Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study
Open accessAbstract
BACKGROUND: Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health. METHODS: This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services. RESULTS: The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government's reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers' concern. CONCLUSION: The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.
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Few studies have explored both practitioner and patient perspectives regarding C-sections and the reasons thereof.
“Few studies have explored both practitioner and patient perspectives regarding C-sections and the reasons thereof”
From "Everywhere you see, C-sections are happening": examining trends and reasons for a rise in cesarean-section deliveries among women in urban informal settlements, Mumbai Metropolitan Region, using a mixed methods approach (2026) · cites this paper as [35]
The Methods (Study design; page not available) describe focus groups with women and interviews with obstetrician-gynecologists about C-section preferences and reasons, so this paper is an example of a study exploring both perspectives. The cited passages do not establish the broader claim that few studies have done so. (LLM, conf=0.82)
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Putri, N. K., Zhafira, D., & Laksana, M. A. C. (2026) · BMJ Open · doi:10.1136/bmjopen-2026-118641
- Authors
- Tadevosyan, M., Ghazaryan, A., Harutyunyan, A., Petrosyan, V., Atherly, A., & Hekimian, K.
- Affiliations
- American University of Armenia (AM)
- University of Vermont (US)
- Columbia University (US)
- Corresponding author
- Tadevosyan, Meri
- Venue
- BMC Pregnancy and Childbirth
- Published
- 2019-01-03
- Volume
- 19
- Issue
- 1
- Pages
- 2-2
- ISSN
- 1471-2393 (ISSN-L)
- PMC
- PMC6318900
- OpenAlex
- W2942386170
- Cited by
- 62
- References
- 30
- Citations by year
- 2026: 7 · 2025: 8 · 2024: 9 · 2023: 13 · 2022: 7 · 2021: 10 · 2020: 7 · 2019: 1
- FWCI
- 6.80
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Pregnancy and Childbirth (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Columbia Academic Commons (Columbia University)
- Topics
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Keywords
- cesarean section rate, vaginal delivery, health care reimbursement, physician incentives, health policy, Armenia
- MeSH terms
- Administrative Personnel, Adult, Armenia, Cesarean Section, Female, Humans, Obstetrics, Pregnancy, Surveys and Questionnaires, Reimbursement, Incentive, Retrospective Studies, Focus Groups, Qualitative Research, Pregnant Women, Pregnant People
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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