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Research Article

Geographic and socioeconomic inequities in cesarean delivery rates at the district level in Madhya Pradesh, India: A secondary analysis of the national family health survey-5

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Article: 2203544 | Received 20 Dec 2022, Accepted 12 Apr 2023, Published online: 04 May 2023
 

ABSTRACT

Background

In India, caesarean delivery (CD) accounts for 17% of the births, of which 41% occur in private facilities. However, areas to CD in rural areas are limited, particularly for the poor populations. Little information is available on state-wise district-level CD rates by geography and the population wealth quintiles, especially in Madhya Pradesh (MP), the fifth most populous and third poorest state.

Objective

Investigate geographic and socioeconomic inequities of CD across the 51 districts in MP and compare the contribution of public and private healthcare facilities to the overall state CD rate.

Methods

This cross-sectional study utilised the summary fact sheets of the National Family Health Survey (NFHS)-5 performed from January 2019 to April 2021. Women aged 15 to 49 years, with live births two years preceding the survey were included. District-level CD rates in MP were used to determine the inequalities in accessing CD in the poorer and poorest wealth quintiles. CD rates were stratified as <10%, 10–20% and >20% to measure equity of access. A linear regression model was used to examine the correlation between the fractions of the population in the two bottom wealth quintiles and CD rates.

Results

Eighteen districts had a CD rate below 10%, 32 districts were within the 10%–20% threshold and four had a rate of 20% or higher. Districts with a higher proportion of poorer population and were at a distance from the capital city Bhopal were associated with lower CD rates. However, this decline was steeper for private healthcare facilities (R2 = 0.382) revealing a possible dependency of the poor populations on public healthcare facilities (R2 = 0.009) for accessing CD.

Conclusion

Although CD rates have increased across MP, inequities within districts and wealth quintiles exist, warranting closer attention to the outreach of government policies and the need to incentivise CDs where underuse is significant.

Responsible Editor Jennifer Stewart Williams

Responsible Editor Jennifer Stewart Williams

Author contributions

RD, AG, NR, AvD, and PP conceptualised the research project. RD, ST, PP, MS, and NT conducted the analysis. All authors contributed to the writing of the manuscript and critical revisions. NR is responsible for the overall content (guarantor) of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data is available in a public, open-access repository, and the corresponding author can also share it. We investigate the geographic and socioeconomic inequities of CD across the 51 districts in MP and compare the contribution of public and private healthcare facilities to the overall state CD rate.

Ethics

Our study utilised the publicly available dataset from the NFHS-4 and NFHS-5 surveys, which does not contain identifiable information and is accessible from the NFHS website. Ethical approval for these surveys was obtained from the ethics review board of the International Institute for Population Sciences in Mumbai, India, and they were also reviewed and approved by the ICF International Review Board. Informed written consent was obtained from all participants before the survey, and the consistent methodology followed in these national surveys ensured that each participant was asked for approval before the patient interview.

Paper context

Caesarean delivery accounts for 17% of the births in India, of which 41% occur in private facilities. District-wise disaggregation of these rates against geographic and socio-economic determinants reveals inequities in access to this procedure in the state of Madhya Pradesh where overall caesarean rates have increased from 8.2% to 12.1% from 2015 to 2021. Understanding the barriers at the grassroot level can help guide policy to encourage equity in government programmes that incentivise access to cesarean deliveries.

Notes

1 Government of India has identified high priority districts (HPD) in each state to ensure equitable health care and to bring about sharper improvements in health outcomes. The bottom 25% of the districts in every state according to the ranking of districts based on composite health index have been identified as HPDs [Citation31].

Additional information

Funding

The author(s) reported that there is no funding associated with the work featured in this article.