Reducing Unnecessary Caesarean Sections in the WHO European Region
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Keynote presentation at the "Reducing unnecessary caesarean sections" World Health Organization Meeting, in 13-14 December 2018
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Reducing Unnecessary Caesarean Sections in the WHO European Region
- 1. Reducing Unnecessary Caesarean Sections in the WHO European Region 13-14 December 2018 Tbilisi, Georgia Alexandre Lourenço WHO Consultant on Health Systems Strengthening & Financing Hospital Administrator/ Coimbra University Hospital PhD candidate/ Nova School of Business & Economics President/ Portuguese Association of Hospital Managers Board Member/ European Association of Hospital Managers
- 2. Outline • The current situation • Drivers behind unnecessary C- sections in caesarean sections • Moving forward • Country examples
- 3. C-section rates, 2015 53.1 46.8 46.0 38.0 37.2 36.2 35.3 34.0 32.9 32.3 32.2 30.2 30.2 30.1 28.7 27.9 27.8 26.3 26.2 26.0 25.4 24.5 21.1 21.0 20.8 20.8 20.8 18.7 17.3 16.2 16.1 16.0 15.9 15.5 0 10 20 30 40 50 60 Per 100 live births Source: OECD, 2018
- 4. Caesareans as a percentage of all births in 2015 Source: Euro-peristat, 2018
- 5. Percentages of births by caesarean delivery in 2010 and differences with 2015 Source: Euro-peristat, 2018
- 6. Mothers aged ≥ 35 years as a percentage of all pregnancies with known maternal age in 2015 Source: Euro-peristat, 2018
- 7. Drivers behind unnecessary caesarean sections Unnecessary C- sections increased maternal and perinatal morbidity increased health care costs Mother preferences Physicians’ perceptions and behaviour Providers behaviour Elective Emergent
- 8. Mother preferences Mother preferences Unnecessary C-sections Labour pain and fear Healthier for the baby Plastic interest Physicians’ beahviour Providers’ beahviour Convenience Poor health literacy Inadequate care delivery
- 9. Physicians’ perceptions and behaviour Physicians’ perceptions and behaviour Unnecessary C-sections Defensive medicine Convenience Financial incentives Mother preferences Providers’ beahviour Litigation & liability premiums Lack of skills/ competencies Inadequate care organization/ work conditions Unclear guidelines/ algorithms Inadequate financial incentives
- 10. Providers’ behaviour Providers behaviour Unnecessary C-sections Staffing models of delivery care Financial incentives Mother preferences Physicians’ perceptions and behaviour Absent facilities licensing Fragmented care Inadequate financial incentives Absent or unclear delivery care model
- 11. Unnecessary C-sections Mother preferences Labour pain and fear Healthier for the baby Plastic interest Convenience Physicians’ perceptions and behaviour Defensive medicine Convenience Financial incentives Providers behaviour Staffing models of delivery care Financial incentives Poor health literacy Inadequate care delivery Litigation & liability premiums Lack of skills/ competencies Inadequate care organization/ work conditions Unclear guidelines/ algorithms Inadequate financial incentives Absent facilities licensing Fragmented care Inadequate financial incentives Absent or unclear delivery care model
- 12. Acknowledge •Raise evidence •Priority health policy Inform •Benchmarking •Making information public can effectively support behaviour change Pay •Payment systems •e.g. single tariff, P4P, penalty tariff Persuade •Non-clinical educational interventions •evidence-based clinical practice guidelines combined with mandatory second opinion for caesarean indication •clinical guidelines, audit, feedback •Supporting tools (e.g. decision aids) Source: based on OECD, 2017
- 13. Country setting & development status Other sectors: education, sanitation, social assistance, labour, housing, environment & others Conceptual framework of integrated people-centred health services 13 Health sector: governance, financing & resources < Service delivery: Networks, Facilities & practitioners PERSON
- 14. Some country examples Estonia Catalonia, Spain Portugal
- 15. 15 Thank you!
Editor's Notes
- increase health care costs Petrou S, Glazener C. The economic costs of alternate modes of delivery during the first two months postpartum: results from a Scottish observational study. BJOG 2002;109:214–7.
- Persuade: importance of behavior change Public campaigns Combined with individual-level interventions:
- Integrated people-centred health services (IPCHS) are a key feature of robust and resilient health systems and are critical for progressing towards universal health coverage (UHC) and the Sustainable Developmental Goals (SDGs). The Framework for integrated people-centred health services was agreed by our ministers at the World Health Assembly in 2016. This approach consciously adopts individuals’, carers’, families’ and communities’ perspectives as participants in, and beneficiaries of, trusted health systems Health systems are organized around the comprehensive needs of people rather than individual diseases, and respects social preferences patients have the education and support they need to make decisions and participate in their own care Carers are able to attain maximal function within a supportive working environment It is broader than patient and person-centred care, encompassing not only clinical encounters, but also including attention to the health of people in their communities and their crucial role in shaping health policy and health services