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Caesarean section in uninsured women in the USA: systematic review and meta-analysis
  1. Ilir Hoxha1,2,3,
  2. Medina Braha4,
  3. Lamprini Syrogiannouli5,
  4. David C Goodman1,6,
  5. Peter Jüni7
  1. 1 Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
  2. 2 Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth Hanover, New Hampshire, USA
  3. 3 Heimerer College, Prishtina, Kosovo
  4. 4 International Business College Mitrovica, Mitrovica, Kosovo
  5. 5 Institute of Primary Health Care, University of Bern, Bern, Switzerland
  6. 6 The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, USA
  7. 7 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, Canada
  1. Correspondence to Dr Ilir Hoxha; ilir.s.hoxha{at}


Objective The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

Study design Systematic review and meta-analysis.

Data sources PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

Eligibility criteria We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

Outcomes The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

Results 12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

Conclusions CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

  • caesarean section
  • health insurance
  • uninsured
  • self-pay
  • medical practice variation
  • underuse

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

  • Funding The authors have not declared a specific grant for this research 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 unpublished data are available from the study.

  • Patient consent for publication Not required.

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