High prevalence of cesarean section births in private sector health facilities- analysis of district level household survey-4 (DLHS-4) of India

Cesarean section (CS) when indicated is a live saving procedure but when performed without appropriate indications can add risk to both mother and baby [1]. Globally there is an ongoing debate on what should be the optimal rates of CS deliveries [2‐5]. As per recently published WHO report, “At population level, Cesarean section rates higher than 10% are not associated with reductions in maternal and new-born mortality rates” [1]. World-wide large disparity is observed in CS rates, highest rates being reported in Latin America and the Caribbean region (40.5), followed by Northern America (32.3), Oceania (31.1), Europe (25), Asia (19.2) and Africa (7.3) [6]. In India as per District level household survey 3 (DLHS) CS rate is 28.1% in private sector and 12% in public sector health facilities [7]. This survey shows share of Cesarean deliveries in institutional births have increased in India, especially in private sector health facilities. DLHS 4 also shows similar trend in various states though country wide reports are not currently available [8].

Researchers across world have come up with various reasons for rising CS rates, important ones being “patient’s preferences”, “fear of vaginal delivery” and “social norms” [9‐11]. Different rates of CS births in public and private sector health facilities suggest that non-medical factors, such as financial gain, may motivate doctors to perform CS deliveries [4, 12].

There are lack of large recent population based studies from India to explore the determinants of CS births and influence of sociodemographic, maternal, pregnancy and delivery related factors on type of delivery (Normal/ Assisted versus Cesarean Section births).

The District Level Household Survey is one of the largest ever demographic and health surveys carried out in India, with a sample size of about seven lakh households covering all districts of the country [7, 8]. The data from these surveys have been useful in setting the benchmarks and examining the progress the country has made after the implementation of reproductive child health (RCH) programme. These surveys are useful for the central and state governments in evaluation, monitoring and planning strategies. In view of the completion of 6 years of National Rural Health Mission (2005-12), there is a felt need to focus on the achievements and improvements so far.

There is a paucity of information on Cesarean section rates based on analysis of India DLHS 4 individual level dataset. In present study we try to fill this gap and create evidence from DLHS-4 individual level dataset on factors associated with Cesarean section deliveries in India.

This study used data from District Level Household Survey (DLHS-4) individual dataset for all births of year 2011 (January 1 to 31st December) [8]. The Ministry of Health and Family Welfare (MoHFW), Government of India, conducted round 4 (DLHS-4) in 26 States and Union Territories of India during 2012-2013 (other than 9 states covered under Annual Health Survey, AHS). In the past, three rounds of DLHS have been undertaken (Round- I in 1998-99, Round-II in 2002-04, and Round-III in 2007-08). A multi-stage, stratified, probability proportional to size sample with replacement design was adopted by DLHS-4. Each district was divided into rural and urban areas. For rural areas primary sampling unit (PSU) was village and the Census of India 2001 was the sampling frame. For urban areas PSU were NSSO Urban Frame Survey (UFS) blocks. UFS blocks in each district have been stratified into million-class cities and non-million class cities and allocation of sample was proportional to relative sizes. Twenty-five households have been selected from each rural and urban PSU. Further detailed description of sample methodology and survey process of DLHS-4 has been mentioned elsewhere [8] ^.The survey obtained detailed information on socio demographic details, maternal characteristics, pregnancy and delivery from ever married woman aged 15-49 years.

As available in public domain (accessed from http://​www.​iipsindia.​ac.​in/​) at the time of analysis, combined individual data set for following 19 states/ UTs (Himachal Pradesh, Punjab, Haryana, Sikkim, Arunachal Pradesh, Nagaland, Manipur, Mizoram, Tripura, Meghalaya, West Bengal, Maharashtra, Andhra Pradesh, Karnataka, Goa, Kerala, Tamil Nadu and Telangana) were used for analysis in present study.

Promoting Institutional deliveries is an important intervention of Government of India to decrease maternal morbidity and mortality. Findings show that although higher proportion of woman deliver at public sector, CS births are more in private sector health facilities. India has observed a sharp rise in institutional deliveries (Fig. 2), from 47% (DLHS 3, 2007-08) to 81.1% in current study (DLHS 4, 2011-12). This sharp increase after launch of the Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK) schemes could be attributed to large extent to these programme being able to increase institutional births and hence decrease home deliveries [13]. Interestingly, earlier higher proportion of institutional deliveries took place in private sector whereas present study shows public sector is now bigger contributor to institutional births. Result also shows of all those delivered in private sector nearly 38% delivered by CS as compared to only 14% in public sector. Various studies have shown that there are multiple factors which influence a woman’s decision to deliver by cesarean section [14]. For profit making some private sector providers may perform unwanted CS deliveries, while woman themselves can also opt for CS delivery due to fear of pain or they believe CS deliveries are safer [15‐19]. In current study, CS rates in private health facilities rates are much greater than the WHO recommended maximum limit of 15% for CS births [3, 20]. Other studies have also confirmed that there is greater prevalence of CS births in private sector health facilities as compared to public sector health facilities [21‐25]. Though there has been a growing demand to revisit these rates, still these rates being selectively high in private sector is area of concern. Flagship program of Government of India. “Pradhan Mantri Surakshit Matritva Abhiyan” (PMSMA) can be utilised so as to reduce service provider induced increased CS rate of private sector.

Significantly higher proportion of woman with age more than 35 years and less than 19 years were associated with increased proportion of cesarean section (p value< 0.001). Others studies have also shown that greater maternal age as an important factor associated with cesarean births because other medical conditions like hypertension, diabetes being more prevalent at higher age group [26, 27].

More cesarean section births took place in urban woman as compared to the ones who resided in rural areas. More accessibility to medical intervention in urban areas, presence of more health facilities and insurances in urban areas can be probable reasons [28].

Wealthier woman, belonging to higher caste group and having some schooling and more likely to deliver by cesarean section (p value< 0.001). Cesarean section seems to be a choice method for woman who can afford it rather than being a procedure for safe delivery when medically indicated [29, 30]. Woman with lower socioeconomic status might cannot afford or do not have access to health facilities which are equipped to perform cesarean delivery. Other studies on CS births in developing countries have also supported this finding [31].

The finding of higher cesarean rates amongst mothers whose first delivery is after age of 35 years is matter of concern, since this contributes to increased further CS deliveries, considering that history of CS delivery is a relative indication for CS in subsequent delivery [32, 33].

Findings shows greater number of antenatal care visits being associated with higher CS Birth rates. Women who had four or more antenatal check-ups were significantly more likely to have a CS births (OR 1.23 95% CI 1.0-1.5). Antenatal care is the care given to pregnant woman by health care provider for safe pregnancy and child birth. Antenatal care is the ideal time to counsel and prepare pregnant woman for normal delivery (if there are no medical indications for CS), since this is the time she can interact with her care giver and plan safe delivery [19, 34]. Other studies have also shown this finding, as greater number of ANC visits allows more interaction between the care provider and pregnant woman, which might influence her to provider induced CS delivery [35, 36]. This finding has programmatic implications, ANC visit can be an opportunity to increase institutional deliveries and counsel mother regarding indications of cesarean section and risk involved [16, 19].

Ultrasound imaging done at least once during current pregnancy was significantly associated with higher risk of CS births. Ultrasound imaging is an essential component of antenatal care services. Also recommended by WHO for safe pregnancy and foetal monitoring [35, 36]. It helps to assess foetal growth, congenital anomalies or maternal complications if any at a very early stage so that the detected condition can be managed at the earliest [37, 38].

Study shows higher risk of cesarean section in case mother had complications of high blood pressure during pregnancy. Antenatal screening for high blood pressure and timely management of such mothers can bring down unwanted CS procedures. As expected, the chance of CS is higher among those who have experienced complications during delivery (excessive bleeding, obstructed labour, breach presentation). Literature also supports this finding as these complications may lead to higher risk to both mother and baby hence cesarean section needed as live saving procedure [4, 39].

The caesarean section is a globally recognised maternal health-care indicator. Unnecessary caesarean sections also pulls resources away from other services in overloaded and weak health systems. In India, CS rates are high in private sector health facilities, though their share in total deliveries is much lesser as compared to public sector health facilities. Hence there is need for strengthening of existing public health facilities especially, emergency obstetric care services so that if medically indicated live saving surgical procedure can be performed in public sector itself rather than drifting woman towards profit driven private sector health facilities. The government of India need to take measures to ensure that caesarean sections are performed based upon medical indications. Appropriate mechanism and specific opportunities for awareness generation and provider education, focused upon populations which are likely to prefer cesarean section, should be developed. Appropriate monitoring and accountability systems should be developed at both national and state levels in India.