**5. Conclusions**

*Maternal and Child Health Matters Around the World*

delivery in bivariate analysis.

**4. Discussion**

which was mostly found at the higher level of education. A small variation in the probability of C-section delivery was observed between the rural and urban residences, but it was an insignificant factor after controlling for others. The effect of level of income on C-section delivery was mild, so were the effects of religion and caste. Besides, the insurance coverage did not show any significant effect on C-section delivery in this analysis, although it had a large gross effect on C-section

This study showed that the actual probability of C-section delivery was about 12% among all deliveries and 24% among all institutional deliveries in West Bengal. The results of logistic regression revealed that the place of delivery, the number of ANC visits, maternal age, birth order and the level of maternal education were the significant factors associated with the C-section delivery. Delivery in private health facilities was the strongest predictor of C-section delivery as expected. This finding is consistent with the findings of previous studies [14, 17, 20, 28, 29, 36, 37]. This finding could be explained in various ways. Firstly, the proprietors of private health facilities are revenue oriented, and they always try to encourage doctors to perform C-section delivery instead of normal delivery because it brings more revenue; secondly, many doctors are also financially motivated and, therefore, advise patients to have C-section; thirdly, generally doctors are very busy persons, engaged in multiple tasks, and, thus, often they perform C-section even before the arrival of the delivery's labour pain, so as to avoid patient call; and fourthly, both doctors and proprietors of private health facilities do not take risks regarding delivery, so doctors perform C-section before the arrival of the actual delivery's labour pain for avoiding any risks. The higher maternal age was also another important significant factor of C-section delivery. This finding is found to be significant in almost all the previous studies [18, 26, 31, 38, 39]. The higher age of women is much more associated with the prolonged labour, unable to progress at the time of birth and foetal distress which could lead to C-section delivery. Birth order (parity) was also another significant factor of C-section delivery. This finding is similar to a large number of studies [15, 27, 40–43]. The pregnancy and delivery complications are higher among the primiparous women or women of lower birth order than women of higher birth order which leads to higher chances of C-section delivery. On the other hand, maternal age and birth order are highly correlated with each other. The probability of having C-section of lower birth order is higher, but once the birth order is controlled, then higher age has greater chances of C-section delivery. So, women of higher age with the low birth order have higher chances to have C-section delivery. Another most important factor of C-section delivery was the level of woman's education. This finding is also consistent with a large number of previous studies [25, 32, 34, 42, 44, 45]. In general, highly educated women are more aware of maternal and child health and quality of care which would lead women to prefer to go to private health facilities for delivering and ultimately lead to have C-section delivery. The higher number of antenatal visits was the significant factor of C-section delivery as expected though the effect was mild. This finding is also consistent with other studies [22, 26, 29, 30, 46]. The higher number of ANC visits might be the result of pregnancy complications which indicates the surgical operation to deliver a baby. The place of residence was not a significant factor in this study. A similar finding has been observed in the study of Kerala, India [31], and in Jordon [47]. These studies argue that well connectivity and availability of health

**66**

From the above analysis, the present study revealed that women's demographic, socioeconomic background characteristics, antenatal care service and delivery care can have an effect on C-section delivery. From the findings of the present study, it could be recommended that there are some steps which may help to reduce or stop the medically unnecessary C-section delivery for the betterment of women and child health and appropriate use of resources. First, it is found that the rates of C-section delivery were almost three times higher in private health sectors than the public health sectors. Therefore, universal guidelines, protocols and medical audit on C-section should be implemented. Further, the public health system should take steps to monitor the reasons of C-section delivery. The results revealed that women at higher age were at more risk for C-section delivery. The results also found that higher educated women were more tend to have C-section delivery. Thus, the maternal and child health-related educational programme should be implemented for educated women as well as uneducated women. Finally, the community health workers should be trained to circulate the awareness about risks and benefits of C-section delivery, so that medically unnecessary C-section deliveries are not requested or demanded by women and their families. One major limitation of this study is that, in the data source (DLHS, 2007–2008), there is no information on whether the C-section delivery was medically indicated or not. Thus, further studies are needed to examine the factors for medically indicated C-section delivery and medically unindicated C-section delivery separately.
