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Health services research
Research
Health system factors and caesarean sections in Kosovo: a cross-sectional study
  1. Ilir Hoxha1,2,3,
  2. Alban Fejza2,
  3. Mrika Aliu3,
  4. Peter Jüni4,
  5. David C Goodman5
  1. 1 Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
  2. 2 Heimerer College, Prishtina, Kosovo
  3. 3 Action for Mother and Children, Prishtina, Kosovo
  4. 4 Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  5. 5 The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
  1. Correspondence to Dr Ilir Hoxha; ilir.s.hoxha{at}dartmouth.edu

Abstract

Objective To investigate the association of caesarean section rates with the health system characteristics in the public hospitals of Kosovo.

Design Cross-sectional survey.

Setting Five largest public hospitals in Kosovo.

Participants 859 women with low-risk deliveries who delivered from April to May 2015 in five public hospitals in Kosovo.

Outcome measures The prespecified outcomes were the crude and adjusted OR of births delivered with caesarean section by health system characteristics such as delivery by the physician who provided antenatal care, health insurance status and other. Additional prespecified outcomes were caesarean section rates and crude ORs for delivery with caesarean in each public hospital.

Results Women with personal monthly income had increased odds for caesarean (OR 1.55, 95% CI 1.06 to 2.27), as did women with private health insurance coverage (OR 3.44, 95% CI 1.20 to 9.85). Women instructed by a midwife on preparation for delivery had decreasing odds (OR 0.32, 95% CI 0.19 to 0.51) while women having preference for a caesarean had increasing odds for delivery with caesarean (OR 3.84, 95% CI 1.96 to 7.51). The odds for caesarean increased also in the case of delivery by a physician who provided antenatal care (OR 2.06, 95% CI 1.16 to 3.67) and delivery during office hours (OR 2.36, 95% CI 1.37 to 4.05), while delivery at the University Clinical Centre of Kosovo decreased the odds for caesarean (OR 0.46, 95% CI 0.24 to 0.90).

Conclusions We found that several health system characteristics are associated with the increase of caesarean sections in a low-risk population of delivering women in public hospitals of Kosovo. These findings should be explored further and addressed via policy measures that would tackle provision of unnecessary caesareans. The study findings could assist Kosovo to develop corrective policies in addressing overuse of caesareans and may provide useful information for other middle-income countries.

  • caesarean section
  • antenatal care
  • health systems
  • low and middle income
  • health care reform

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2018-026702

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    Footnotes

    • Contributors IH and DCG developed the idea for the study. IH, AF, PJ and DCG designed the study and the plan for analysis. IH, AF and MA managed and supervised data collection and performed literature review. IH, AF, PJ and DCG analysed and interpreted the data. IH, AF, PJ and DCG drafted the report, which was critically reviewed by all authors.

    • Funding Solidar Suisse funded this study. All authors had full access to all of the data (including statistical reports and tables) in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    • Competing interests None declared.

    • Ethics approval This study was approved by the Ethical-Professional Committee of The Hospital and University Clinical Service of Kosovo.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional unpublished data are available from the study.

    • Patient consent for publication Not required.