Implications of Private Practice in Public Hospitals
on the Cesarean Section Rate in Thailand
Piya Hanvoravongchai, M.D.,
Jongkol Letiendumrong, M.D.,
Yot Teerawattananon, M.D.,
Viroj Tangcharoensathien , M.D., Ph.D.
Senior Research Scholar Programme,
Health Systems Research Institute and Thailand Research Fund, Thailand
Abstract
Cesarean section rate in developed countries increased significantly during 1971-1990. In Thailand the rate increased steadily from 15.2% in 1990 to 22.4% in 1996. Cesarean section rate increases with the decline of vaginal delivery, as operative delivery (vacuum and forceps) remained unchanged. There is limited evidence on Thai Cesarean procedures.
Anecdotal evidence on high cesarean procedures among private patients leads to a census of all delivery in June 1998 in 29 provincial hospitals, using an interview questionnaire by obstetric nurses with permission of the obstetric department head.
An obvious magnitude, 37.2% of patients pay unofficial gratitude money for obstetrician personal delivery services. The average cesarean section rate in the sample hospitals was 27.2%. Private patients risked undergoing cesarean section 2.92 times of non-private cases. Logistic regression showed a steeper gradient: private cases have a 5.83 higher chance of primary cesarean section than non-private cases (p<0.001) and delivery during in office hours had a 2.45 higher chance of cesarean than out of office hours (p<0.001). Financial implications of US$ 2.5 million was estimated for each one percent of cesarean procedures. Private practice could lead to deterioration of public confidence on obstetric services in public hospitals. Consequently it encourages a move to private practice and finally unnecessary cesarean procedures. This vicious cycle could not be easily broken unless more multi-disciplinary understanding of this complex issue and multiple measures are introduced.
We conclude that private practice, whereby physicians feel obliged to provide personal delivery services, when triggered by leisure and time conflict, leads to higher and possibly unnecessary cesarean procedures.
Key words: cesarean section, private practices, Thailand.