Health care supply, payment system and medical practice : evidence from obstetric practice.

Summary A significant proportion of deliveries are performed by cesarean section in Europe and worldwide. The objectives of this thesis are to highlight the non-medical determinants, notably economic and financial, explaining the development of this practice, as well as its consequences on women's health after childbirth, in relation to other factors such as the local concentration of hospital structures. Our analysis focuses on two countries: France and Switzerland. In the first part of the thesis, we highlight the influence of two non-medical determinants: the payment system and the behavior of obstetricians. We show that fee-for-service financing and the number of obstetricians influence the practice of cesarean section. The increase in cesarean section use between 2003 and 2006 can be attributed primarily to changes in hospital and patient characteristics. IT may indicate that coding practices are changing to account for increased use of cesarean section. Following the Shelton Brown III identification strategy, we find a potential impact of obstetrician physicians' leisure demand on emergency cesarean section practice. The second part of the thesis is devoted to the study of the quality of obstetric care. We analyze the impact of cesarean section on the occurrence of obstetric complications and the impact of the concentration of care on the quality of obstetric care. Caesarean section can be a factor ( obstetrical complications and the concentration of births has a negative impact on the quality of obstetrical care.