Examining obstetric interventions and respectful maternity care in Hungary: Do informal payments for continuity of care link to quality?

• Published in: Birth (Berkeley, Calif.) Vol. 48; no. 3; pp. 309 - 318
• Main Authors: Rubashkin, Nicholas, Baji, Petra, Szebik, Imre, Schmidt, Erika, Vedam, Saraswathi
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 01.09.2021
• Subjects: Autonomy; cesarean birth; Childbirth & labor; Clinical standards; Continuity of care; Cross-sectional studies; cross‐sectional survey; Epidural; Episiotomy; Health care; Induced labor; Induction; Informal care; informal cash payments; Informal economy; Intervention; Maternal child nursing; Midwifery; Midwives; Obstetrics; Payments; Physicians; Prenatal care; Public health; Women; Hungary; cross-sectional survey; informal cash payments; continuity of care; cesarean birth
• ISSN: 0730-7659; 1523-536X; 1523-536X
• DOI: 10.1111/birt.12540

Background In Hungary, 60% of women pay informally to secure continuity with a “chosen” provider for prenatal care and birth. It is unclear if paying informally influences quality of maternity care. This study examined associations between incentivized continuity care models and obstetric procedures and respectful care. Methods This is a cross‐sectional survey of a representative sample of Hungarian women (N = 589) in 2014. We calculated descriptive statistics comparing experiences among women who paid informally for continuity with a chosen provider with those who received care in the public health system. After adjusting for social and clinical covariates, we used logistic regression to estimate the odds of obstetric procedures and disrespectful care and linear regression to estimate the level of autonomy (MADM scale). Results Of women in our sample, 317 (53%) saw a chosen doctor, 68 (11%) a chosen midwife, and 204 (33%) had care in the public system. Women who paid an obstetrician informally had the highest rates of cesarean (49.5%), induction of labor (31.2%), and epidural (15%), and reported lower rates of disrespectful care (41%) compared to public care (64%). Paying for continuity with an obstetrician significantly predicted cesarean (aOR 1.61 [95%CI 1.00‐2.58]), episiotomy (2.64, [1.39‐5.03]), and epidural (3.15 [1.07‐9.34]), but not induction of labor (1.59 [0.99‐2.57]). Informal payment continuity models predicted increased autonomy scores (doctor: 3.97, 95% CI 2.39‐5.55; midwife: 7.37, 95% CI 5.36‐9.34) and reduced odds of disrespectful care. There were no differences in the prevalence of scheduled cesareans or inductions performed without a medical indication. Conclusions Continuity models secured with informal payments significantly increased both women's experience of respectful care and rates of obstetric procedures. Intervention rates exceed global standards, and women do not choose elective procedures to preserve continuity.