Washington State Institute for Public Policy
Cesarean section reduction programs: Multi-faceted hospital-based interventions (private pay population)
Health Care: Health Promotion
Benefit-cost estimates updated December 2016.  Literature review updated November 2015.
These interventions encompass bundled reform packages adopted by hospitals in order to change physician decision-making in performing cesarean sections. While the specific components of these bundled reform packages vary, they typically include the adoption of physician best practices, especially guidelines on when cesarean sections should be performed, and the limitation of inductions before 39 weeks of gestation. Most reform packages also attempt to change physician behavior by publishing either their anonymous or identified cesarean section rates via a report card or by creating a physician review board that regularly audits the appropriateness of performed cesarean sections. These packages can also include the recruitment of physicians to serve as local opinion leaders or potentially other clinical or non-clinical interventions.

The benefits presented in the benefit-cost analysis are specific to the privately insured population.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2015). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $116 Benefits minus costs $301
Participants $36 Benefit to cost ratio $9.86
Others $142 Chance the program will produce
Indirect $41 benefits greater than the costs 100 %
Total benefits $335
Net program cost ($34)
Benefits minus cost $301
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Health care associated with hospital readmissions $5 $0 $4 $2 $11
Health care associated with Cesarean sections $111 $36 $138 $56 $341
Adjustment for deadweight cost of program $0 $0 $0 ($17) ($17)
Totals $116 $36 $142 $41 $335
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $34 2014 Present value of net program costs (in 2015 dollars) ($34)
Comparison costs $0 2014 Cost range (+ or -) 20 %
The average per-participant cost of these programs was computed as the product of 80 hours per health care provider and average Washington State 2014 hourly wages of the appropriate professionals (typically obstetrician/gynecologists, general practitioners and nurse staff) for training in best practices, implementation of guidelines, and quarterly audit and review of hospital cesarean section rates. The estimate of the required staff hours were taken from Chaillet et al. (2015). A cluster-randomized trial to reduce cesarean delivery rates in Quebec. New England Journal of Medicine, 372(18), 1710-1721.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Cesarean sections 7 115838 -0.243 0.075 26 0.000 0.000 27 -0.243 0.001
Citations Used in the Meta-Analysis

Chaillet, N., Pasquier, J.-C., Dube, E., Fraser, W.D., Abrahamowicz, M., Dugas, M., Burne, R., et al. (2015). A cluster-randomized trial to reduce cesarean delivery rates in Quebec. New England Journal of Medicine, 372(18), 1710-1721.

Liang, W.H., Yuan, C.C., Hung, J.H., Yang, M.L., Yang, M.J., Chen, Y.J., & Yang, T.S. (2004). Effect of peer review and trial of labor on lowering cesarean section rates. Journal of the Chinese Medical Association : Jcma, 6(6), 281-6.

Main, E. K. (1999). Reducing cesarean birth rates with data-driven quality improvement activities. Pediatrics, 103(1), 374-83.

Myers, S.A., & Gleicher, N. (1993). The Mount Sinai cesarean section reduction program: an update after 6 years. Social Science & Medine, 3(10), 1219-22.

Poma, P.A. (1998). Effect of departmental policies on cesarean delivery rates: a community hospital experience. Obstetrics and Gynecology, 91(6), 1013-8.

Robson, M.S., Scudamore, I.W., & Walsh, S.M. (1996). Using the medical audit cycle to reduce cesarean section rates. American Journal of Obstetrics and Gynecology, 174(1), 199-205.

Sanchez-Ramos, L., Kaunitz, A.M., Peterson, H.B., Martinez-Schnell, B., & Thompson, R.J. (1990). Reducing cesarean sections at a teaching hospital. American Journal of Obstetrics and Gynecology, 163(3), 1081-7.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov