https://orcid.org/0000-0001-9800-0110
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ABSTRACT
Background
Low rates of caesarean delivery (CD) (<10%) hinder access to a lifesaving procedure for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding which factors contribute most to CD rates.
Objectives
We aimed to determine caesarean delivery rates at Bihar’s first referral units (FRUs) stratified by facility level (regional, sub-district, district). The secondary aim was to identify facility-level factors associated with caesarean delivery rates.
Methods
This cross-sectional study used open-source national datasets from government FRUs in Bihar, India, from April 2018–March 2019. Multivariate Poisson regression analysed association of infrastructure and workforce factors with CD rates.
Results
Of 546,444 deliveries conducted at 149 FRUs, 16961 were CDs, yielding a state-wide FRU CD of 3.1%. There were 67 (45%) regional hospitals, 45 (30%) sub-district hospitals, and 37 (25%) district hospitals. Sixty-one percent of FRUs qualified as having intact infrastructure, 84% had a functioning operating room, but only 7% were LaQshya (Labour Room Quality Improvement Initiative) certified. Considering workforce, 58% had an obstetrician-gynaecologist (range 0–10), 39% had an anaesthetist (range 0–5), and 35% had a provider trained in Emergency Obstetric Care (EmOC) (range 0–4) through a task-sharing initiative. The majority of regional hospitals lack the essential workforce and infrastructure to perform CDs. Multivariate regression including all FRUs performing deliveries demonstrated that presence of a functioning operating room (IRR = 21.0, 95%CI 7.9–55.8, p < 0.001) and the number of obstetrician-gynaecologists (IRR = 1.3, 95%CI 1.1–1.4, p = 0.001) and EmOCs (IRR = 1.6, 95%CI 1.3–1.9, p < 0.001) were associated with facility-level CD rates.
Conclusion
Only 3.1% of the institutional childbirths in Bihar’s FRUs were by CD. The presence of a functional operating room, obstetrician, and task-sharing provider (EmOC) was strongly associated with CD. These factors may represent initial investment priorities for scaling up CD rates in Bihar.
Responsible Editor Jennifer Stewart Williams
Responsible Editor Jennifer Stewart Williams
Author contributions
AP and RD contributed equally to this work and are co-first authors. AP, RD, AG, NR, and NPR were involved in the study conception and design. AP, RD, MS and SH performed the acquisition of data and analysis. AP, RD, MS, AJ, AG, NR, and NPR were involved in the drafting the manuscript and critical revisions.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The datasets used and/or analysed during the current study are available from the corresponding author at reasonable request. http://rchiips.org/nfhs/nfhs4.shtml
Ethics and consent
Not applicable. All datasets were publicly available.
Paper context
Low rates of caesarean delivery hinder access for the most vulnerable populations in low-resource settings, but there is a paucity of data regarding factors contributing most to caesarean delivery rates. Only 3.1% of the institutional childbirths in Bihar’s First Referral Units were by caesarean delivery. The presence of a functional operating room, obstetrician, and task-sharing provider was strongly associated with caesarean delivery, which may represent initial investment priorities for scaling up caesarean delivery in Bihar.