Drivers of C-Section Deliveries

CSBC diagnosed the drivers of C-Section deliveries in India to advise BMGF on creating relevant Social and Behaviour Change Communication (SBCC) materials. For the diagnosis, we undertook an extensive review of maternal health policies, national and international guidelines on C-Sectional deliveries and the global literature. Through the review, we discovered the interplay of multiple dynamic factors driving the behaviours of healthcare professionals and pregnant women and their caregivers. Therefore, we advised our project partner to adopt a comprehensive approach to improving pregnancy and childbirth outcomes rather than promoting a single solution.

Introduction

C-Section rates in India increased from 17.2% in 2015-16 to 21.5% in 2019-21, with Telangana recording the highest rate of 60.7% and Nagaland recording the lowest rate of 5.2% in 2019-21 (NFHS V, 2019-21). Further, the prevalence of C-Section deliveries vary by region, type of institution and geography.

• Regional variations: C-Section deliveries are more prevalent in the southern region
• Institutional variations: Private healthcare sectors are a hub for C-Section deliveries. In 2019-21, 47.4% of the deliveries performed in the private sector were C-Sectional versus 14.3% in the public sector (NFHS V, 2019-21)
• Geographical variations: C-Sections are more prevalent in urban areas with 32.3% of the deliveries being C-Sectional as opposed to 17.6% in rural areas (NFHS V, 2019-21)

Scope of Work

Given the overall high prevalence of C-Section deliveries along with the regional, institutional and geographical variations, CSBC was tasked with diagnosing the underlying reasons driving these trends and suggesting potential solutions to inform the design of Social and Behaviour Change Communication materials.

Approach

Potential drivers of the above-listed trends may be medical, systemic or personal and societal. Due to limited medical expertise, we focused on the systemic and personal and societal reasons. To further diagnose the same, we undertook an extensive review of maternal health policies, national and international guidelines on C-Sectional deliveries and the global literature.

Findings

1. Dearth of data to draw detailed conclusions about the patterns in C-Section deliveries and their side-effects

• There is an absence of a standard classification system that prevents comparison of C-Section rates across different facilities, cities, and countries in a useful and actionable manner
• Data on outcome indicators such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being is limited which prevents research on health effects in the immediate and long term

2. Interplay of extrinsic and intrinsic factors drive healthcare providers to suggest and perform C-Section deliveries

2A. Extrinsic factors

• Systemic:
  • Improvements in healthcare infrastructure: Improvements in healthcare infrastructure may naturally increase the rate of C-Section deliveries
  • Increase in institutional deliveries: Higher institutional deliveries may mean higher chances of detecting risky pregnancies
• Demographic:
  • Late marriages and pregnancies: Late pregnancies may often cause complications in vaginal deliveries
  • Poor antenatal care: Poor provision of antenatal care services or a lack of their uptake may put the pregnancy at risk
  • Increase in incidence of diseases: Diseases such as anaemia or lifestyle diseases such as obesity may put pregnancy at risk

2B. Intrinsic factors

• Convenience: C-Section deliveries can be scheduled and take lesser time to perform
• Incentive: In the case of the private sector, C-Section deliveries offer higher monetary incentives
• Beliefs: Healthcare providers may not believe C-Section to be as harmful and believe that vaginal deliveries may be comparatively more painful for pregnant women
• Risk Aversion: Risk aversion may make healthcare providers assume the worst outcome and pre-recommend a C-Section delivery
• External Pressure: Pressure from pregnant women and caregivers to perform C-Section deliveries as they may want the baby to be born on a specific auspicious date or may want a pain free delivery

3. Interplay of demographic and personal & social factors drive pregnant women and caregivers to opt for C-Section deliveries

3A. Demographic factors: Education and wealth positively correlate with the decision to undergo C-Section deliveries

3B. Personal and societal factors

• Low maternal self-efficacy: Pregnant women may opt for C-Section deliveries due to the fear of labour pain, fear of failing vaginal birth, fear of harming the baby, etc.
• Information asymmetry: Pregnant women and their families may have limited information about the benefits of a vaginal delivery and/or the consequences of a C-Section delivery
• Delivery on auspicious dates: C-Section deliveries give pregnant women and their caregivers the liberty to pre-determine the delivery date on a preferred auspicious day
• Social status: Many families view C-Section deliveries to be fashionable, a sign of modernity or an indication of taking good care of daughters-in-law
• Social influences: Unsuccessful vaginal deliveries or successful C-Section deliveries in their social network may influence the choice of mode of delivery of pregnant women

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