Alarming Trends of Cesarean Section—Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India

Abstract

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.

Determinants of cesarean mode of childbirth among Rwandan women of childbearing age: Evidence from the 2019–2020 Rwanda Demographic and Health Survey (RDHS)

“…This study found an association between level of education and likelihood of CD, with higher education levels conferring reduced risk. These findings are in line with other studies showing that a high level of maternal education is associated with a lower risk of CD [9, 15]. However, the reason for this association is unknown.…”

“…In our study, the risk of CD was decreasing with maternal education but increases with higher wealth status and in women giving birth in private healthcare facilities. Similar findings have been made in previous studies [9,15,20,30]. Maternal age was not associated with CD, which contrasts with findings from other publications [31][32][33].…”

“…Our secondary data analysis of 8092 women from a nationally representative sample revealed a CD prevalence rate of 15%, indicating a decade‐long increase in CD prevalence in Rwanda. Increased CD prevalence is a worldwide trend that has been observed in a number of other countries [9, 15, 28, 29]. In our study, the risk of CD was decreasing with maternal education but increases with higher wealth status and in women giving birth in private healthcare facilities.…”

“…Previous research has found that institutional births in Rwanda, particularly in private facilities, are increasingly likely to be by CD, and the Rwanda Demographic and Health Survey (RDHS) has demonstrated a similar trend over the last three decades [8]. Furthermore, it was discovered that educated women living in urban areas and of high socioeconomic status (SES) are more likely to deliver by CD than their counterparts with low education levels, living in rural areas, and of low SES [9,10,11]. CD rates are increasing for a variety of reasons aside from clinical need.…”

Prevalence and Associated Factors of Cesarean Section Delivery in Nepal

“…The adjusted odds ratio underscores a substantial association between the place of delivery and the possibility of undertaking a CS. This nding aligns with global trends where private health facilities often witness higher rates of cesarean sections (42), which may be in uenced by the perceived convenience of scheduled deliveries (43), patient demands (43)(44)(45), and potential nancial considerations (28,38,40).…”