The 1999 conflict in Kosovo left the country with some of the worst maternal and infant health outcomes in all of Europe. Although many maternal and infant health indicators have since improved, the fragmented system has allowed other health outcomes to worsen, including dramatically increasing cesarean rates. The overall cesarean section (CS) rate grew from 7.5 percent to 27.3 percent between 2000 and 2015, exceeding international guidelines. Given the country’s resource constraints and history of poor maternal and infant health, the potential health risks and excessive financial burdens associated with medically unnecessary CS represent a serious concern for Kosovo. In 2016, the Kosovar Ministry of Health identified the dramatic rise in the CS rate as a principal target for policy interventions to improve child and maternal health.
In partnership with AMC, the Dartmouth Global Health Policy Lab sought to investigate possible causes of rising cesarean rates in order to develop policy interventions. Following extensive preparation and desk review, the Dartmouth team commenced fieldwork in Kosovo, conducting a mixed methods study consisting of semi-structured interviews with various healthcare actors and analysis of existing data and literature sources. From June 21 through August 18, 2017, the Dartmouth Global Policy Health Policy Lab team conducted more than 40 interviews with health workers, government officials, health administrators, NGO leaders, and other healthcare experts in Kosovo. Additional literature review and data analysis supplemented interview findings.
Through these methods, the Dartmouth team identified six major factors linked with rising rates and overprovision of CS in Kosovo that may be susceptible to policy interventions. These major factors included: maternal misconceptions surrounding birth, underutilization of antenatal care at the primary level, diminished midwife autonomy, absence of established national cesarean guidelines, financial and informal incentives, and legal and media pressures. Although many other health system and economic factors contribute to cesarean overuse, these six areas of interest emerged as the most feasible targets for policy intervention. A detailed outline of key findings and associated policy options can be found in Section 3 of this report.