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LETTER |
Chia-Nien Liu is a doctoral candidate at the Institute of Health Policy and Management and Ming-Chin Yang is with the Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei, Taiwan.
Correspondence: Requests for reprints should be sent to Chia-Nien Liu, Department of Living Science, National Open University. No. 172, Chung-Cheng Rd, Lu Chow, Taipei County, Taiwan 24702, Republic of China (e-mail: chris.liu{at}msa.hinet.net).
The article by Tsai and Hu showed the effects of 3 different reimbursement systems on primary cesarean deliveries in Taiwan and defined primary cesarean delivery as a "woman’s choice."1 We think this is an oversimplified conclusion, and we would like to provide some additional explanations regarding the influence of traditional cultural beliefs and to elaborate the mechanism by which insurance systems affect cesarean deliveries.
The rates of cesarean deliveries in Taiwan hospitals were as high as 32% to 34% from 1993 to 2001.2 We suggest that a Taiwanese cultural belief is an important factor, aside from medical reasons. In Taiwan, many people believe that an auspicious time of birth has beneficial effects on children’s fate and may also ensure the safety of mothers and children.3,4 Huang et al. found that women who underwent cesarean deliveries ranked the importance of the nonmedical factors in their decision as follows: "to choose a good timing," "easier to arrange delivery time," "to avoid delivery pains," "afraid of no relatives or friends to provide company," "worried that vaginal delivery will affect sexual life," and "cesarean delivery was covered by insurance."5
Although women’s participation in the decisionmaking process is important,6 physicians were the ones to make final decisions. Insurance coverage may affect not only patients’ choices directly but also physicians’ behaviors indirectly. These indirect effects may be related to physicians’ concerns about malpractice liability,7 their own preference for surgical birth, and their tight schedules of work and leisure.1,8 These reasons may encourage doctors to perform cesarean sections on insured women. We argue that "woman’s choice" was not the only factor to explain the relationship between health insurance and increase in use of cesarean delivery in Taiwan.
Tsai and Hu showed that the odds ratios for cesarean delivery of women covered by Government Employees’ Insurance or Labor Insurance compared with uninsured women were much higher than those found in previous studies conducted in Taiwan.5,9 We think that a few points deserve to be noted. First, the ownership of hospitals in different studies would have an impact on physicians’ behavior. Previous studies were based on data from public teaching hospitals, while Tsai and Hu’s data were from a private hospital. Physicians in private hospitals might tend to accede to patient’s requests or perform primary cesarean deliveries more aggressively to reduce waiting time in the labor process.10 Second, the design of the Labor Insurance reimbursement scheme would influence the hospital choice of women who originally intended to undergo cesarean deliveries. The reimbursement fees for cesarean deliveries were set according to the accreditation level of hospitals. Thus, the higher the accreditation level, the higher the reimbursement for the services provided by those hospitals. This scheme might encourage women to select private hospitals with higher accreditation levels, such as the hospital in Tsai and Hu’s study, to meet their requests. This may partly explain why women covered by Labor Insurance had higher odds ratios for use of cesarean delivery.
Finally, we suggest that the intervention of insurance would have effects both on women’s choice and on physicians’ behavior, and this should always be taken into consideration in studying and planning for maternity services.
References
1. Tsai YW, Hu TW. National health insurance, physician financial incentives, and primary cesarean deliveries in Taiwan. Am J Public Health. 2002;92:1514–1517.
2. Department of Health, Taiwan, Republic of China. Daily average utilization rate and caesarian section rate by locality, Taiwan area, 1993–2001. Available at: http://www.doh.gov.tw/newverprog/proclaim. Accessed December 12, 2002.
3. Yang YO, Chao YM, Shieh SL, Chien ML. The implied meaning of specified time for cesarean birth: a phenomenological study [in Chinese]. Nurs Res.1997;5:331–340.
4. Lo JC. Patients’ attitudes vs. physicians’ determination: implications for cesarean sections. Soc Sci Med. In press.
5. Huang CY, Yang MC, Chen WJ. Maternal factors associated with the use of cesarean section: a case study of the National Taiwan University Hospital [in Chinese]. Chin J Public Health.1997;16:309–318.
6. Peskin EG, Reine GM. What is the correct cesarean rate and how do we get there? Obstet Gynecol Surv.2002;57:189–190.[Medline]
7. Rostow VP, Osterweis M, Bulger RJ. Medical professional liability and the delivery of obstetrical care. N Engl J Med. 1989;321;1057–1060.[ISI][Medline]
8. Keeler EB, Brodie M. Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q.1993;71:365–404.[ISI][Medline]
9. Chu CL, Kuo HS. The Relationship Between Insurance and Cesarean Section in A Medical Center [master’s thesis, in Chinese]. Taipei, Taiwan: Institute of Health and Welfare Policy, National Yang-Ming University; 1994.
10. de Regt RH, Minkoff HL, Feldman J, Schwarz RH. Relation of private or clinic care to the cesarean birth rate. N Engl J Med.1986;315:619–624.[Abstract]
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