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Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis
Open accessAbstract
Objective: 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. Design: Systematic review and meta-analysis. Data sources: MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the first year of records through February 2016. Eligibility criteria: 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. Outcomes: 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. Results: 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 (τ 2 ≤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 (τ 2 ≥0.179). Conclusions: 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.
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In low- and middle-income countries, cesarean decisions may reflect personal or provider preferences, institutional pressures, or sociocultural beliefs rather than evidence-based clinical criteria.
“This issue is especially salient in low‐ and middle‐income countries (LMICs), where cesarean decisions may reflect personal or provider preferences, institutional pressures, or sociocultural beliefs rather than evidence‐based clinical criteria [3, 4].”
From Determinants of Delivery Mode Preferences and Decision‐Making Among Jordanian Women: A Cross‐Sectional Study (2025) · cites this paper as [4]
The Discussion (Implications for research; page unavailable) describes possible hospital pressure on physicians to perform more cesareans, and Strengths and limitations identifies women’s preferences among potential non-medical factors. The paper does not establish this combination of factors specifically for LMICs or discuss sociocultural beliefs as a driver of cesarean decisions. (LLM, conf=0.84)
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Cited by
Sorted by citations
Bawadi, H., Hamdan, Z., Shaqra, N. A., Maaitah, M., Suleimat, A., Basha, A., Saleh, S., El -Zibdah, M., Khater, R., & Abdulla, A. (2025) · Journal of Pregnancy · doi:10.1155/jp/8395387 · Cited by 1
“This issue is especially salient in low-and middle-income countries (LMICs), where cesarean decisions may re fl ect personal or provider preferences, institutional pressures, or sociocultural beliefs rather than evidence-based clinical criteria [3, 4].”
Metadata
- Authors
- Hoxha, I., Syrogiannouli, L., Luta, X., Tal, K., Goodman, D. C., da Costa, B. R., & Jüni, P.
- Affiliations
- University of Bern (CH)
- St. Michael's Hospital (CA)
- Corresponding author
- Hoxha, Ilir
- Venue
- BMJ Open
- Publisher
- BMJ
- Published
- 2017-02
- Volume
- 7
- Issue
- 2
- Pages
- e013670
- ISSN
- 2044-6055 (ISSN-L)
- PMC
- PMC5318567
- OpenAlex
- W2588003684
- Cited by
- 97
- References
- 0
- Citations by year
- 2026: 6 · 2025: 12 · 2024: 12 · 2023: 10 · 2022: 7 · 2021: 12 · 2020: 15 · 2019: 13 · 2018: 6 · 2017: 3
- FWCI
- 1.74
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by-nc
- Locations
- BMJ Open (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Bern Open Repository and Information System (University of Bern) (submittedVersion, cc-by-nc)
- HighWire Press Open Archive (submittedVersion)
- Topics
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
- Keywords
- cesarean section, for-profit hospitals, nonprofit hospitals, financial incentives, hospital ownership, public vs private hospitals, childbirth, financial conflicts of interest
- MeSH terms
- Cesarean Section, Hospitals, Proprietary, Hospitals, Public, Hospitals, Voluntary, Humans
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