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Background Our objective is to investigate factors increasing the likelihood of Caesarean sections in Hungary, in particular whether planned Caesarean deliveries might be a consequence of the widespread informal payment practice in obstetric care. Methods We use data from the “Cohort '18 - Growing Up in Hungary” birth cohort study. In the 1st wave a nationwide representative sample (N = 8,287) of pregnant women was surveyed in 2018/2019. The 2nd wave was conducted 6 months after childbirth. Data was analyzed by a multinomial logistic regression model. The output variable was the type of childbirth: natural (ref.)/Caesarean/planned Caesarean. The explanatory variables were informal payment at birth, private/public prenatal care, maternal health, SES. Results Based on the explanatory model (Pseudo-R2=0.278) the increased likelihood of planned Caesarean section is associated with out of pocket payment at birth (Exp(B)=3.749). This health system related factor absorbs the effect of social background for the possibility of planned Caesarean section, since its inclusion in the model reduces the independent influence of SES. However, the likelihood of planned Caesarean delivery compared to natural births is also determined by the mother' age and physical condition. Conclusions The high Caesarean delivery rates (over 40%) in Hungary are largely due to features of health system finance, particularly for planned Caesarean deliveries (22% of births). Although deliveries basically take place in public hospitals, the presence of an out of pocket paid private doctor at birth is a frequent and socially selective factor. Whereas planned Caesarean sections are strongly determined by SES, at the system level it is channeled into the various private or informal forms of financing. Key messages Informal payment within the general public care system strengthens the social selection in prenatal and delivery care in Hungary. This effect is reflected in the proportion of planned Caesarean sections.

The impact of informal payment on Caesarean delivery rates in obstetric care in Hungary