Prevalence and Determinants of Caesarean Section in South and South-east Asian Women

Background Caesarean section is considered a preferable and safe method of delivery. In the last decade, its prevalence has increased in both developed and developing countries. In the context of developing countries viz., South Asia (the highest populated region) and South-east Asia (the third highest populated region), the preference for, and variation in, caesarean section delivery and its associated maternal socioeconomic characteristics are still to be determined. Objective To study the magnitude of caesarean delivery in the South and South-east Asian countries, by correlating the maternal socioeconomic characteristics with the preference for caesarean sections. Methodology Data on ever-married women of nine developing countries of South and South-east Asia viz., Vietnam, India, Maldives, Timor-Leste, Nepal, Indonesia, Pakistan, Bangladesh and Cambodia, from Demographic and Health Survey has considered. Both bivariate and multivariate binary logistic regression models were used to estimate the probability that a woman undergoes caesarean section and to assess the influence of maternal socioeconomic characteristics towards the preference for caesarean section. Conclusion In seven urban and four rural regions of nine South and South-East Asian countries, a significant inclination towards the caesarean delivery above the more recent outdate WHO recommended optimal range of 10-15% or the more recent study by top researchers of 19% has been found. The analysis confirmed that the prevalence of caesarean section and its associated maternal socioeconomic characteristics varied widely among these nine South and South-East Asian countries.

Caesarean section in developed and developing countries [1]- [3], has considered as the 2 most preferred method of child birth. The preferences of caesarean section is found to 3 be comparatively high in the last decade [4], and one of the significant reason for this is 4 the reduction in risk of death to mother and child during delivery [5], [6]. The reasons 5 for the increase in C-section are due to various factors. In most of the developing 6 countries, demographic changes, social and educational improvement have led to an 7 growing number of women delaying their pregnancies until getting on their end of fertile 8 life [7]. This social development pooled with the approachability to birth control and 9 infertility treatment has increased the number of women experiencing their first 10 pregnancy only after 35 years of age [8]. The Caesarean section or C-section is a 11 surgical procedure, where delivery proceeds through the abdominal and uterine incision. 12 This procedure is appropriate in situations where vaginal (or normal) delivery will 13 increase life risks for the mother and the baby. Although caesarean delivery is 14 considered a relatively safe delivery method, the risk of complication is higher [9] as 15 compared to a vaginal birth or a natural method of birth. One of the major issue with 16 the caesarean deliveries other than the post-delivery risks and complication is the cost, 17 which increases due to the operation and longer stays in hospitals, and that creates a . In the past, the World Health Organization [15], had suggested that 21 although caesarean section is a safe method, but if caesarean rate exceeds the limit of 22 10-15%, it may not lead to better outcomes. However, that previous suggestion had 23 come under criticism for multiple reasons. The WHO may have changed it's view as it 24 released a statement in 2015 with the headline. Every effort should be made to provide 25 caesarean sections to women in need rather than to achieve a specific rate. Earlier studies that were incomplete because they examined data from limited sets of countries 31 and often examined outcomes in wealthier countries. In addition, many studies used 32 data from varying years without accounting for heterogeneity across years.

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Furthermore, what is being overlooked is that the WHO document [15] looked at 35 only a correlation only with mortality. Morbidity, both fetal and maternal, were not 36 taken into account for these rates. It is essential to keep foremost in mind that fetal 37 morbidity should be weighed much more higher than maternal morbidity as failure to 38 do C-section when indicated can result in babies with profound brain damage which are 39 catastrophic not only for the babies entire future life but also catastrophic for the 40 parental caregivers and the rest of the family.

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The rate of caesarean section is usually defined as the fraction of women who 43 adopted a caesarean delivery procedure among total childbirths in a specified 44 time-period in a specific geographic area". The prevailing models and estimates of the 45 caesarean rate in a specific geographic area are appropriate under the assumption that 46 in this selected area almost all deliveries took place in medical institutions, as the  Timor-Leste, Nepal, Indonesia, Pakistan, Bangladesh and Cambodia, a considerable 50 proportion of child deliveries are carried out at home (Table 1) and are completely free 51 of risks and complications associated with caesarean deliveries.

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As the caesarean is a surgical procedure and is only possible at medical institutions; 54 Therefore, in the present study, the prevalence of caesarean section among women from 55 different South and South-east Asian countries, who have experienced the institutional 56 deliveries, have been investigated. In this study, an attempt has been made to provide a 57 better understanding of the behavioural pattern of among women of these countries 58 towards caesarean section. Through this study, the dependency and importance of the 59 socio-economic factors on the caesarean section preference for delivery have also been 60 explored.  The relationship with incidences of caesarean section with some of associated maternal 69 socio-economic characteristics viz., maternal age, place of residence, level of maternal 70 education, birth order of the child, and type of medical facility that opted for delivery 71 and size of the baby, has been modelled. Age as reported subjectively by mother, and 72 grouped into 6 subgroups: 15-19, · · · , 40-44. The 45 to 49 age group was not taken into 73 account due to a lack of sufficient data. The type of place of residence has classified as 74 rural and urban. The educational qualification has classified into four classes, primary, 75 secondary and higher. Birth order of the born child, which has grouped into first, 76 second, third, fourth and fifth or more. The medical institutions that opted for the 77 delivery were grouped together whether government or private facilities. The size of the 78 child was classified as below average, average and above average and large. Our interest 79 lies in to find the prevalence of caesarean section in the countries of South and  based on her socio-economic characteristics, viz., maternal age, place of residence, level 94 of maternal education, birth order of the child, and type of medical facility that opted 95 for delivery and size of the baby. The results obtained from the regression analyses have 96 been presented in terms of the odds ratios (ORs) with 95% confidence interval (CI).  To obtain a better estimate for the prevalence of caesarean deliveries in each of the 122 selected South and South-east Asian Countries, the population is classified into two 123 disjointed sub-populations based on their place of delivery viz., institutional or 124 non-institutional. Here, institutional deliveries referred to those deliveries occurred at 125 any private or government medical institutions, whereas births occurred other than any 126 medical institutions, are considered as non-institutional births. To visualise the 127 prevalence of caesarean section and the population at risk, only institutional deliveries 128 have been taken into account for investigation.  the child, i.e., chance to get caesarean section is high to women having least birth order. 149 In countries Maldives and Bangladesh, caesarean rates are very high and found for all 150 birth orders. From Figure 3, it has found that caesarean is more preferred to women 151 whose baby sizes are either very large or smaller than average. Irrespective of the size of 152 the baby, caesarean rates in Maldives, Nepal and Bangladesh have been found to be 153 very high. Figure 4  Women with higher education are more likely to have a caesarean section compared 180 to those who have less education. Women who have opted for private institutions for 181 delivery, compared to governmental medical institutions, are more likely to undergo a 182 caesarean section. The order of birth showed a constant decrease in caesarean section. 183 The place of residence showed that urban women, compared to their rural counterparts, 184 have seen to be more likely to experience caesarean sections. The size of the baby has 185 found significant in some countries except Timor-Leste, Nepal, Indonesia, Bangladesh 186 and Cambodia, which shows that women in these countries whose baby size is above 187 average or below average with reference to average size are more likely to give birth by 188 caesarean section.

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As caesarean section is a surgical procedure and is possible only if the location is 191 equipped with medical facilities; therefore, women whose delivery is not institutional 192 cannot be considered to be exposed to a caesarean delivery and are not part of the 193 population of interest. Only women who were married and whose deliveries were Bangladesh has found to 4.45 and 5.2 times higher than those rates based on the total 205 number of births, respectively. Our findings suggest that women with higher education 206 are more likely to undergo caesarean as compared to uneducated women. The age of 207 women was found to have a weak positive impact (the odds are slightly higher than one) 208 on the risk of caesarean (i.e., every one-year increment on women's age, the risk of 209 caesarean is approximately 1.1 times in women as compared to women with normal 210 delivery). There are positive trends found for caesarean delivery in private hospitals.

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Our results indicate that odds for caesarean delivery in private hospitals as compared to 212 government hospitals are very high. Results suggest that women with higher education 213 are more likely to have caesarean sections than women who are uneducated. The age of 214 women with low impact (odds are slightly higher than 1) on the risk of caesarean Of all the other determinants of the prevalence of caesarean delivery in any medical 232 facility, the choice of place of birth viz., Government and private facilities may be a 233 strong influence on the choice to undergo a caesarean section. Increases in the caesarean 234 rates create a heavy burden on the health system [15] and also increases the risk of 235 other health problems to both mother and baby, and unwanted caesarean delivery also 236 puts a huge financial burden on the family economic status.