Conclusions
Our findings depict high CS rates in India with a rising trend. However, the sectoral and subnational geographic differences are noteworthy given that they might be driven due to supply-side factors such as low service delivery capacity in rural public facilities and limited antenatal care and demand-side factors such as higher maternal age, education, and economic status, greater preference among private sector, etc. Indian national and subnational estimates match other lower-middle-income countries in Southeast Asia and South America.1Our findings build upon earlier work using periodic household surveys.2We use administrative HMIS data that is routinely collected at a high geographic resolution that can be better accessed by policymakers and health planners. There are multiple limitations. There are data completeness and accuracy challenges inherent to HMIS. However, previously HMIS CS rates have been known to agree with those from the National Family Health Survey data.5The lack of public data prevented investigating disaggregated CS rates by rural-urban regions, levels of care, and emergency vs. elective surgeries. Regardless, these findings are important for future research and policymaking. Excess cesarean sections in India are driven largely by the private sector in districts clustered in south and central India while several states in North and Northeast India lack CS delivery capacity in public facilities. To ensure equitable care, India needs a targeted (state-level) policy approach regulating the private sector and simultaneous public system strengthening.
References
1. Betran AP, Ye J, Moller A-B, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021 Jun;6(6).
2. Guilmoto CZ, Dumont A. Trends, Regional Variations, and Socioeconomic Disparities in Cesarean Births in India, 2010-2016. JAMA Netw Open. 2019 Mar 1;2(3):e190526.
3. Ye J, Zhang J, Mikolajczyk R, Torloni MR, Gülmezoglu AM, Betran AP. Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data. BJOG. 2016 Apr;123(5):745–53.
4. Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA. 2015 Dec 1;314(21):2263–70.
5. Zadey S, Nickenig Vissoci JR. Analyzing surgical volumes, rates, and need in rural india. medRxiv. 2021 Nov 4;