Gerald and Patricia Turpanjian School of Public Health, American University of Armenia, 40 Marshal Baghramian Ave, 0019, Yerevan, Armenia.
Health Services Research Center, Larner College of Medicine, University of Vermont, 89 Beaumont Ave, 89 Beaumont Ave, Burlington, VT, 05405, USA.
BMC Pregnancy Childbirth. 2019 Jan 3;19(1):2. doi: 10.1186/s12884-018-2158-6.
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.
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.
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.
The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.
亚美尼亚的剖宫产率呈上升趋势；剖宫产率从 2000 年的 7.2%上升到 2017 年的 31.0%。本研究旨在探讨导致亚美尼亚剖宫产率快速上升的潜在因素，并确定剖宫产和阴道分娩（VB）的实际成本，这与卫生部产科保健国家证书计划的报销率不同。
这是一项部分混合的同期定量定性同等地位研究。研究小组通过对妇产科医生（OBGYN）和政策制定者的深入访谈（IDI）以及对妇女的焦点小组讨论（FGD）收集定性数据。研究的定量阶段从提供者的角度采用自下而上的成本核算（仅考虑直接变量成本），包括提供者的自我管理调查和母婴医院记录的回顾。调查问卷是根据与不同医疗服务提供者的 IDI 开发的。
VB 的平均估计直接变量成本为 35219 AMD（94.72 美元），CS 的平均估计直接变量成本为 80385 AMD（216.19 美元）。CS 与 VB 的平均直接变量成本比为 2.28，高于政府 1.64 的报销比。CS 给妇产科医生的奖金比 VB 高出 11 倍，这表明妇产科医生可能有巨大的经济动机在没有医疗需要的情况下进行 CS。定性研究分析表明，经济激励、产妇要求和缺乏监管可能是导致剖宫产率上升的原因。虽然妇产科医生没有报告说 CS 的较高报销可能导致 CS 率上升，但政策制定者认为 CS 率高与报销机制有关。研究的定量阶段证实了政策制定者的担忧。
该研究表明，剖宫产率的上升与当前的医疗保健报销制度之间存在重要关系。
