**Abstract**

It has been well recognised that medically unnecessary caesarean section (C-section) delivery could increase morbidity risks for both the mother and her child and also could put strain on both institutional and individual assets mainly in developing countries. The present study tried to assess the variations in C-section delivery rates by women's background characteristics and to examine the factors associated with C-section delivery in West Bengal—a state of India. Data from the third round of the District Level Household and Facility Survey (DLHS-3) 2007–2008, covering 6447 ever-married women of age 15–49 years, were used. The results reveal that about 12% women delivered their babies by C-section irrespective of place of delivery, but it rose to about 24% in only institutional delivery. It is also found that the rate of C-section delivery was excessively high in private health facilities (55.8%) followed by higher educated women (50.4%) and for health insurance (36.4%), and antenatal care service eight or more times (36%). The results of predicted (adjusted) probability computed from logistic regression reveal that delivery in private health facilities, higher maternal age, lower birth order and higher level of education were the main influential factors of C-section delivery.

**Keywords:** antenatal care (ANC), place of delivery, caesarean section delivery, West Bengal, India

## **1. Introduction**

The operation for caesarean delivery constitutes a major surgical procedure. There are a large number of adverse effects on women and infants after the C-section delivery. Study found that C-section delivery is associated with a higher risk of ureteral tract and vesical damage, hysterectomy, abdominal pain, maternal mortality, uterine rupture in future pregnancies, neonatal respiratory morbidity, placenta previa and foetal death [1]. It was revealed that women who delivered their baby by elective C-section have 2.84 times more chance of maternal death than women who delivered their baby normally [2]. A study from Africa found that C-section delivery is associated with stillbirths, neonatal deaths and neonatal morbidity [3]. C-section delivery individually minimises the overall risk to foetus death from the breech birth presentations, although it raises the risk of severe neonatal and maternal morbidities and mortality in cephalic presentation [4]. Women who delivered their first baby by C-section have slightly higher long-term morbidity

than those women delivered their baby normally [5]. A study from Mexico revealed that children born by C-section are less likely to receive breastfeeding than the children born normally [6]. There is also evidence from highly developed countries that C-section is associated with adverse psychosocial results, for example, dissatisfaction, distress and problem with woman and child bonding [7]. Another study demonstrated that caesarean childbirths lead to higher financial burden than vaginal deliveries [8].

In this regard, the World Health Organization (WHO) issued an agreement proclamation in 1985, stating that, "There is no justification for any region to have C-section (CS) rates higher than 10–15%" [9]. But there is considerable debate about whether CS rates over 15% mean an over-utilisation of the procedure. But it is true that "as with any surgery, caesarean sections are associated with short and long term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care" [10]. According to the District Level Household and Facility Survey (DLHS), the average C-section rate in West Bengal was 11.8% in DLHS-3, 2007–2008 [11], and it also varied from district to district in West Bengal. There was interdistrict variation in C-section rates in West Bengal with Kolkata having the highest C-section rate (34.1%), and Malda having the lowest C-section rate (only 1.8%) in DLHS-3, 2007–2008 [11]. The rate of C-section increased significantly from 3.4% in DLHS-2, 2002–2004 [12], to about 12% in DLHS-3, 2007–2008, and again it rose to 22% (Factsheet DLHS-3, 2012–2013) [13], which was a matter of concern.

The present study was based on the following four observations which were conceptualised by Leone et al. [14]: *first*, recent increasing trends in C-section delivery in West Bengal; *second*, evidence that medically unnecessary C-section could increase morbidity risks for both the woman and her child; *third*, unnecessary medical interventions and C-section could put strain on both institutional and individual assets; *fourth*, evidence from more developed countries demonstrates that C-section delivery is associated with adverse psychosocial outcomes such as distress, dissatisfaction and problems with maternal-infant bonding. On the basis of these observations, the present study tried to explore variations in C-section delivery rates by women's background characteristics and to examine the factors influencing the C-section delivery in West Bengal—a state of Eastern India. The findings of this study could be helpful for policymakers and planning to improve women's health and to make appropriate use of healthcare resources.

This study surveyed the existing studies and tried to find out the associated non-clinical factors of C-section delivery for selecting the relevant independent factors for the present analysis. Among maternal factors, previous studies found that the probability of having C-section delivery increases with the increase in maternal age [15–18]; the likelihood of having C-section delivery decreases with the increase in parity [19–21]. Among socioeconomic factors, existing studies showed that the probability of having C-section delivery increases with the increase in the maternal level of education [16, 22, 23]; with the increase in the level of income, the probability of having C-section delivery also increases [24, 25]; urban women tend to have more C-section delivery than rural women [26, 27]. Among institutional factors, previous studies found that the type of hospitals and number of antenatal care (ANC) visits play a vital role for C-section delivery. Delivering in private health facilities has higher tendency to undergo C-section delivery than delivering in public hospitals [20, 28–31]. The likelihood of C-section delivery increases with the increase in number of ANC visits [19, 21, 32]. Women who have health insurance are more likely to have C-section delivery than women who do not have any health insurance [33, 34].

**61**

*Correlates of Caesarean Section Delivery in West Bengal, India: An Analysis Based on DLHS-3*

The present analysis was based on the data from the third round of the District Level Household and Facility Survey, carried out during December 2007–2008 in India (DLHS-3, 2007–2008). The District Level Household and Facility Survey was a countywide survey covering 601 districts of India [11]. This survey was designed to gather information at the district level on different aspects of women's healthcare utilisation for Reproductive and Child Health (RCH) including accessibility to the health facilities and to evaluate the health facility capacity and readiness regarding infrastructure. DLHS-3 surveyed a sum of 22213 households and 21878 ever-married women in West Bengal. However, this study was based on 6447 ever-married women of age 15–49 years who had given live birth between January 1, 2004, and the survey date. This was the third round of data which were in the public domain.

The outcome or dependent variable was C-section delivery; a dichotomous variable was coded as "1" for yes and "0" for no, or, simply, those women aged 15–49 years who delivered their last live birth after January 1, 2004, by surgical procedure were coded as "1", and those women aged 15–49 years who delivered their last live birth after January 1, 2004, by natural process/vaginally or with assistance

The C-section delivery is an outcome of demographic, socioeconomic, insurance status and institutional factors. Among demographic factors, maternal age at last birth (below 20, 20–24, 25–29 and 30+ years) and birth order (first birth order, second birth order and third birth order or above) were taken. The level of mother's education (no schooling, up to 5 years, 6–10 years, 11+ years), household wealth index (poor, middle and rich), religion (Hindus, Muslims and others), caste/tribe (Scheduled Caste (SC), Scheduled Tribe (ST) and others or general) and place of residences (rural and urban residence) were taken from socioeconomic factors. Coverage by health insurance scheme (yes, no) was also included as an explanatory variable. Antenatal care services include the number of ANC visits (up to three times, four to seven times and eight or more times) and places of ANC services (no ANC visits, only public health facilities, only private health facilities, public/private health facilities, and home or elsewhere), and the place of delivery (public health

facilities, private health facilities) were taken from institutional factors.

The differences in C-section delivery by women's background characteristics were gross differentials and had been obtained through bivariate analysis. As a number of factors were strongly associated with each other, there was the possibility of confounding. Therefore, it was necessarily desirable to detect the net effect. For this purpose, logistic regression model had been used. In this model, the coefficient (B) and odds ratio (Exp B) were estimated. In order to assess the true differences, it was desirable to obtain adjusted probabilities; by that one can see the actual difference in probabilities [35]. The adjusted probabilities were computed from the coefficients of logistic regression analysis for C-section delivery. A p-value of less than and equal to 0.05 was considered as the significant association between

*DOI: http://dx.doi.org/10.5772/intechopen.88838*

**2. Data and methods**

**2.1 Outcome variable**

or instrument were coded as "0".

**2.2 Explanatory variables**

**2.3 Statistical analysis**

independent variable and outcome variable.

*Correlates of Caesarean Section Delivery in West Bengal, India: An Analysis Based on DLHS-3 DOI: http://dx.doi.org/10.5772/intechopen.88838*
