meant a C-section! Let’s not wait until it’s too late, when C-sections become the ‘normal’ in countries that can ill afford the costs and risks to mothers and babies.