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Caesarean sections and private insurance: systematic review and meta-analysis
  1. Ilir Hoxha1,2,
  2. Lamprini Syrogiannouli2,
  3. Medina Braha3,
  4. David C Goodman1,4,
  5. Bruno R da Costa2,
  6. Peter Jüni5
  1. 1 Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
  2. 2 Institute of Primary Health Care, University of Bern, Bern, Switzerland
  3. 3 Department of Management and Marketing, International Business College Mitrovica, Mitrovica, Kosovo
  4. 4 The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, USA
  5. 5 Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Ilir Hoxha; ilir.hoxha{at}


Objective Financial incentives associated with private insurance may encourage healthcare providers to perform more caesarean sections. We therefore sought to determine the association of private insurance and odds of caesarean section.

Design Systematic review and meta-analysis.

Data sources MEDLINE, Embase and The Cochrane Library from the first year of records through August 2016.

Eligibility criteria We included studies that reported data to allow the calculation of OR of caesarean section of privately insured as compared with publicly insured women.

Outcomes The prespecified primary outcome was the adjusted OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance. The prespecified secondary outcome was the crude OR of births delivered by caesarean section of women covered with private insurance as compared with women covered with public insurance.

Results Eighteen articles describing 21 separate studies in 12.9 million women were included in this study. In a meta-analysis of 13 studies, the adjusted odds of delivery by caesarean section was 1.13 higher among privately insured women as compared with women with public insurance coverage (95% CI 1.07 to 1.18) with no relevant heterogeneity between studies (τ2=0.006). The meta-analysis of crude estimates from 12 studies revealed a somewhat more pronounced association (pooled OR 1.35, 95% CI 1.27 to 1.44) with no relevant heterogeneity between studies (τ2=0.011).

Conclusions Caesarean sections are more likely to be performed in privately insured women as compared with women using public health insurance coverage. Although this effect is small on average and variable in its magnitude, it is present in all analyses we performed.

  • caesarean section
  • health insurance
  • private insurance
  • financial incentives
  • medical practice variation
  • health services

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 and the use is non-commercial. See:

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  • Contributors IH, LS, DCG and PJ conceived and designed the study. IH, LS and MB performed the data extraction and preparation. IH, LS, BRdC and PJ analysed the data. IH, DCG and PJ wrote the paper, which was critically reviewed and approved by all authors. 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.

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

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