Impact of the organization of care on the practice of cesarean section.

Summary Cesarean section rates are high and continue to rise in high-income countries. Overuse of cesarean sections increases costs and reduces quality of care. It is therefore necessary to identify the determinants of cesarean sections in order to optimize their practice.We conducted a retrospective cohort study covering deliveries in 11 maternity hospitals in the Yvelines department during 2008-2014. We estimated multilevel logit models incorporating numerous individual and hospital characteristics known to influence obstetric practices.We examined the impact of private supplementary insurance on the cesarean section practice of French hospitals under T2A. We found that private hospitals, funded by the same public payer as public hospitals, performed more cesarean sections than public hospitals. This result is explained by the additional payments covered by private supplementary insurance and billed only by private hospitals. We then examined whether hospital staffing levels affected cesarean section rates. We found that higher staffing levels of obstetricians and midwives were associated with lower cesarean section rates. Finally, we examined the impact of prenatal care on cesarean section rates as well as the effect of socioeconomic status on prenatal care attendance affecting the cesarean section decision. We found that women who did not attend childbirth preparation were more likely to have a cesarean section, and that the most disadvantaged women were less likely to attend childbirth preparation when they were more likely to have a cesarean section.