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Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis
  1. Ilir Hoxha1,2,
  2. Lamprini Syrogiannouli2,
  3. Xhyljeta Luta1,
  4. Kali Tal1,2,
  5. David C Goodman1,3,
  6. Bruno R da Costa2,
  7. Peter Jüni4
  1. 1Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
  2. 2Institute of Primary Health Care, University of Bern, Bern, Switzerland
  3. 3The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
  4. 4Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto, Canada
  1. Correspondence to Dr Ilir Hoxha; ilir.hoxha{at}


Objective Financial incentives may encourage private for-profit providers to perform more caesarean section (CS) than non-profit hospitals. We therefore sought to determine the association of for-profit status of hospital and odds of CS.

Design Systematic review and meta-analysis.

Data sources MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the first year of records through February 2016.

Eligibility criteria To be eligible, studies had to report data to allow the calculation of ORs of CS comparing private for-profit hospitals with public or private non-profit hospitals in a specific geographic area.

Outcomes The prespecified primary outcome was the adjusted OR of births delivered by CS in private for-profit hospitals as compared with public or private non-profit hospitals; the prespecified secondary outcome was the crude OR of CS in private for-profit hospitals as compared with public or private non-profit hospitals.

Results 15 articles describing 17 separate studies in 4.1 million women were included. In a meta-analysis of 11 studies, the adjusted odds of delivery by CS was 1.41 higher in for-profit hospitals as compared with non-profit hospitals (95% CI 1.24 to 1.60) with no relevant heterogeneity between studies (τ2≤0.037). Findings were robust across subgroups of studies in stratified analyses. The meta-analysis of crude estimates from 16 studies revealed a somewhat more pronounced association (pooled OR 1.84, 95% CI 1.49 to 2.27) with moderate-to-high heterogeneity between studies (τ2≥0.179).

Conclusions CS are more likely to be performed by for-profit hospitals as compared with non-profit hospitals. This holds true regardless of women's risk and contextual factors such as country, year or study design. Since financial incentives are likely to play an important role, we recommend examination of incentive structures of for-profit hospitals to identify strategies that encourage appropriate provision of CS.

  • caesarean section
  • for-profit hospital
  • non-profit hospital
  • financial incentives
  • medical practice variation
  • health services

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  • Contributors IH, DCG and PJ have developed the idea for the study. IH, XL and DCG were involved in the study conception, preliminary literature review and design of the search strategy and the study protocol. IH, LS and XL were involved in screening and data extraction of papers. All authors reviewed data extraction output. IH, LS, BRdC and PJ designed and performed the meta-analysis. IH, LS, KT, BRdC and PJ drafted the report, which was critically reviewed and approved by all authors.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Data sharing statement No additional data are available.