Publicly insured caesarean sections in private hospitals: a repeated cross-sectional analysis in Chile

OBJECTIVE: To measure the likelihood of delivery by caesarean section (C-section) for publicly insured births as compared with privately insured births, across all hospitals and within private hospitals. DESIGN: Repeated cross-sectional analysis. SETTING: The universe of hospital births in 15 regions of Chile. PARTICIPANTS: 2 405 082 singleton births between 2001 and 2014. OUTCOME MEASURES: C-section rates by type of hospital and type of insurance; contribution to overall C-section rates of subgroups by type of insurance and type of hospital; adjusted OR of privately insured births delivered by C-section compared with publicly insured births, across all hospitals and within private hospitals; percentage of discharges related to maternal morbidity and mortality across groups; length of stay after delivery. RESULTS: An increasing percentage of publicly insured births occur in private facilities each year. Approximately three out of four publicly insured births in private hospitals are delivered by C-section. The adjusted odd of C-section delivery in a private maternity unit is lower for those privately insured than for those with public insurance: OR 0.6, 95% CI 0.56 to 0.64. There is no evidence that these women would have been more likely to have a C-section out of medical necessity. CONCLUSIONS: We find an association between high C-section rates and publicly insured women delivering at private institutions in Chile, and show that this group is driving the overall high and growing rates. There is a need for a more informed surveillance on the part of the public insurance system of its private providers’ C-section practices.