Background Cesarean section (CS) delivery rate has increased significantly both globally and in India, thereby posing a burden on overstretched health systems. Objective This study plans to understand the factors associated with CS rate with an objective to (1) analyze the trends of CS delivery from 1998-99 to 2019-21 and (2) understand the proximate determinants of CS deliveries in India. Methods Analysis of secondary data (National Family Health Survey) of a nationally representative sample of 230,870 women (year 2019-21) was undertaken to explore the trends, distribution, and determinants of CS deliveries in India and within states. Multivariable analyses were performed to determine the proximate variables associated with CS and elective CS. The relative interaction effect of confounding factors, such as number of antenatal care (ANC) visits, place of residence, and wealth status, on cesarean delivery was assessed. A composite index was generated using trust, support, and intimate partner violence variables (termed the partner human capital index [PHI]) to study its influence on CS deliveries, with a low PHI indicating abusive partner and a high PHI indicating supportive partner. Statewise spatial distribution of the most significantly associated factors, namely, wealth quintile and ANC checkups, were also analyzed. Results The overall prevalence of CS was 21.50% (49,634/230,870) which had risen from 16.72% (2312/13,829) in 1998-99. The adjusted odds of CS deliveries were significantly higher among women who were highly educated (odds ratio [OR] 7.30, 95% CI 7.02-7.60; P<.001), had 4 or more ANC visits (OR 2.28, 95% CI 2.15-2.42; P<.001), belonging to the high-wealth quintile (OR 7.87, 95% CI 7.57-8.18; P<.001), and from urban regions. Increasing educational level of the head of the household (OR 3.05, 95% CI 2.94-3.16; P<.001) was also found to be a significant determinant of CS deliveries. The odds of selection of elective and emergency CS were also significantly higher among women from richer families (OR 1.66, 95% CI 1.25-2.21; P<.001) and those belonging to Christian religion (OR 1.67, 95% CI 1.14-2.43; P=.008). Adjusting the cesarean delivery by PHI, the odds of outcome were significantly higher among women with moderate and high PHI compared with those with low PHI (OR 1.46, 95% CI 1.36-1.56 and OR 1.61, 95% CI 1.49-1.74, respectively; P<.001 for both). The interaction effect result reiterates that women with more than 4 ANC checkups, high PHI, and belonging to the richer wealth quintile were more likely to undergo cesarean delivery (OR 22.22, 95% CI 14.99-32.93; P<.001) compared with those with no ANC visit, low PHI, and poorest women. Conclusions The increasing trend of CS deliveries across India is raising concerns. Better education, wealth, and good support from the partner have been incriminated as the contributory factors. There is a need to institute proper monitoring mechanisms to assess the need for CS, especially when performed electively.

BACKGROUND Caesarean section (CS) delivery rate has increased significantly both globally and within India posing a burden on overstretched health systems. OBJECTIVE To analyze the trends of CS delivery from 1998-99 to 2019-21 and to understand the proximate determinants of CS deliveries in India. METHODS Analysis of secondary data (National Family Health Survey) of a nationally representative sample of 230,870 women (year 2019-21) was undertaken to explore the trends, distribution, and determinants of CS deliveries in India and within states. Multivariable analyses were performed to determine the proximate variables associated with CS and elective CS. The relative interaction effect of confounding factors such as number of ANC visit, place of residence and wealth status on cesarean delivery were assessed. A composite index was generated using trust, support and intimate partner violence variables named as partner human capital index (PHI) to study it’s influence on CS deliveries. State wise spatial distribution of most significantly associated factors namely wealth quintile and ANC checkups were also analyzed. RESULTS Overall prevalence of CS is 21.4% which had risen from 6.6% in 1998-99. The adjusted odds of CS deliveries were significantly higher among women who were highly educated (OR: 7.30; 7.02-7.60), with four-or-more ANC visit (OR: 2.28; 2.15-2.42), belonging to high wealth quintile (OR:7.87; 7.57-8.18), and from urban region. Increasing educational attainment of the head of the household (OR: 3.05; 2.94- 3.16) was also found to be a significant determinant of CS deliveries. The odds of selection in cesarean delivery based on elective and emergency were also significantly higher among richer (OR: 1.66; 1.25-2.21), and women belonging to Christian religion (OR: 1.67; 1.14-2.43). Adjusting the cesarean delivery by PHI, the odds of outcome were significantly higher among the women with moderate and high PHI compared to their counterpart women with low PHI (OR: 1.46; 1.36- 1.56 & OR: 1.61; 1.49- 1.74 respectively, p<0.001). The interaction effect of confounding factors confirms as the women with more than 4 ANC checkups, high PHI and belonging to richer wealth quintile were more likely to undergo cesarean delivery (OR: 22.22 p<0.001) compared to those with no ANC visit, low PHI, and poorest women. CONCLUSIONS Increasing trend of CS deliveries across India is raising concerns. Better education, wealth and good partner’s support have been incriminated as the contributory factors. There is a need to institute proper monitoring mechanisms to assess the need of CS, especially when performed electively. Also, underutilization of CS among poorer, less educated women with lower PHI raises serious concerns about access to a life-saving procedure.

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