Dataset Information

Trends in cesarean section rates in private and public facilities in rural eastern Maharashtra, India from 2010-2017.

ABSTRACT:

Introduction

Rates of cesarean sections (CS) have increased dramatically over the past two decades in India. This increase has been disproportionately high in private facilities, but little is known about the drivers of the CS rate increase and how they vary over time and geographically.

Methods

Women enrolled in the Nagpur, India site of the Global Network for Women's and Children's Health Research Maternal and Neonatal Health Registry, who delivered in a health facility with CS capability were included in this study. The trend in CS rates from 2010 to 2017 in public and private facilities were assessed and displayed by subdistrict. Multivariable generalized estimating equations models were used to assess the association of delivering in private versus public facilities with having a CS, adjusting for known risk factors.

Results

CS rates increased substantially between 2010 and 2017 at both public and private facilities. The odds of having a CS at a private facility were 40% higher than at a public facility after adjusting for other known risk factors. CS rates had unequal spatial distributions at the subdistrict level.

Discussion

Our study findings contribute to the knowledge of increasing CS rates in both public and private facilities in India. Maps of the spatial distribution of subdistrict-based CS rates are helpful in understanding patterns of CS deliveries, but more investigation as to why clusters of high CS rates have formed in warranted.

SUBMITTER: Simmons E

PROVIDER: S-EPMC8360542 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ImportanceThe rates of cesarean deliveries have more than doubled in India, from 8% of deliveries in 2005 to 17% of deliveries in 2016. The World Health Organization recommends that cesarean deliveries should not exceed 10% to 15% of all deliveries in any country. An understanding of the association of private and public facilities with the increase in cesarean delivery rates in India is needed.ObjectiveTo assess the association of public vs private sector health care facilities with cesarean delivery rates in India and to estimate the potential cost savings if private sector facilities followed World Health Organization recommendation for cesarean deliveries.Design, setting, and participantsThis cross-sectional study used institutional delivery data from the representative National Family Health Survey (NFHS) in India, including data from the NFHS-1 (1992-1993), the NFHS-3 (2005-2006), and the NFHS-4 (2015-2016). The NFHS-3 and NFHS-4 provided data on 22 647 deliveries and 195 366 deliveries, respectively. The NHFS-4 was the first survey to provide data on out-of-pocket expenditures for delivery by facility type, allowing for a comparison of cesarean deliveries and costs between public and private facilities. The primary sample comprised all pregnant women who delivered infants in public and private institutional facilities in India and who were included the NFHS-3 and the NFHS-4; data on pregnant women who were included in the NFHS-1 were used for comparison. The study's findings were analyzed through geographic mapping, data tabulation, funnel plots, multivariate logistic regression analyses, and potential cost-savings scenario analyses. Data were analyzed from June to December 2019.Main outcomes and measuresThe main outcome was the rate of cesarean deliveries by facility type (public vs private) and by participant socioeconomic, demographic, and health characteristics. Secondary outcomes were the potential number of avoidable cesarean deliveries and the potential cost savings if private sector facilities followed the World Health Organization recommendations for cesarean deliveries.ResultsIn the NFHS-3, 22 610 total births occurred at institutional facilities. Of those, 2178 births (15.2%) were cesarean deliveries in public facilities, and 3200 births (27.9%) were cesarean deliveries in private facilities. Of 195 366 total institutional births in the NFHS-4, 15 165 births (11.9%) were cesarean deliveries in public facilities, and 20 506 births (40.9%) were cesarean deliveries in private facilities. The cesarean delivery rate in public health facilities increased from 7.2% in the NFHS-1 to 11.9% in the NFHS-4, whereas in private health facilities, the rate increased from 12.3% to 40.9% during the same period. A substantial increase was found in cesarean delivery rates between the NFHS-3 (2005-2006) and the NFHS-4 (2015-2016), with 22 states exceeding the World Health Organization's upper threshold of 15% in the NFHS-4. The odds ratio for cesarean deliveries in private facilities compared with public facilities increased from 1.62 (95% CI, 1.49-1.76) in the NFHS-3 to 4.17 (95% CI, 4.04-4.30) in the NFHS-4. The number of avoidable cesarean deliveries would have been 1.83 million, with a potential cost savings of $320.60 million, if private sector facilities in India had followed the 15% threshold for cesarean delivery rates recommended by the World Health Organization.Conclusions and relevanceIn this study, private sector health facilities were associated with a substantial increase in cesarean deliveries in India. Further research is needed to assess the factors underlying the increase in cesarean deliveries in private sector facilities.

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