Assessments of facility-based delivery services

The rising trend of caesarean section (CS) delivery throughout the world has become a serious public health issue. In India the rate of CS has increased from 3% to 10% between 1992-93 and 2005-06 (IIPS, 2007). The present study seeks to explore the level and trend of caesarean section delivery in India. It also attempts to identify the causes of alarming growth rate of CS in some parts of India. The analysis is based on third District Level Household and Facility Survey and three rounds of National Family Health Survey conducted in India. Logistic regression model is used to understand the net impact of various explanatory variables on woman’s experience of CS. A number of doctors and patients from different public and private institutions were interviewed to identify the underlying causes of high growth rate of CS. Besides the profit maximization tendency of the private medical institutions, rise in institutional deliveries and patients’ choice for CS, poor doctor-population ratio, 24 hours unavailability of obstetricians in the medical institutions, poor infrastructural support for normal delivery, constant threat of case suits and physical harassment against doctors are cited as some of the important causes of increase in caesarean section delivery.

Rising overmedicalisation of childbearing in low income countries is seen as a worrying phenomenon as resources are scarce and could create a further risk for mother and child’s health. Some Indian States have seen sky rocketing c-section rates reaching twice as high levels than the recommended WHO 15%. It is not clear whether this increase is determined by demand or supply. The aim of this study is to understand the interaction between health systems and individual socio-economic factors in determining the probability of a c-section .
Multilevel modelling at district and cluster level is used to analysed the 2007-8 Indian DHLS..
Results show that after controlling for key risk factors, private institutions have a higher risk to perform c-sections. On the demand side higher education levels rather than wealth seems to increase the likelihood of a c-section. While cluster level is not significant, district level effects are significant in all the states demonstrating the need to control for health systems factors. This research shows that at this stage supply factors might be stronger than demand. It confirms the need to invest in further research to understand whether the quest for increased institutional deliveries in a country with a high maternal mortality might not be compromised by a push for overmedicalisation.