Originalarbeit
Caesarean Sections in Beijing, China – Results from a Descriptive Study Unnötige Kaiserschnittentbindungen in Beijing, China – Die Ergebnisse einer deskriptiven Studie
Authors
Y. Hu, H. Tao, Z. Cheng
Key words ▶ china ● ▶ unnecessary Caesarean ● sections ▶ excess economic burden ● Schlüsselwörter ▶ China ● ▶ unnötige Schnittentbin ● dungen ▶ Kosten ●
Bibliography DOI http://dx.doi.org/ 10.1055/s-0035-1549937 Published online: 2015 Gesundheitswesen © Georg Thieme Verlag KG Stuttgart · New York ISSN 0941-3790 Correspondence Prof. Hongbing Tao School of Medizin und Gesundheitsmanagement Tongji Medical College Huazhong Universität für Wissenschaft und Technologie No. 13 Hangkong Straße 430030 Wuhan China [email protected]
Abstract
Zusammenfassung
Objective: Caesarean section rates are increasing dramatically in China. The predominant contributor to the increase in China was the unnecessary Caesarean section. The objective of this study was to estimate the excess economic burden caused by unnecessary Caesarean sections vs. vaginal delivery for Beijing and all China. Methods: The 33 476 obstetric medical case files from randomly selected 17 hospitals of Beijing in 2011 were taken for our descriptive approach. Based on the individual medical files and on a definition of what necessary and unnecessary Caesarean sections are, we sampled also the data for costs and length of stay for comparisons with vaginal deliveries. The Mann-Whitney U test and Pearson chi-square test statistics were used to test for significant difference in the analysis. Results: The Caesarean section rate was 58.5 % among all deliveries and that rate of unnecessary Caesarean sections was 71.5 % among all the Caesarean sections but 41.8 % among all deliveries in Beijing. The hospitalisation expenses of unnecessary Caesarean sections were 472 US$ higher than that of a vaginal delivery on average. The total excess economic burden caused by unnecessary Caesarean sections can be estimated to 38.97 million US$ for Beijing and to 3.29 billion US$ all over China in 2011. This is equivalent to the annual health expenditure of over 139 575 residents in Beijing and of 11 783 120 residents in China, respectively. Conclusion: Socio-economic factors are possible reasons for the increase of unnecessary Caesarean section in China and more analytical attention should be paid to that problem in order to propose fitting practical reactions.
Ziel: Die Kaiserschnitt-Rate steigt dramatisch in China. Der vorherrschende Faktor für die Zunahme waren unnötige Kaiserschnitte. Ziel dieser Studie war es, die wirtschaftliche Belastung durch unnötige Kaiserschnitte im Vergleich zu vaginalen Entbindung für Peking und ganz China zu schätzen. Methodik: 33 476 geburtshilfliche medizinische Akten von 17 Krankenhäusern in Peking aus dem Jahr 2011 wurden ausgewertet, um die Situation von unnötigen Kaiserschnitten in Peking, China zu beschreiben und die wirtschaftliche Belastung, die sie im Vergleich zu vaginalen Entbindungen verursachten zu schätzen. Der MannWhitney U-Test und Pearson Chi-Quadrat-TestStatistik wurden verwendet, um signifikanten Unterschied in der Analyse zu prüfen. Ergebnisse: Schnittentbindungen waren 58,5 % aller Entbindungen und unnötige Schnitt entbindungen waren 71,5 % damit, und 41,8 % aller Entbindungen in Peking. Die Krankenhauskosten von unnötigen Kaiserschnitten waren im Durchschnitt 472 US$ höher als die der vaginalen Entbindung. Die Kosten der unnötigen Schnittentbindungen können auf 38,97 Million US$ für Beijing und 3,29 Billion US$ für das gesamte Land in 2011 geschätzt werden. Diese Summe entspricht den Gesamtausgaben für die Krankenversorgung von 139 575 Einwohnern in Beijing, bzw. etwa 11 783 120 Einwohnern in China. Schlussfolgerung: Sozioökonomische Faktoren sind die möglichen Ursachen für diesen Sachverhalt und daher sollte größere analytische Aufmerksamkeit diesem Problem gewidmet werden, um geeignete praktische Schritte gegen die Verschwendung knapper Ressourcen durch unnötige medizinische Leistungen begründen zu können.
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Hu Y et al. Caesarean Sections in Beijing … Gesundheitswesen
Downloaded by: University of British Columbia. Copyrighted material.
Affiliation School of Medizin und Gesundheitsmanagement, Tongji Medical College, Huazhong Universität für Wissenschaft und Technologie, Wuhan, China
Introduction
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Caesarean section (CS) rates are high and continue to rise both in developed and developing countries in recent years. Many of them have largely exceeded the 15 % upper the limit as it was suggested by the World Health Organization in 1985 [1, 2]. In the United States, the CS rate has increased by 50 % from 20.7 % in 1996 to 31.1 % in 2006. This is reported being due to the patientchoice of a cesarean delivery [3, 4]. In Brazil and in Mexico, the national rate of CS was found to be 37 and 39 % respectively [1]. The increase of CS rates in Europe has also been well recorded across nearly all European countries (excluding Iceland and Finland) [5, 6]. In China, the CS rate increased from about 5 % in the 1960s to about 20 % in the late 1980s and the early 1990s. But the CS rate in urban cities of China has been dramatically increased further since the mid-1990 s to 39.5 % in 2002 [7, 8]. A global survey of the WHO shows that the CS rate in China was 46.2 % in 2007– 2008, which was the highest in Asia and the second place in the world [9]. Many aspects contribute to this increase. The CS on maternal request and CS without any medical indications are reported the predominant reasons [10, 11]. A total of 63 % of all worldwide CSs without medical indications are performed in China [12]. In 2008, it was calculated the number of 1 976 606 unnecessary CS in China [13]. These unnecessary CS can have a negative impact on maternal and neonatal health. They also result in an unnecessarily high resource consumption and excess economic burden for any paying party [11, 12, 14, 15]. The analytical scene is paying increasing attention to that observation but reflects mostly the costs of alternative modes of delivery. Few is done to calculate the excess economic burden of unnecessary CS compared with vaginal delivery [13, 16–20]. In this paper, we describe the situation regarding unnecessary CS in Beijing, China and try to estimate the excess economic burden caused by unnecessary CS vs. vaginal delivery for Beijing and all China.
Methods
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The data were drawn from obstetric medical case files from 17 hospitals of Beijing in 2011. We sampled these cases by randomly selecting these 17 hospitals from all the hospitals in Beijing. The total of the 33 476 obstetric medical case files included 19 896 case files from 11 secondary hospitals and 13 580 case files from 6 tertiary hospitals. The cost data such as per capita consumption expenditure and per capita income were taken from the Statistical Yearbook of China for that year. It always was clarified that we only had access to the data on an anonymous basis with no access to the women’s names. We have used the following first and the second diagnosis, which were documented in the medical files in order to identify caesarian sections being performed because of a proven medical indication: contracted pelvis, cephalopelvic disproportion in labour, transverse presentation, abnormal soft birth canal, placenta praevia, placental abruption, prolapse of cords. All these reason are classified as necessary CSs. All the other CSs we classified as unnecessary CSs. In this study, the prevalence, the length of stay, the hospitalization expenses and their structures regarding unnecessary CSs were compared with vaginal delivery. The hospitalization expenses and the length of stay show a skewed distribution. We Hu Y et al. Caesarean Sections in Beijing … Gesundheitswesen
decided to use the median for describing the average. The distribution of other features was described with the arithmetic mean. The Mann-Whitney U test and Pearson chi-square test were practiced in order to test for significant differences between both groups but coming from the same sample and for independence. The authors assume that all the CSs not being classified as being necessary can be considered as being the indicated alternative for an uncomplicated vaginal delivery. Thus, the difference of costs between both the categories is the excess economic burden caused by unnecessary CSs. We are using the term “cost” equivalent to the term price, because we did not evaluate on the hospitals’ true costs for performing services. We finally estimated the excess economic burden caused by unnecessary CS for all the country assuming that Beijing could roughly be taken as representing all China. That might be seen problematic because over estimating the problem but should be precise enough to address the issue for further studies. Due to the data available in China, the directnon-medical costs and the indirect costs can only be crudely estimated. For the purpose of that study, the excess economic burden of each case of unnecessary CS is calculated as the sum of the excess direct medical costs, the excess direct non-medical costs and the excess indirect costs. Excess direct medical costs are the average hospitalization expenses of unnecessary CS minus the average hospitalization expenses of vaginal delivery. Excess direct non-medical costs is calculated as the product of daily per capita consumption expenditure of Beijing in 2011 multiplied with the difference between the average length of stay of unnecessary CS and the average length of stay of vaginal delivery. In this study, the indirect costs refer to the loss of human capital in the labor market. However, from the perspective of the whole society, we assume that the loss of human capital in the labor market due to the families with childbirth would be filled or substituted by other workers; therefore, the excess indirect costs are assumed being zero in this estimation. The total number of unnecessary CSs in Beijing in 2011 is the product of the rate of unnecessary CS in Beijing in 2011and the number of births in Beijing in 2011. The total excess economic burden of unnecessary CS of Beijing in 2011 is the product of excess economic burden of each case of unnecessary CS multiplied with the total number of unnecessary CS of Beijing in 2011. The per capita daily consumption expenditure of Beijing in 2011 was calculated by the per capita annual consumption expenditure divided by 365 days.
Results
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The number of all the deliveries taken from the medical files was 33 476 with 13 890 cases of vaginal delivery and 19 586 CSs. The CS rate was 58.5 %. The number of unnecessary CS was 14 008, which accounts for 71.5 % of all CSs and for 41.8 % of all deliveries. The hospitalization expenses and the length of stay of CS were ▶ Table 1). higher than that of vaginal delivery ( ● The difference is statistically significant (P
Caesarean Sections in Beijing, China – Results from a Descriptive Study Unnötige Kaiserschnittentbindungen in Beijing, China – Die Ergebnisse einer deskriptiven Studie
Authors
Y. Hu, H. Tao, Z. Cheng
Key words ▶ china ● ▶ unnecessary Caesarean ● sections ▶ excess economic burden ● Schlüsselwörter ▶ China ● ▶ unnötige Schnittentbin ● dungen ▶ Kosten ●
Bibliography DOI http://dx.doi.org/ 10.1055/s-0035-1549937 Published online: 2015 Gesundheitswesen © Georg Thieme Verlag KG Stuttgart · New York ISSN 0941-3790 Correspondence Prof. Hongbing Tao School of Medizin und Gesundheitsmanagement Tongji Medical College Huazhong Universität für Wissenschaft und Technologie No. 13 Hangkong Straße 430030 Wuhan China [email protected]
Abstract
Zusammenfassung
Objective: Caesarean section rates are increasing dramatically in China. The predominant contributor to the increase in China was the unnecessary Caesarean section. The objective of this study was to estimate the excess economic burden caused by unnecessary Caesarean sections vs. vaginal delivery for Beijing and all China. Methods: The 33 476 obstetric medical case files from randomly selected 17 hospitals of Beijing in 2011 were taken for our descriptive approach. Based on the individual medical files and on a definition of what necessary and unnecessary Caesarean sections are, we sampled also the data for costs and length of stay for comparisons with vaginal deliveries. The Mann-Whitney U test and Pearson chi-square test statistics were used to test for significant difference in the analysis. Results: The Caesarean section rate was 58.5 % among all deliveries and that rate of unnecessary Caesarean sections was 71.5 % among all the Caesarean sections but 41.8 % among all deliveries in Beijing. The hospitalisation expenses of unnecessary Caesarean sections were 472 US$ higher than that of a vaginal delivery on average. The total excess economic burden caused by unnecessary Caesarean sections can be estimated to 38.97 million US$ for Beijing and to 3.29 billion US$ all over China in 2011. This is equivalent to the annual health expenditure of over 139 575 residents in Beijing and of 11 783 120 residents in China, respectively. Conclusion: Socio-economic factors are possible reasons for the increase of unnecessary Caesarean section in China and more analytical attention should be paid to that problem in order to propose fitting practical reactions.
Ziel: Die Kaiserschnitt-Rate steigt dramatisch in China. Der vorherrschende Faktor für die Zunahme waren unnötige Kaiserschnitte. Ziel dieser Studie war es, die wirtschaftliche Belastung durch unnötige Kaiserschnitte im Vergleich zu vaginalen Entbindung für Peking und ganz China zu schätzen. Methodik: 33 476 geburtshilfliche medizinische Akten von 17 Krankenhäusern in Peking aus dem Jahr 2011 wurden ausgewertet, um die Situation von unnötigen Kaiserschnitten in Peking, China zu beschreiben und die wirtschaftliche Belastung, die sie im Vergleich zu vaginalen Entbindungen verursachten zu schätzen. Der MannWhitney U-Test und Pearson Chi-Quadrat-TestStatistik wurden verwendet, um signifikanten Unterschied in der Analyse zu prüfen. Ergebnisse: Schnittentbindungen waren 58,5 % aller Entbindungen und unnötige Schnitt entbindungen waren 71,5 % damit, und 41,8 % aller Entbindungen in Peking. Die Krankenhauskosten von unnötigen Kaiserschnitten waren im Durchschnitt 472 US$ höher als die der vaginalen Entbindung. Die Kosten der unnötigen Schnittentbindungen können auf 38,97 Million US$ für Beijing und 3,29 Billion US$ für das gesamte Land in 2011 geschätzt werden. Diese Summe entspricht den Gesamtausgaben für die Krankenversorgung von 139 575 Einwohnern in Beijing, bzw. etwa 11 783 120 Einwohnern in China. Schlussfolgerung: Sozioökonomische Faktoren sind die möglichen Ursachen für diesen Sachverhalt und daher sollte größere analytische Aufmerksamkeit diesem Problem gewidmet werden, um geeignete praktische Schritte gegen die Verschwendung knapper Ressourcen durch unnötige medizinische Leistungen begründen zu können.
▼
▼
Hu Y et al. Caesarean Sections in Beijing … Gesundheitswesen
Downloaded by: University of British Columbia. Copyrighted material.
Affiliation School of Medizin und Gesundheitsmanagement, Tongji Medical College, Huazhong Universität für Wissenschaft und Technologie, Wuhan, China
Introduction
▼
Caesarean section (CS) rates are high and continue to rise both in developed and developing countries in recent years. Many of them have largely exceeded the 15 % upper the limit as it was suggested by the World Health Organization in 1985 [1, 2]. In the United States, the CS rate has increased by 50 % from 20.7 % in 1996 to 31.1 % in 2006. This is reported being due to the patientchoice of a cesarean delivery [3, 4]. In Brazil and in Mexico, the national rate of CS was found to be 37 and 39 % respectively [1]. The increase of CS rates in Europe has also been well recorded across nearly all European countries (excluding Iceland and Finland) [5, 6]. In China, the CS rate increased from about 5 % in the 1960s to about 20 % in the late 1980s and the early 1990s. But the CS rate in urban cities of China has been dramatically increased further since the mid-1990 s to 39.5 % in 2002 [7, 8]. A global survey of the WHO shows that the CS rate in China was 46.2 % in 2007– 2008, which was the highest in Asia and the second place in the world [9]. Many aspects contribute to this increase. The CS on maternal request and CS without any medical indications are reported the predominant reasons [10, 11]. A total of 63 % of all worldwide CSs without medical indications are performed in China [12]. In 2008, it was calculated the number of 1 976 606 unnecessary CS in China [13]. These unnecessary CS can have a negative impact on maternal and neonatal health. They also result in an unnecessarily high resource consumption and excess economic burden for any paying party [11, 12, 14, 15]. The analytical scene is paying increasing attention to that observation but reflects mostly the costs of alternative modes of delivery. Few is done to calculate the excess economic burden of unnecessary CS compared with vaginal delivery [13, 16–20]. In this paper, we describe the situation regarding unnecessary CS in Beijing, China and try to estimate the excess economic burden caused by unnecessary CS vs. vaginal delivery for Beijing and all China.
Methods
▼
The data were drawn from obstetric medical case files from 17 hospitals of Beijing in 2011. We sampled these cases by randomly selecting these 17 hospitals from all the hospitals in Beijing. The total of the 33 476 obstetric medical case files included 19 896 case files from 11 secondary hospitals and 13 580 case files from 6 tertiary hospitals. The cost data such as per capita consumption expenditure and per capita income were taken from the Statistical Yearbook of China for that year. It always was clarified that we only had access to the data on an anonymous basis with no access to the women’s names. We have used the following first and the second diagnosis, which were documented in the medical files in order to identify caesarian sections being performed because of a proven medical indication: contracted pelvis, cephalopelvic disproportion in labour, transverse presentation, abnormal soft birth canal, placenta praevia, placental abruption, prolapse of cords. All these reason are classified as necessary CSs. All the other CSs we classified as unnecessary CSs. In this study, the prevalence, the length of stay, the hospitalization expenses and their structures regarding unnecessary CSs were compared with vaginal delivery. The hospitalization expenses and the length of stay show a skewed distribution. We Hu Y et al. Caesarean Sections in Beijing … Gesundheitswesen
decided to use the median for describing the average. The distribution of other features was described with the arithmetic mean. The Mann-Whitney U test and Pearson chi-square test were practiced in order to test for significant differences between both groups but coming from the same sample and for independence. The authors assume that all the CSs not being classified as being necessary can be considered as being the indicated alternative for an uncomplicated vaginal delivery. Thus, the difference of costs between both the categories is the excess economic burden caused by unnecessary CSs. We are using the term “cost” equivalent to the term price, because we did not evaluate on the hospitals’ true costs for performing services. We finally estimated the excess economic burden caused by unnecessary CS for all the country assuming that Beijing could roughly be taken as representing all China. That might be seen problematic because over estimating the problem but should be precise enough to address the issue for further studies. Due to the data available in China, the directnon-medical costs and the indirect costs can only be crudely estimated. For the purpose of that study, the excess economic burden of each case of unnecessary CS is calculated as the sum of the excess direct medical costs, the excess direct non-medical costs and the excess indirect costs. Excess direct medical costs are the average hospitalization expenses of unnecessary CS minus the average hospitalization expenses of vaginal delivery. Excess direct non-medical costs is calculated as the product of daily per capita consumption expenditure of Beijing in 2011 multiplied with the difference between the average length of stay of unnecessary CS and the average length of stay of vaginal delivery. In this study, the indirect costs refer to the loss of human capital in the labor market. However, from the perspective of the whole society, we assume that the loss of human capital in the labor market due to the families with childbirth would be filled or substituted by other workers; therefore, the excess indirect costs are assumed being zero in this estimation. The total number of unnecessary CSs in Beijing in 2011 is the product of the rate of unnecessary CS in Beijing in 2011and the number of births in Beijing in 2011. The total excess economic burden of unnecessary CS of Beijing in 2011 is the product of excess economic burden of each case of unnecessary CS multiplied with the total number of unnecessary CS of Beijing in 2011. The per capita daily consumption expenditure of Beijing in 2011 was calculated by the per capita annual consumption expenditure divided by 365 days.
Results
▼
The number of all the deliveries taken from the medical files was 33 476 with 13 890 cases of vaginal delivery and 19 586 CSs. The CS rate was 58.5 %. The number of unnecessary CS was 14 008, which accounts for 71.5 % of all CSs and for 41.8 % of all deliveries. The hospitalization expenses and the length of stay of CS were ▶ Table 1). higher than that of vaginal delivery ( ● The difference is statistically significant (P
