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. 2023 Feb 13:25:e41892.
doi: 10.2196/41892.

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

Anuj Kumar Pandey  1 , Mukesh Ravi Raushan  1 , Diksha Gautam  1 , Sutapa Bandyopadhyay Neogi  1
Affiliations

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

Anuj Kumar Pandey et al. J Med Internet Res. .

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.

Keywords: abdominal delivery; cesarean section; health promotion; obstetrics; reproductive health service; surgical obstetric procedure; women health services.

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Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
Survey participants descriptions of NHFS-5. C-section: cesarean section; NFHS: National Family Health Survey.
Figure 2
Figure 2
Percentage of women delivered through caesarean section in India (1998-2021). CS: cesarean section.
Figure 3
Figure 3
Spatial distribution of percentage of caesarean section delivery across Indian States. NFHS: National Family Health Survey.
Figure 4
Figure 4
Spatial distribution of percentage of c-section (cesarean section) delivery among women with no ANC check-ups versus 4 or more ANC check-ups across Indian States 2019-21. ANC: antenatal checkup; C-section: cesarean section.
Figure 5
Figure 5
Spatial distribution of percentage of cesarean section (c-section) delivery among women belonging to different wealth status across Indian States 2019-21. C-section: cesarean section.
See this image and copyright information in PMC

References

    1. Betran Ana Pilar, Ye Jiangfeng, Moller Ann-Beth, Souza João Paulo, Zhang Jun. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021 Jun;6(6):e005671. doi: 10.1136/bmjgh-2021-005671. https://gh.bmj.com/lookup/pmidlookup?view=long&pmid=34130991 bmjgh-2021-005671 - DOI - PMC - PubMed
    1. Betran A P, Torloni M R, Zhang J J, Gülmezoglu A M, WHO Working Group on Caesarean Section WHO Statement on Caesarean Section Rates. BJOG. 2016 Apr;123(5):667–70. doi: 10.1111/1471-0528.13526. https://europepmc.org/abstract/MED/26681211 - DOI - PMC - PubMed
    1. Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, Moller A, Say L, Hosseinpoor AR, Yi M, de Lyra Rabello Neto D, Temmerman M. Global epidemiology of use of and disparities in caesarean sections. The Lancet. 2018 Oct;392(10155):1341–1348. doi: 10.1016/s0140-6736(18)31928-7. - DOI - PubMed
    1. Prakash KC, Neupane S. Cesarean deliveries among Nepalese mothers: changes over time 2001-2011 and determinants. Arch Gynecol Obstet. 2014 Feb 31;289(2):421–7. doi: 10.1007/s00404-013-2976-8. - DOI - PubMed
    1. Gibbons L, Belizán J, Lauer J, Betrán A, Merialdi M, Althabe F. World Health Organization (WHO) Geneva, Switzerland: World Health Organization; 2021. Jun 11, [2023-01-24]. Background Paper, 30: The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. https://tinyurl.com/mvy3tyzh .