Assessing geographical and economic inequalities in caesarean section rates between the districts of Bihar, India: a secondary analysis of the National Family Health Survey

Abstract

BackgroundIn Bihar, one of the most populous and poorest states in India, caesarean sections have increased over the last decade. However, an aggregated caesarean section rate at the state level may conceal inequities at the district level.ObjectivesThe primary aim of this study was to analyse the inequalities in the geographical and socioeconomic distribution of caesarean sections between the districts of Bihar. The secondary aim was to compare the contribution of free-for-service government-funded public facilities and fee-for-service private facilities to the caesarean section rate.SettingBihar, with a population in the 2011 census of approximately 104 million people, has a low GDP per capita (US$610), compared with other Indian states. The state has the highest crude birth rate (26.1 per 1000 population) in India, with one baby born every two seconds. Bihar is divided into 38 administrative districts, 101 subdivisions and 534 blocks. Each district has a district (Sadar) hospital, and six districts also have one or more medical college hospitals.MethodsThis retrospective secondary data analysis was based on open-source national datasets from the 2015 and 2019 National Family Health Surveys, with respective sample sizes of 45 812 and 42 843 women aged 15–49 years.ParticipantsSecondary data analysis of pregnant women delivering in public and private institutions.ResultsThe caesarean section rate increased from 6.2% in 2015 to 9.7% in 2019 in Bihar. Districts with a lower proportion of poor population had higher caesarean section rates (R2=0.45) among all institutional births, with 10.3% in private and 2.9% in public facilities. Access to private caesarean sections decreased (R2=0.46) for districts with poorer populations.ConclusionMarked inequalities exist in access to caesarean sections. The public sector needs to be strengthened to improve access to obstetric services for those who need it most.

A Review of the National Family Health Survey Data in Addressing India’s Maternal Health Situation

“…It depicted that more than one-fifth of the institutional deliveries are C-section in most Indian provinces with maximum prevalence in southern provinces of Telangana, Kerala, and Andhra Pradesh. Another study was conducted on geographic and economic inequalities in C-section in the various districts of Bihar and reported that C-section delivery rate has increased from NFHS 4 to NFHS 5 [ 44 ]. Both these studies contend that increasing age of women, literacy of women, and economic strata are positively associated with C-section delivery in India [ 43 , 44 ].…”

“…Another study was conducted on geographic and economic inequalities in C-section in the various districts of Bihar and reported that C-section delivery rate has increased from NFHS 4 to NFHS 5 [ 44 ]. Both these studies contend that increasing age of women, literacy of women, and economic strata are positively associated with C-section delivery in India [ 43 , 44 ]. Critical appraisal of NFHS 5 data on maternal health indicator revealed prevalence of anaemia during pregnancy has increased from 15 to 17 provinces as compared to NFHS- 4 [ 68 ].…”

“…Five studies have specifically focused on institutional delivery including C-section delivery, in which three studies were conducted using NFHS 1 [40], NFHS 2 [41], and NFHS 4 [42], respectively. While two studies used both NFHS 4 and 5 [43,44], nine studies have exclusively looked into ANC. Out of these nine studies, three studies are based on NFHS 2 [45][46][47], while one study on NFHS 3 [48] and four studies on NFHS 4 [49][50][51][52].…”

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

“…This makes the surgical volume indicator challenging to collect and interpret. Furthermore, surgeries, like laparoscopic surgeries for asymptomatic gallstones, cesarean sections, and so on, are performed more often as a result of advanced technologies, fewer side effects, and the fear of complications [32, 33]. This could be masking the true figure of unmet surgical need.…”