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![[Read eLetter]](/icons/misc/sectionDOWN.gif){kind=icon}
Rethinking "Woman's Choice" of Cesarean Delivery
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Chia N. Liu, Lecturer The Formosan Medical Association, Ming C, Yang
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chris.liu{at}msa.hinet.net Chia N. Liu, et al.
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The article by Tsai and Hu1 showed the different effects of reimbursement systems on primary cesarean deliveries in Taiwan, and defined it as a "woman's choice". We think it was an oversimplified conclusion and would like to provide some additional explanations regarding the influence of traditional cultural beliefs and to elaborate the mechanism of insurance systems on cesarean deliveries The rates of cesarean sections in hospitals of Taiwan remained were as high as 32-34% from 1993 to 2001.2 We suggest that the unique cultural belief of Taiwanese is an important factor aside from medical reasons. In Taiwan, many people believe that choosing an auspicious time of birth has promising effects on children's fate, and may also ensure the safety of mothers and children.3,4 Huang et al.5 found that women who underwent cesarean deliveries ranked the importance of the non-medical factors 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 their insurance". Although women's participation in the decision-making process regarding how to deliver their babies has emerged,6 physicians were the ones to make final decisions. Insurance coverage possibly not only affects patients' choices directly but also physicians' behaviors indirectly. These indirect effects may be related to physicians' concerns of 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 strongly argued that "woman's choice" was not the only factor to explain the mechanism between intervention of health insurance and increase in C/S utilization in Taiwan. Tsai's article1 showed that the odds ratio of women covered by Government Employee's Insurance or Labor Insurance compared to the uninsured women were much higher than that of previous studies conducted in Taiwan.5,9 We think that there are a few points that 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's data were from a private hospital. Physicians in private hospitals might tend to satisfy patient's requests or perform primary cesarean deliveries more aggressively to reduce waiting time in labor process.10 Secondly, the design of Labor Insurance's reimbursement scheme would influence the hospital seeking behavior of women who originally intended to undergo cesarean sections. The reimbursement fees of cesarean sections were set according to the accreditation level of hospitals. Thus, the higher the accreditation level was 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's study, to meet their requests. This may partly explain why women covered by Labor Insurance had higher odds ratio to use cesarean delivery in Tsai's article. Finally, we suggest that the intervention of insurance would have both effects on women's choice and physicians' behavior, and this should always be taken into consideration in studying and planning for the maternity services. Chia N. Liu, MS Ming C. Yang, DrPH About the Authors Chia N, Liu is a doctoral candidate at the Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan. Ming C. Yang is with the Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taipei, Taiwan. Requests for reprints should be sent to Chia N. Liu, Department of Living Science, National Open University. No.172, Chung -Cheng Rd, Lu Chow, Taipei County, Taiwan 24702, ROC.(e-mail: chris.liu@msa.hinet.net) Reference 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, ROC. 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, et al. The implied meaning of specified time for cesarean birth: a phenomenological study. Nursing Research. 1997;5:331-340. (in Chinese) 4. Joan C. Lo. Patients' attitudes vs. physicians' determination: implications for cesarean sections. Soc Sci Med. (forthcoming). 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. Chinese J Public Health. 1997;16:309-318. (in Chinese) 6. Peskin EG, Gabrielle R. What is the correct cesarean rate and how do we get there? [letter]. Obstet Gynecol Surv. 2002;57:189-190. 7. Rostow VP, Osterweis M, Bulger RJ. Medical professional liability and the delivery of obstetrical care. N Engl J Med. 1989;321;1057-1060. 8. Keeler EB, Brodie M. Economic incentives in the choice between vaginal delivery and cesarean section. Milbank Q. 1993;71:365-404. 9. Chu CL, Kuo HS. The Relationship Between Insurance and Cesarean Section in A Medical Center [Master Thesis]. Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan, 1994. (in Chinese) 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. | |||
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