Figure 1 compares the prevalence of delivery by caesarean section in different states of India. Among the states, the highest prevalence of caesarean section can be found in the southern state of Telangana (57%), followed by Andhra Pradesh (40%), Kerala (36%), Tamil Nadu (34%), Jammu and Kashmir (33%) and Goa (31.4%), The National Capital Territory has also a higher prevalence of such delivery by surgical procedure, around 27%. Orissa has experienced a whopping of around 375% in caesarean deliveries between 2005-06 to 2015-16. Jharkhand is the only state which has witnessed a decline in caesarean deliveries. NFHS-4 shows that 7 states have prevalence of C-section deliveries that is more than 30%, and, 8 states have the same in between 10% to 20%, and, 9 states less than 10%.
< Table 1>
Table 1 shows the distribution of women who have given at least one birth in last five years preceding the survey by some selected background characteristics. Majority of mothers, around 39 percent of women belong to the prime reproductive age group i.e. (25-29) years. When it comes to educational level, around 45 percent of the women were educated up to secondary level, also a large portion of the women belong to the rural area. Caste and religion wise people of other backward classes and Hindus are predominant 44 percent and 79 percent respectively. Around one-fourth of mothers belong to the poorest quartile and when it comes to the topmost quartile, only 15 percent belong to the richest section. Region wise, around one-fourth of women, belong to Northern region and around three percent, i.e. minimum sample was taken from the North-eastern region which accounts to sample of around 91,113 from this region. Overall, the total observations are 259,627.
Table 2 demonstrates the feeding practices (whether colostrum feeding was done by women post-delivery) of women who have given birth under caesarean section or normal delivery. It was observed that colostrum feeding percentages are high among women who delivered their babies normally, because the sample size belong to the group is high compare to the caesarean section delivery. It was found that total 56.6% and 72% women whose delivery was under caesarean and normal, respectively, have practiced colostrum feeding.
As it can be vividly seen in the table, the percentage of women who could breastfeed their children in earlier age-group are much higher in case of normal delivery as compared to caesarean section delivery; this is uniform across all the age groups. For instance, under caesarean section, around 49% women in age-group of less than 20 years, while under normal delivery around 72% women have experienced colostrum feeding. Whereas, in age-group of 35 years and above, around 57% women under caesarean and 68% women under normal delivery have fed their children.
Education is also seen to be going upward hand in hand with colostrum feeding. Under caesarean section delivery, about 50% women with no education fed colostrum to their children; under normal delivery, about 66% women with no education level fed their children. However, 56% women under caesarean delivery and 74% women under normal delivery with higher education level, have experience colostrum feeding to their children.
In urban area, the percentage of colostrum feeding women is high among women with normal (i.e., 74%) delivery in comparison to caesarean delivery (i.e., 57%). Colostrum feeding is highest among christian women in both types of deliveries. Among muslim women, around 55% with caesarean delivery and around 69% with normal deliveries have fed this children.
A significant percent point difference can be seen between colostrum feeding practice of the top most wealth quintile in comparison to those quintiles at bottom. Only around 52% women who belong to poorest wealth quintile and caesarean deliveries and around 68% from normal deliveries have experienced colostrum feeding. Further, North Eastern and Southern region have a higher prevalence of women feeding colostrum to their babies across both the types of delivery.
Besides, the colostrum feeding practices was observed among women who had given birth by caesarean and normally by some maternal characteristics. In case of multiple births (twins, triplets etc.) the percentage of women feeding colostrum is less as that of in single births, also higher percent of women of second parity are practicing the same.
ANC visits seems to be playing a positive relation with colostrum feeding. For instance, around 58% women with four and above ANC visits and caesarean delivery, which is highest among women with none and one to three ANC visits. Similarly, in normal delivery category, around 73% women with four and above ANC visits have fed colostrum to their children. Further, it is very surprising to observe that only around 38% women whose child’s size at birth was very small and delivered via caesarean section, have fed colostrum to their children, and among normal delivery group around 57% women.
Public health facility deliveries had higher percentage of women feeding colostrum to their children in comparison to private. Around 53% women who delivered via caesarean in private facility, and around 77% women whose normal delivery took place in public health facility have experienced colostrum feeding.
Table 3 compares the post-natal complications faced by women within two months after delivery, who had undergone delivery by caesarean section or normal delivery. In this table, unlike the previous table, the percentage of post-natal complications are significantly higher in case of caesarean delivery compared to normal delivery. In fact such pattern is uniform across all the covariates. It was found that total 23.9% and 19.2% of women have faced post-natal complications under caesarean section and normal delivery, respectively.
It can be seen; higher the age-group of the women, lower was the chance of facing post-natal complications. As, around 31% and 25% of women experienced caesarean delivery and belongs to age-groups less than 20 years and 20-24 years, who faced post-natal complications, whereas, only around 25% and 19% of women who delivered their children normally and comes under the same age-group, respectively.
In case of education level, similar pattern was found. Around 22% women with higher education level and caesarean delivery, while around 21% women with same education but normal delivery have faced the risk of post-natal complications. In both types of delivery, women from rural areas have faced higher percentage of post-natal complications than its counterpart (i.e., urban areas).
Highest percent of ones who faced complications and delivered under caesarean section are, 25% women who belongs to schedule tribe. Whereas, highest percentage of women who faced post-natal complications and delivered normally are, 20% women who belongs to schedule castes social group.
Women of the bottom most quintile is more prone to post-natal complications, this is independent of the delivery procedure also those at the top of the quintile were seen to be facing less complications. Around 26% women from poorest quintile and caesarean delivery have faced post-natal complication, while, only around 20% women from same wealth quintile but under normal delivery have experience complications. In case of richest wealth index, around 23% and 21% women under caesarean and normal delivery, respectively face the post-natal complications. Northern region has maximum percent of women 27 percent and 21.3 percent facing any sort of post-natal complications in caesarean delivery and normal delivery respectively.
Further it also shows the comparison between post-natal complications faced by women undergone caesarean section or the normal delivery by some maternal factors. It was found that women who delivered her first child in younger age-group, have faced high post-natal complications in caesarean section deliveries, while the same case was not with the normal deliveries. For instance, among caesarean section delivered, around 25% women in age-group 20-24 years, and around 20% women .in age-group of 35 years and above have faced the post-natal complications; whereas, among normally delivered, around 19% and 20% women have faced the complications in same age-group categories, respectively.
Women with multiple births have experienced less post-natal complications compare to the women who did not had multiple births, in both types of delivery categories. Among women who have practiced caesarean section and normal delivery, out of them around 30% and 27% of women, respectively, with first parity faced complications.
Women who did not go for any ANC checkup and those whose child born was very small in size, faced more post-natal complications independent of the type of delivery procedure undergone. In case of caesarean section delivery, around 26% underweight, and around 22% overweight women, while in case of normal delivery, around 19% underweight, and 20% overweight women had to face more complications.
Overall, it can be noted women who delivered by caesarean section had higher prevalence of post-natal complications in first two months following delivery. Even if we compare by delivery place i.e public or private, it has been observed that independent of the type of delivery facility, women who delivered by caesarean section faced more complications.
Table 4 shows the effect of caesarean section on postnatal complications through propensity score matching, we have used it to control biases related to background characteristics and to find out actual effect that caesarean section has on post-natal complications. Average treatment effect on the treated (ATT), Average treatment effect on the untreated (ATU), Average treatment effect (ATE) show the estimate after matching.
It is seen that among the unmatched treatment group i.e., those had undergone for caesarean section delivery, the prevalence of post-natal complications is around 24%, and the same for control group i.e. those who had undergone for normal delivery is 18%. After matching, the value of ATT is around 24% in treatment group and 17.4 in control group, it means that if these women, who had caesarean delivery, would they not have undergone for caesarean section delivery then the prevalence of post-natal complications among them would have been only 17.4%. Average treatment effect on untreated show that women who had not undergone for C-section, if they would have undergone for the caesarean section, the post-natal complication would have increased to 19.6%. ATE shows the difference between the treated and untreated women, here it is around 2.4%.