Health and environment
Is the world experiencing a caesarean section epidemic? The use of this practice is increasing in parallel to the establishment of private actors in the health sector. Using the example of Algeria, economists Ahcène Zehnati, Marwân-al-Qays Bousmah and Mohammad Abu-Zaineh reveal the differences in practice between the private and public health sectors.
Over the past two decades, several developing countries have experienced a growing private sector within their healthcare systems. Confronted with the underinvestment—or total lack of involvement—of their governments, private players have increasingly emerged to respond to the shortfalls of the public sector, such as accessibility and waiting time. This is thus a mixed healthcare system.
In a study carried out in Algeria and published in 2021, the economists Ahcène Zehnati, Marwân-al-Qays Bousmah, and Mohammad Abu-Zaineh examine cesarean section births to study the differences in medical care and the dual practices by practitioners between these two sectors. In Algeria, like in various other contexts, this practice has become increasingly common. So much, in fact, that some scientists have called it a “cesarean section epidemic1.”
What are the consequences of private-sector healthcare services and the dual practices provided by practitioners? How can we explain the increase in the number of c-sections performed? Can this growing decision to perform cesarean sections be medically justified? How do we bring the public and private healthcare sectors together to reach objectives of efficiency and equity within the healthcare system? This study attempts to answer all these questions.
- 1The Lancet. (2018). Stemming the Global Caesarean Section Epidemic. The Lancet, 392(10155), 1279.
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Two Faces of the Same System
Over the past two decades, Algeria has experienced considerable progress in terms of healthcare. Between 1990 and 2015, the child mortality rate has dropped from 39% to 22%, while the maternal mortality rate has also declined, from 216 for every 100,000 births to 140 for every 100,000 births.
This evolution has gone hand-in-hand with the growth of the for-profit private healthcare sector. The Algerian government encouraged this phenomenon in order to improve healthcare access in medical deserts throughout the country and reduce geographical inequalities in healthcare delivery. Between 2001 and 2014, public investment in healthcare had therefore dropped from 77% to 73%, thus illustrating the gradual evolution of private financing. Faced with this trend, the Algerian Ministry of Health continues to manage public hospitals as it simultaneously tries to regulate the rapidly evolving private sector.
This transformation of the healthcare sector has seen dual practices emerge. To maximize their income, a growing share of Algerian practitioners share their time between the private and public sector—with some leaving the public sector completely. This trend is particularly prevalent in gynecology, in which the private sector made up 75% in 2012. This phenomenon partially explains the current deficit of specialists in the public sector.
However, the development of private healthcare services does not seem to have the results the Algerian government was seeking out. The private sector is limited in economically disadvantaged areas like the western High Plains and southern Algeria, where the public sector plays a major role. While the Algerian Constitution guarantees its citizens free access to care, in reality, it is another matter completely.
Furthermore, obstacles remain in accessing healthcare. The first of these is the relational obstacle of accessing the necessary care in public hospitals; the financial obstacle is second, due to the ability to afford private care. What’s more? Having the two healthcare sectors complement each other could even have harmful consequences on both the health and economic domain.
Prescriptions Without Reason
As previously mentioned, the rate of c-sections has greatly increased over the past decade around the world, and especially in developing countries. In fact, the rate of cesarean sections jumped from 7% in 1990 to 19% in 2014. This increase seems justified to a certain level, as c-sections can improve care for some pregnant women and can also guarantee their health as well as that of their newborn child. While an “ideal” rate for cesarean sections does not exist, WHO has estimated that, as a standard, it should sit between 10% and 15%. A rate higher than this is not associated with a decrease in maternal and neonatal mortality rates, and, from a medical perspective, is therefore not justified.
In their study, Ahcène Zehnati, Marwân-al-Qays Bousmah, and Mohammad Abu-Zaineh demonstrate that in Algeria, the number of c-sections performed in the private sector is much higher than the public sector. Only 7% of women who gave birth in a public establishment had a cesarean section, whereas this number went up to 53% in the private sector. The researchers have thus revealed a strong correlation between the place and type of birth. A woman who gives birth in a private clinic has a 34 percentage-point higher probability of having a c-section
Confronted with this fact, it appears non-medical determinants are considered when practitioners decide whether to perform a cesarean section. Certain factors, such as the size of the baby, gestational diabetes, and edema increase one’s chances of having a c-section in the public sector. However, no correlation whatsoever has been observed in the private sector. Cesarean sections performed by private healthcare institutions are therefore often not medically justified. Furthermore, it should be noted that a c-section is a practice that carries risks and potential complications, which is something that is rarely relayed by medical professionals.
The Profitable Practice of C-Sections
If the rate of cesarean sections cannot be justified by medical reasons, what is the cause? In 2014, Ahcène Zehnati2 revealed that these practices can be motivated by financial reasons. In fact, cesarean sections are more lucrative than vaginal births. They can be scheduled and are quicker, thus easing the management of healthcare establishments. Practitioners therefore seek to change how they treat their patients, in favor of this practice, to maximize their personal financial gains. This explains why the rate is much higher in for-profit establishments. In Algiers and Béjaia, 72% of c-sections were performed in private clinics, making up approximately 50% of their total revenue.
- 2Zehnati, A. (2014). Economic analysis of the emergence and development of private care in Algeria. Université de Bourgogne / Université de Béjaia.
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However, it is possible that non-medical factors (such as education and income level) influence the decision of whether a cesarean section should be performed or not. The wealthier and more educated a woman is, the greater chance she will give birth in a private clinic and have a c-section. This said, place of residence also plays a role: women living in urban areas and in the northwest region of the country are more likely to give birth by c-section than those living in rural areas and north-central Algeria.
What Are the Solutions to these Practices?
Confronted with this trend and their harmful consequences, what can we do to resolve it? Even though the Algerian government is currently attempting to regulate private healthcare services, it is obvious that it must do more. By spanning out from the Middle East and North Africa to encompass a more global scope, Marwân-al-Qays Bousmah, Bruno Ventelou, and Mohammad Abu-Zaineh have demonstrated in 20163 that the increase of private healthcare services of poorly governed states are associated with inferior healthcare results. In other terms? The increase of the private sector will only have a positive impact on the overall level of health if it is associated with a good institutional quality. On the contrary, the duality of the healthcare system and the juggling of services offered by practitioners to both the private and public sectors could lower the quality of care and place new obstacles in front of individuals seeking out healthcare. In short, it would have an overall harmful effect on the population’s health.
Given the situation in Algeria, Ahcène Zehnati, Marwân-al-Qays Bousmah, and Mohammad Abu-Zaineh deem it is necessary to implement an appropriate legal framework to better coordinate the activities of the private and public sectors and thus reinforce their complementarity. As public establishments become saturated, relevant legislation should be put in place to reinforce oversight of the growing private sector and regulate the activities of practitioners. The goal of this is to improve healthcare services throughout the country and limit unjustified medical practices like cesarean sections.
The “cesarean section epidemic” and the overmedicalization of childbirth has given rise to interventional studies that seek to improve the decision process regarding delivery type by involving healthcare workers and the women themselves. This is the project put in place by QUALI-DEC, which evaluates non-clinical tools to guide future mothers and help them choose the best mode of delivery for them.
- 3Bousmah, M.-A.-Q., Ventelou, B., & Abu-Zaineh, M. (2016). Medicine and democracy: The importance of institutional quality in the relationship between health expenditure and health outcomes in the MENA region. Health Policy, 120(8), 928–935.
