Trends in cesarean delivery (1992-93 to 2015-16):
Figure 1 depicts the trends of C-section delivery from 1992-93(NFHS-1) to 2015-16 (NFHS-4). The prevalence of CS delivery substantially increased from 2.9% in 1992-93 to 17.2% in 2015-16 at the national level. In case of Tamil Nadu, the rate of CS delivery rapidly increased (from 7.1% in 1992-93 to 34.1% in 2015-16), while comparatively slower progress in C-section delivery had been observed in Bihar (from 1.1% in 1992-93 to 6.2% in 2015-16). We found a large gap in cesarean delivery between Tamil Nadu and Bihar in all four survey years.
Cesarean delivery according to the states and union territories of India:
Table 1 displays the prevalence of CS deliveries in all the states and union territories of India. On average, the rate of cesarean birth was 19.2% in India, ranging from 7.1% in Nagaland to 59.7% in Telangana. It was observed that Kerala, Tamil Nadu, Andhra Pradesh, and Telangana together comprised 24.5% of all C-section delivery in India. In nine states, the rate of CS delivery was lower than 10% namely, Rajasthan (9.9%), Meghalaya (9%), Bihar (7.4%), and Nagaland (7.1%). Among union territories, the prevalence of CS delivery was ranging from 39.9% in Lakshadweep to 17.1% in Daman and Diu.
Table 2 presents socio-demographic characteristics of the women. A substantial proportion of women were in the age group of 20-24 years (56%), married between 18-24 years of age (54%). Nearly 60% of women belong to average BMI. Almost a quarter of the respondents had no formal education and about 46% of them had a secondary level of education. Majority of the women were living in rural areas, affiliated to Hindu religion, and belonged to OBC social group. The distribution of study participants decreased from bottom to upper quintile of household wealth. Around 71% of the women in India were depends on public hospitals to conduct the delivery. A substantial proportion (47%) of participants has received 4 or more than 4 times ANC visits during their pregnancy. Only 15% and 11% of respondents had ever experienced pregnancy loss and delivery complications respectively. Most of the women were watching television compared to reading newspapers or magazines and listening to radio in their daily life. The study participants from central India were comparatively higher than any region in India.
Prevalence of cesarean delivery by socio-demographic characteristics:
Table 3 presents the proportion of cesarean delivery by socio-demographic characteristics of women. The results show that the prevalence of cesarean delivery was substantially lower among the older women (aged 35-49 years) than the younger women (aged 15-24 years and 25-35 years) at the national level. Similarly, in Bihar, the rate of CS delivery decreased with the increasing age of women. Contrastingly, in Tamil Nadu, the incidence of C-section delivery increased among the older age group of women. For instance, in Tamil Nadu, about 44% of women aged 35–49 years had given birth to the C-section as compared to 31% of younger women (aged 15-24 years). The prevalence of CS delivery also increased with increasing age at marriage. A greater percentage of women who married at 25 years or above had their most recent birth at C-section. Birth order had a negative association with C-section delivery where the incidence of CS delivery was found to be decreased with higher-order children in Bihar and Tamil Nadu and as well as at the national level. The occurrence of C-section delivery was significantly higher among overweight/obese women as compared to thin and normal women. It is noticed that CS delivery had a rising trend with an increasing level of education in which respondents with higher education had a higher proportion of CS delivery. The prevalence of CS delivery was lower among Muslim women compared to Hindus, Christians, and others at the national level and Bihar. On the other hand, in Tamil Nadu, the rate of CS delivery was lower among Hindu women than the Muslims, Christians, and others. The prevalence of C-section delivery was lowest among Scheduled Tribe women, followed by Scheduled Caste women, whilst the General caste women had the highest rate of CS delivery in both the states and India. Furthermore, the rate of C-section delivery increased among women from bottom to upper quintile of household wealth at the national level as well as two other selected states.
In regard to public-private distribution, the incidence of CS birth was remarkably higher in private hospitals than the public hospitals at the national level (43 vs. 13%). In Bihar, the proportion of C-section delivery was 34.1% in private hospitals, while it was only 2.9% in public hospitals. In Tamil Nadu, over half (52.8%) of the deliveries in private hospital shad occurred in C-section.
There was a positive relationship between the number of ANC visits and the prevalence of CS deliveries where mothers who received four or more ANC visits had higher CS delivery compared with women who did not have sufficient ANC. A significantly higher percentage of women who had experienced pregnancy loss undergo C-section delivery as compared with those who did not experience pregnancy loss. Similarly, mothers who had faced delivery complications at the time of childbirth were more likely to experience CS deliveries in India and Bihar. In Tamil Nadu, contrasting results were found where women who experienced delivery complications considerably were less likely to deliver in C-section than those who did not experience delivery complications.
Exposure to mass media had a positive impact on CS delivery. Women who had access to any mass media reported higher experience of C-section delivery in India and Bihar. In Tamil Nadu, women’s exposure to newspaper/magazine only made significant difference CS birth. Our study found that the prevalence of CS delivery significantly differed across the rural-urban residence and geographical regions. Women residing in rural areas were less frequent in CS birth compared with women living in urban areas. Regarding geographical region, the highest rate of C-section delivery was observed in South region (38.2%), followed by West region (21.5%), while the lowest the prevalence of CS birth was found in Central region (10.6%), followed by East region (14.6%).
Table 4 presents the results of the multivariate logistic regression models showing the socio-demographic factors associated with cesarean delivery for India, Bihar, and Tamil Nadu.
The results show that the likelihood of C-section delivery increased with increasing age of women where women aged 25-34 years (OR= 1.20; 95% CI: 1.16-1.25) and35-49 years (OR=1.57; 95% CI: 1.46-1.68) were less likely to have cesarean birth compared with women aged 15-24 years. Similarly, the odds of cesarean birth increased with rising age at first marriage. Women who married at 18-24 years and above 24 years were 8% (OR=1.08; 95% CI: 1.04-1.12) and 48% (OR=1.48; 95% CI: 1.39-1.57) more likely to have C-section delivery respectively than those who married under 18 years of age. Birth order was negatively associated with cesarean birth where women with two (OR=0.75; 95% CI: 0.72-0.78), three (OR=0.46; 95% CI: 0.43-0.49), and four or more birth order (OR=0.30; 95% CI: 0.28-0.32) had a lower likelihood of CS delivery. Regarding maternal BMI, it was found that the likelihood of cesarean delivery for overweight women was more than two-fold (OR=2.23; 95% CI: 2.12-2.24).
Educational attainment of women was found to be positively associated with C-section delivery in which women with higher education were 42% (OR=1.42; 95% CI: 1.04-1.20) more likely to have cesarean delivery compared with uneducated women. Compared to Hindu women, the probability of CS delivery was significantly higher among Muslims (OR=1.05; 95% CI: 1.00-1.11), whilst the odds of CS delivery were 14% (OR= 0.76; 95% CI: 0.70-0.82) lower for Christian women. Social group also had a significant influence on C-section delivery. Women belonged Scheduled Tribe (OR= 0.79; 95% CI: 0.74-0.84) and Other Backward Classes (OR= 0.86; 95% CI: 0.82-0.90) were less likely and women belonged to General caste (OR=1.07; 95% CI: 1.01-1.12) were more likely to have cesarean birth compared to Scheduled Caste women. Wealth quintile of the household also had a strong positive correlation with C-section delivery. Compared to the poorest women, the likelihood of cesarean birth was 57% higher among the richest quintile of household wealth (OR= 1.57; 95% CI: 1.35-1.59).
Place of delivery had a strong association with CS delivery. It was found that women delivered in private hospitals were associated with almost four-fold increased odds of C-section delivery (OR=3.90; 95% CI: 3.77-4.03). Antenatal care visits acted as enabling factors of C-section delivery. Women received four or more ANC visits were 1.6 times (OR=1.6; 95% CI: 1.50-1.70) more likely to have cesarean birth compared to those who did not receive ANC service. Women who had ever pregnancy loss (OR=1.22; 95% CI: 1.17-1.27) were more likely to undergo cesarean delivery than those who did not experience pregnancy loss. Women who had delivery complications were less likely to experience C-section delivery (OR= 0.18; 95% CI: 0.16-0.20). Furthermore, it is observed that exposure to mass media had a positive association with cesarean births. For instance, women who had exposure to radio and television were 15% (OR=1.15; 95% CI: 1.10-1.20) and 13% (OR=1.13; 95% CI: 1.07-1.19) more likely to have cesarean birth.
In regard to place of residence, rural women were significantly less likely to have cesarean delivery (OR= 0.89; 95% CI: 0.86-0.93) compared to their urban counterparts. Compared to women from North region, women residing in East (OR= 1.32; 95% CI: 1.25-1.40), Northeast (OR= 1.46; 95% CI: 1.37-1.55) and South region (OR= 2.14; 95% CI: 2.03-2.26) were more likely and women from Central (OR= 0.94; 95% CI: 0.90-0.99) and West region (OR= 0.89; 95% CI: 0.84-0.95) were less likely to have cesarean birth.
Bihar and Tamil Nadu:
The odds of cesarean delivery increased with the increasing age of women in both Bihar and Tamil Nadu. However, the association of age on cesarean delivery appears to be stronger in Tamil Nadu as compared to Bihar. The impact of age at marriage on cesarean delivery was found to be significant in Tamil Nadu only. The results show that women who married at 25 years or later were 35% more likely to have C-section delivery (OR= 1.35; 95% CI: 1.07-1.72) compared to those who married before 18 years. Birth order had a negative relationship with cesarean delivery in both states. The odds of cesarean delivery decreased with the increasing birth order. For instance, mothers with four or more order-child were 68% and 78% lower likelihood of having cesarean delivery in Bihar and Tamil Nadu, respectively. Regarding mothers’ BMI, overweight condition of women increased the odds of cesarean delivery in both states. However, the likelihood of cesarean birth was slightly higher in Tamil Nadu (OR=2.26; 95% CI: 1.86-2.75) as compared to Bihar (OR=1.92; 95% CI: 1.51-2.43). Although we found a strong association between educational attainment of women and cesarean delivery at the national level, a marginal association was found in Bihar and the association became insignificant in case of Tamil Nadu. In Bihar, women who belonged to forward caste were significantly more likely to have a cesarean birth (OR= 1.28; 95% CI: 1.00-1.63) as compared to SC women. We found a decreasing trend in cesarean delivery from bottom to upper quintile of household wealth in Tamil Nadu. However, wealth index was found to be less important in Bihar. Place of delivery was found to be a strong predictor of cesarean delivery. In Bihar, women delivered in private hospitals were associated with almost 13 fold increased odds of cesarean delivery (OR=12.86; 95% CI: 10.92-15.15) as compared to public hospitals. In Tamil Nadu, the likelihood of cesarean birth in private hospitals increased by nearly three-fold (OR=2.74; 95% CI: 2.40-3.13). The number of ANC visits was positively correlated with cesarean delivery in Bihar. Women who received four or more ANC visits were 1.8 times more likely to have a cesarean birth (OR= 1.82; 95% CI: 1.49-2.13) compared with women who did not receive ANC service. In Tamil Nadu, women who had pregnancy loss were at 24% increased likelihood of having cesarean birth (OR= 1.24; 95% CI: 1.06-1.46) compared with women who had no pregnancy loss. Likewise, women having delivery complications were associated with 63% higher odds of cesarean delivery (OR= 1.63; 95% CI: 1.41-1.88) in Bihar, whereas women having delivery complications were associated with 67% decreased odds of cesarean delivery (OR= 0.33; 95% CI: 0.28-0.38) in Tamil Nadu. We found no significant association between women’s exposure to mass media (newspaper/magazine, radio, and television) and cesarean delivery in both states. Place of residence had a significant relationship with cesarean birth in Bihar where women living in rural areas were 20% less likely to have a cesarean birth (OR= 0.20; 95% CI: 0.65-0.99) as compared to urban women.