Patterns of cesarean birth rates in the public and private hospitals of Romania

Caesarean sections (CSs) are essential surgical procedures that can save lives during childbirth, but can also pose health risks for mothers and infants. However, CS rates continue to rise globally beyond recommended values. This study provides a national and regional analysis of CS rates in Romania in 2020 across public and private hospitals, probing the influence of financial incentives on CS overuse, under the Romanian Diagnosis-Related Group (Ro-DRG) payment system. Ro-DRG data was aggregated from all 191 Romanian hospitals (171 public, 20 private) that reported deliveries in 2020, and described using quantitative methods. For each hospital, the Ro-DRG data included the total number of deliveries, the distribution across relevant Ro-DRG codes, and the average length of hospital stay. In 2020, 149,466 childbirth cases were reported through the Ro-DRG system; 89% in public and 11% in private hospitals. The national CS rate was 52.9%, with public hospitals reporting a rate of 49.7% compared to 79.8% in private hospitals. Regionally, CS incidence ranged from 29.89 to 71.42%. The Ro-DRG analysis revealed a high prevalence of high-complexity codes for both CS and natural deliveries, associated with higher payments. Additionally, the average length of hospital stay for CSs was longer in public (5.24 days) than in private hospitals (3.31 days), raising questions about hospital practices and resource utilization. The study suggests that financial incentives might be a contributing factor increasing Romanian CS rates. Targeted policy interventions are essential for aligning financial incentives with clinical necessity and ensuring the efficient use of healthcare resources.