Research Article| Volume 8, ISSUE 2, P335-342, June 2020

Ok

# Prevalence and determinants of voluntary caesarean deliveries and socioeconomic inequalities in India: Evidence from National Family Health Survey (2015-16)

Published:September 03, 2019

## Abstract

### Introduction

With a substantial increase in Institutional births in India, the prevalence of C-section section deliveries witnessed a sharp rise, with a highly skewed prevalence among births in private health facilities. The study aims to investigate the dynamics of voluntary C-section across different socio-cultural strata in India, along its major drivers.

### Methods

The study used data on 249,949 live births in the five years preceding 2015-16 NFHS-4 covering 699,686 women from 601,000 households across 640 districts in the country. Bivariate and binary logistic regression analysis have been used to analyses the data. The economic inequalities in voluntary C-section have been analyzed using the poor-rich ratio and the concentration index (CI)

### Results

Seventeen percent of live births in five years preceding NFHS-4 were delivered by C-section, a sharp rise from 9% in 2005-06. C-section deliveries are common among first births (24%), in private sector health facilities (41% of deliveries), higher educated mothers and those residing in urban areas (28%). The likelihood of C-section deliveries is significantly higher among mother from high-income families. Values of the poor-rich ratio (0.092) and concentration index (0.031) has significantly revealed that voluntary C-section is more concentrated among the affluent class of households in India.

### Conclusions

The study concludes that older women, higher educated mothers, residing in urban areas and, belonging to high socio-economic status are the ones who opt for voluntary C-section deliveries and seek private instructional delivery. The government of India should strengthen the regulatory protocol for private health facilities.

## 1. Introduction

Over the years there has been growing efforts to improve maternal health situation through increasing access and utilization of reproductive health services in most developing countries including India. These efforts were significantly pronounced initially as part of achieving Millennium Development Goals (MDGs) and now to achieve Sustainable Development Goals (SDGs). Those efforts have been very conducive in increasing institutional deliveries and deliveries assisted by trained personnel. However, with the increasing prevalence of institutional deliveries, there has been a growing concern over the rising cesarean section (CS) deliveries. In fact, CS delivery is the surgical intervention to overcome any serious delivery complications, which has resulted in saving lives of a large number of pregnant women in developing countries and has been instrumental in reducing maternal mortality ratio.
• Mylonas I.
• Friese K.
Indications for and risks of elective cesarean section.
However, the C-section deliveries conducted due to reasons beyond a medical emergency may lead to different type of complications during post-natal period and may lead to various kinds of gynecological morbidities.
• Gayathry D.
• Guthi V.R.
• Bele S.
A study of maternal morbidity associated with caesarean delivery in tertiary care hospital.
According to WHO guidelines (1985) on the proportion of cesarean section delivery in any country, the international healthcare community has considered 5–15% of total deliveries as cesarean section deliveries as normal. It has also been specified in the WHO guidelines that there is no additional benefit accrues to the mothers when the C-section rates exceed the estimated level.
• World Health Organization
WHO Statement of caesarean section rates.
However, there has been an upward trend in global cesarean rates over the past few decades.
• Betrán A.P.
• Ye J.
• Moller A.B.
• Zhang J.
• Gülmezoglu A.M.
• Torloni M.R.
The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014.
The prevalence of C-section deliveries are far from the normal range of 5–15% and have been emerging as a matter of concern in a number of developed as well as the developing countries. The observed increase in C-section deliveries may not be fully accounted for by changes in the clinical factors, which indicate the need for a C-section but some socio-economic and structural factors have been working as a catalyst behind the increasing prevalence of C-section deliveries.
• World Health Organization
WHO Statement of caesarean section rates.
It is worth mentioning that the decision to perform a C-section is mostly unplanned, and it is done for emergency reasons, when the health of the baby or mother, or both of them is in danger. This may occur because of a problem during pregnancy or after a woman has gone into labor, such as if labor is happening too slowly or if the baby is not getting enough oxygen. While, some C-sections are considered elective/voluntary, meaning the mother requests them for non-medical reasons before she goes into labor. A woman may choose to have a C-section if she previously had a complication by vaginal delivery or if she wants to plan when she delivers.
• Nierenberg C.
Vaginal Births vs. C section. Live science contributor.
Such a pattern is emerging due to people's perception that cesarean delivery is much safer now than in the past and to the recognition that most studies looking at the risks of cesarean section may have been biased, as women with medical or obstetric problems were more likely to have been selected for an elective cesarean section. Thus, the occurrence of poor maternal or neonatal outcomes may have been due to the problem necessitating the cesarean delivery rather than to the procedure itself.
• Hannah M.E.
Planned elective cesarean section: a reasonable choice for some women?.
The C-section deliveries reportedly prevent approximately 187,000 maternal and 2.9 million neonatal deaths annually worldwide. However, unnecessary CS presents risks for both women and neonates.
• Campbell O.M.
• Graham W.J.
Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works.
• Lumbiganon P.
• Laopaiboon M.
• Gülmezoglu A.M.
• et al.
Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08.
• Wilmink F.A.
• Hukkelhoven C.W.
• Lunshof S.
• Mol B.W.
• van der Post J.A.
• Papatsonis D.N.
Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry.
• Maine D.
Monitoring Emergency Obstetric Care: A Handbook.
The chances of having a normal delivery post caesarean drop substantially. In the subsequent caesarean births, the effect of surgical deliveries on mother's body can be easily seen.
• Mishra U.S.
• Ramanathan M.
Delivery-related complications and determinants of caesarean section rates in India.
Caesarean section deliveries are associated with poor maternal and infant health outcomes, such as higher incidences of maternal infection and uterine hemorrhage, infant respiratory distress and hypoglycemia; all of which may adversely impact breastfeeding success. Researchers have shown that women who deliver by caesarean section are less likely to breastfeed, or delay breastfeeding initiation. Delays in breastfeeding initiation accompanying caesarean section deliveries are associated with maternal/infant separation, reduced suckling ability, decreased infant receptivity, and insufficient milk supply, which are predictive of shortened breastfeeding duration.
• Hobbs A.J.
• Mannion C.A.
• McDonald S.W.
• Brockway M.
• Tough S.C.
The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum.
It has been found that mothers who gave birth via caesarean section were more likely to discontinue breastfeeding compared to those who gave birth vaginally.
• Pérez-Ríos N.
• Ramos-Valencia G.
• Ortiz A.P.
Cesarean delivery as a barrier for breastfeeding initiation: the Puerto Rican experience.
An early study by Rowe-Murray and Fisher (2002), found that babies born via caesarean section were less likely to be have skin-to-skin contact immediately after birth and were more likely not to have attempted breastfeeding within the first 24 h of delivery.
• Rowe‐Murray H.J.
• Fisher J.R.
Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding.
Over the last 21 years, at all India level, the caesarean rate has increased from 2.9% of the childbirth in 1992-93 to 7.1 in 1998-99 and further rise to 8.5% in 2005-06. The latest round of Indian Demographic Health Survey (NFHS-4, 2015-16) reported that caesarean deliveries (17.2%) has rapidly increased during the last 10 years. It is a fact that all the procedure and protocols for C-section delivery, irrespective of voluntary or emergency, is possible only if there is an institutional delivery. That is why, with increasing prevalence of institutional deliveries, there is a higher likelihood of voluntary cesarean, especially with women's development, increasing participation in decisions about their own health and their increased participation in labour-force. It is hypothesized that with the existing demographic transition in the country, where the increasingly larger proportion of women prefer to have fewer number of children, significantly larger number of them are expected to prefer to avoid labor pain and adopt selective date and time of delivery of the baby. This phenomenon is known as voluntary cesarean section. This paper attempts to investigate the dynamics of voluntary cesarean section across different socio-cultural strata in India, along its major drivers. The specific objectives of this study are to analyze the socio-economic factors affecting the preference of C-section and voluntary C-section deliveries among all the births in the last five years preceding the survey in India and to understand the economic inequalities across the Indian states.

## 2. Materials and methods

### 2.1 Data

The study used the two rounds of the National Family Health Survey (NFHS) conducted during 2005–2006 (NFHS-3) and 2015–2016 (NFHS-4). NFHS is a nationally representative, large-scale, a repeated cross-sectional survey in representative samples of households throughout India. Both the surveys have been conducted under the stewardship of the Ministry of Health and Family Welfare: Government of India. The International Institute for Population Sciences, Mumbai has been designated as the nodal agency for different rounds of NFHS and ORC Macro, Calverton, Maryland, USA, currently known as the ICF International have been providing the technical support in different rounds of NFHS.
NFHS-4 (2015-16) collected information from a nationally representative sample of 601,509 households, 699,686 women age 15–49 (NFHS-4, IIPS Mumbai). Findings of this study are based on a total of 51,511 deliveries taken place for five years preceding the 2005-06 NFHS-3 and 2,59,627 deliveries taken place during five years preceding the 2015-16 NFHS-4. Details about the NFHS-4 designs, tools and protocols are presented in the national report of NFHS-4 (IIPS & ICF, 2017) and all relevant information are available in public domain on http://rchiips.org/NFHS/districtfactsheet_NFHS-4.shtml.

### 2.2 Response variable

The response variable for the study is voluntary C-section deliveries among currently married women age 15–49 years. The specific questions are asked about Voluntary Caesarian deliveries (C-section) to currently married women ages 15–49 years about Such questions are “Was Delivered by Caesarean section, that is did they cut your belly open to take the bay out?” If Yes “When was the Decision made for you to have a C section? Was it before the onset of labour or after the onset of labour?” (Options given for the question are ‘Before onset of labour’, ‘After onset of labour’ and ‘Don't Know’)

### 2.3 Independent variable

A set of independent variables such as mother characteristics, child characteristics and household characteristics were used in the analysis. The independent variable used in the analysis are mother's age, education, place of residence, caste of mothers, religion, wealth quantile, age of mothers at first birth, birth order, number of antenatal care visit (ANC visit), size of child at birth, and place of delivery.

### 2.4 Statistical analysis

The data analysis has been performed STATA version 13.0 software. Bivariate and multivariate binary logistic regression analyses have been used to understand the prevalence of delivery by C-section and to determine the factor associated with it.
loge [P(Yi = 1| Xi) / 1- P(Yi = 1| Xi)] = loge[π|1-π] = α+β1Xi1, βkXik

Where Yi is the binary response variable and Xi is the set of explanatory variables like socioeconomic characteristics. The dependent variable for the study is the prevalence of C-section deliveries.
The poor-rich ratio (poorest quintile/richest quintile) and the concentration index (CI) have been used to understand the economic inequalities in voluntary C-section among women. The poor-rich ratio is defined as the ratio of the percentages of women who had undergone for C-section among the poorest to the percentage of women who had undergone for C-section among those in the richest wealth quintile. If the poor-rich ratio is greater than 1, it indicates that the women from poorest quintile are more likely to undergo through C-section deliveries than among those from the richest wealth quintiles. On the contrary if the poor-rich ratio has a value of less than 1, women from the poorest quintile are less likely than the women from richest quintile to have C-section deliveries.
The concentration indices were used to measure the overall inequalities in C-section among the women from different wealth quintiles. The concentration index is defined as twice the area between the concentration curve and the line of equality (the 45-degree line) and the index is bounded between −1 and 1. So, in the case, if there is no economic inequality, the concentration index is zero. The convention is that the index takes a negative value when the curve lies above the line of equality, indicating the disproportionate concentration of the health variable among the poor, and a positive value when it lies below the line of equality. If the health variable is “bad” such as ill health, a negative value of the concentration index means ill health is higher among the poor.
Formally, the concentration index is defined as
$Equation 1.$
(1)

Where, μ is the mean of the health sector variable. H is the health outcome of the individual, and r is the rank of the individual in the wealth distribution. The sign of the concentration index indicates the direction of any relationship between the health variable and position in the living standards distribution, and its magnitude reflects both the strength of the relationship and the degree of variability in the health variable.
• O'Donnell O.
• Van Doorslaer E.
• Wagstaff A.
• Lindelow M.
Analyzing Health Equity Using Household Survey Data.
The study has estimated the concentration index for the last rounds of NFHS, i.e. NFHS-4.

## 3. Results

Table 1 shows the prevalence of C-section deliveries and associated factors among currently married women age 15–49 years according to some selected background characteristics in India in NFHS-3 (2005-06) and NFHS-4 (2015-16). On a national scale, the prevalence of C-section deliveries has substabtially increased during the last decade from 2005-06 (8.5%) to 2015-16 (17%). Although, the prevalence of C-section deliveries has increased in almost each group of socio-economic and demographic characteristics included in the analysis. The increase in C- section deliveries were more pronounced among women age 15–24 years (from 7% to 17%), having the first birth order (15%–24%), lower age (less than 20 years) at first birth (from 4% to 11%), residing in urban areas (from 17% to 28%) and deliveries conducted in private health facilities (28%–41%).
Table 1Prevalence and Determinants of delivery by C-section in India, (2005-06 to 2015-16).
Background CharacteristicsPrevalence of delivery by C-section
Age (Years)
15-24®7.416.7
25–349.71.35***[1.22–1.48]17.81.28***[1.24–1.33]
35 and above6.82.20***[1.86–2.61]15.31.83***[1.71–1.95]
Years of schooling
No education®2.56.0
Primary6.51.06 [0.90–1.24]11.51.19*** [1.12–1.27]
Secondary14.71.11[0.97–1.26]21.41.41***[1.34–1.48]
Higher35.31.35***[1.15–1.58]38.71.51***[1.43–1.61]
Residence
Rural®5.612.9
Urban16.81.04 [0.95–1.13]28.31.18***[1.14–1.23]
Caste
SC ®6.014.5
ST2.80.71***[0.59–0.86]8.30.75***[0.71–0.79]
OBC7.80.95 [0.85–1.07]17.30.88***[0.84–0.91]
Others13.51.01 [0.90–1.14]23.40.99 [0.95–1.04]
Religion
Hindu ®8.617.3
Muslims6.40.99 [0.88–1.11]15.11.08*** [1.03–1.13]
Christian16.50.99 [0.83–1.18]24.90.99 [0.93–1.07]
Others12.41.01 [0.85–1.20]20.51.02 [0.95–1.09]
Wealth Index
Poorest®1.54.4
Poorer3.51.26*[0.97–1.64]9.71.25***[1.17–1.33]
Middle7.01.17 [0.91–1.49]19.11.66***[1.56–1.76]
Richer12.41.36**[1.07–1.74]26.91.79***[1.68–1.90]
Richest25.81.42***[1.10–1.82]35.91.63***[1.53–1.75]
Age of mother at birth
less than 20®4.311.4
20–3414.51.19***[1.08–1.31]20.41.17***[1.13–1.22]
35–4945.91.47*[0.95–2.26]47.72.35***[1.99–2.77]
Birth order
14.823.8
2–38.20.67***[0.62–0.73]15.90.69***[0.68–0.72]
4–51.90.30***[0.25–0.37]4.10.31***[0.29–0.34]
6 and above1.10.30***[0.21–0.42]2.20.26***[0.23–0.31]
Antenatal care visit
None®0.86.4
1–34.41.35**[1.04–1.75]12.71.17***[1.10–1.25]
4+21.01.94***[1.50–2.50]27.71.79***[1.69–1.91]
Don't know13.21.70**[1.10–2.61]22.21.75***[1.52–2.03]
Size of child at birth
Very small®7.514.9
Smaller than average7.80.78***[0.64–0.94]15.410.92**[0.83–1.01]
Average8.00.76***[0.64–0.89]16.40.85***[0.78–0.93]
Large than average9.90.86*[0.72–1.02]21.01.05***[0.96–1.15]
Very Large12.71.13 [0.90–1.42]24.41.19***[1.07–1.32]
Place of delivery
Public sector health facility®15.211.9
NGO or trust hospital/clinic24.51.32**[0.98–1.78]35.83.07***[2.65–3.55]
Private sector health facility27.81.63***[1.50–1.77]41.03.84***[3.73–3.97]
Total8.517.2
® reference; *P < 0.10, **p < 0.05, ***p < 0.01.
It was observed that as wealth quantile increases of the households, C section deliveries also increases in both the successive rounds of NFHS in India. A significantly larger proportions of women having higher secondary education and above (39%), residing in urban areas (28%), belonging to non-SC/ST and non-OBC caste group (23%) and having Christian religion (25%) were more likely to have C-section deliveries in the recent round of NFHS (2015-16). There is a significant positive association between number of ANC visits and prevalence of C-section deliveries in India.
It is evident from NFHS-4 results that C-section deliveries were significantly more likely to happen among women who had the delivery after attaining age 35 (AOR = 2.4, p < 0.01) as against those who had the delivery by age 20 years. The occurrence of deliveries by C-section was negatively associated related to the order of birth. Results depict that as birth order increases, the prevalence of C-section deliveries decreased in both the surveys although, the proportion has increased from 2005-06 to 2015-16. Similarly, as the size of the child increases, C-section deliveries also increases, which suggests that larger size of the child at birth significantly have higher odds (AOR = 1.17, p < 0.01) of C-section deliveries during the last decade. Findings of the study revealed that the prevalence of C-section deliveries was more among women who had four or more antenatal care visits in both the survey, however, the proportion has increased from 21% in 2005-06 to 28% in 2015-16.
There is a remarkable difference in the occurrence of C-section deliveries according to the place of delivery in a public or a private health facility. C-section deliveries in the public health sectors decreased from 15% to 12% during the last one decade in India, whereas in the private health sectors, it has increased to 41% in 2015-16 from 28% in 2005-06. The prevalence in C-section delivery was much higher even in NGO or trust hospitals (36%) over the public health sectors in the last decade. These findings are affirmed even after analyzing the adjusted effects of place of delivery on the prevalence of C-sections using logistic regression odds ratios. It is evident from the findings in Table 1 that NGO or trust hospital/clinic are over three times more likely (AOR = 3.1 p < 0.001) and private hospitals/clinics were four times more likely (AOR = 3.8, p < 0.001) than the public hospitals to conduct C-section deliveries in India.
During the last one decade, there has been sustantial increase in the prevalence of C-section deliveries in different states of India, which differs in the socio-cultural environment of its people. Fig. 1 shows the changes in prevalence of C-section deliveries in India from the periods 2005-06 to 2015-16. The prevalence of C-section was relatively higher in states like Andhra Pradesh (48%), Kerala (36%), Tamil Nadu (34%), Jammu & Kashmir (33%), Goa (31%), Punjab (25%), West Bengal (24%) and Karnataka (24%) in 2015-16. While, C-section deliveries are lowest in the states Nagaland (5.8%), Bihar (6.2%), Meghalaya (7.6%), however, a rapid increase in C-section deliveries has occurred in these states from 2005-06 to 2015-16.
Results of the prevalence and factors associated with voluntary C-section (before the onset of labor pain) and emergency C-section (after the onset of labor pain) according to some selected socio-economic and demographic characteristics are presented in Table 2. Results portray that about 9.4% women reported that their delivery was section -section deliveries, which was decided before the onset of labor pain. On the other hand, 7.6% of deliveries were conducted by C-section, where the decision for C-section was taken after onset of the labor pain i.e emergency C-section, which has been an essential component of protecting women from maternal death. It was observed that women, who were having 12 or more years of schooling (22%), coming from the wealthiest households (21%), living in urban areas (16%), Christian religion (14%) and non-SC/ST caste were more likely to undergo voluntary C-section than other women. These findings remain unaltered even if analyzed by adjusting for other predictors included in the logistic regression model. Findings from the logistic regression odds ratio shows that mother's age group (25–34 years) were significantly more likely (AOR-1.06, p < 0.10) to have voluntary C-section deliveries than their other counterparts. Similarly, women completed their education higher secondary and above were 12% more likely to have voluntary C section. Furthermore, it is observed that mothers from the other caste groups were reporting a higher prevalence of voluntary C-section deliveries. Results from binary logistic regression analysis also shows that women from the OBC caste-group were significantly less likely (OR = 0.92. p < 0.05) to have voluntary C-section than their counterparts. According to religion, Christian women reported a higher prevalence of voluntary C-section than their counterparts. Logistic regression results also show that Christian women were 1.32 times (p < 0.01) more likely to have delivery by C-section at before onset of labor pain. The finding of the study shows that as wealth index increases, the prevalence of voluntary C-section has also increased according to their respective socioeconomic status in India.
Table 2Percent distribution and logistic regression odds ratio of voluntary C-section by some selected background characteristics, India (2015-16).
Background CharacteristicsBefore onset of labor pains (Voluntary C-section)After onset of labor pains (Emergency C-section)
Age (Years)
15-24®8.87.8
25–3410.01.06* [0.99–1.12]7.70.95 [0.89–1.01]
35 and above8.91.10 [0.98–1.22]6.30.91 [0.82–1.02]
Years of schooling
No education®2.93.0
Primary6.21.08 [0.97–1.21]5.20.92 [0.83–1.03]
Secondary11.91.07 [0.98–1.17]9.30.93 [0.85–1.02]
Higher21.91.12**[1.01–1.24]16.60.89**[0.80–1.99]
Residence
Rural®6.95.9
Urban16.01.03[0.97–1.08]12.10.98 [0.92–1.03]
Caste
SC ®8.16.3
ST4.30.92 [0.83–1.02]3.91.04 [0.94–1.15]
OBC9.30.92 **[0.85–0.98]7.81.10***[1.03–1.18]
Others13.20.99 [0.92–1.07]10.11.01 [0.93–1.09]
Religion
Hindu ®9.67.6
Muslims8.21.02 [0.95–1.10]6.80.97 [0.90–1.05]
Christian14.61.32***[1.17–1.49]10.00.74***[0.65–0.83]
Others10.30.93 [0.84–1.04]10.21.03 [0.92–1.15]
Wealth Index
Poorest®1.92.5
Poorer4.91.29***[1.15–1.45]4.80.77***[0.69–0.87]
Middle10.61.48***[1.32–1.65]8.30.68***[0.61–0.76]
Richer15.21.59***[1.41–1.77]11.60.63***[0.56–0.70]
Richest20.71.67***[1.48–1.89]15.00.60***[0.53–0.68]
Age of mother at birth
less than 20®6.25.2
20–3411.21.02 [0.95–1.09]9.00.99 [0.92–1.05]
35–4933.11.89***[1.49–2.39]14.40.53***[0.41–0.67]
Birth order
12.111.5
2–39.61.49***[1.41–1.57][6.20.67***[0.64–0.71]
4–52.11.33***[1.16–1.53]1.90.73***[0.64–0.85]
6 and above0.91.09 [0.82–1.45]1.30.87 [0.65–1.16]
Antenatal care visit
None®3.52.7
1–36.20.80***[0.72–0.89]5.81.32***[1.18–1.48]
4+15.60.98 [0.88–1.09]12.01.10*[0.99–1.22]
Don't know13.71.19 [0.93–1.52]7.80.74**[0.58–0.95]
Size of child at birth
Very small®7.96.8
Smaller than average8.41.06 [0.90–1.25]7.00.95 [0.80–1.22]
Average9.01.07 [0.93–1.24]7.40.94 [0.81–1.09]
Large than average11.51.12 [0.96–1.31]9.40.90 [0.77–1.06]
Very Large14.71.28***[1.08–1.52]9.60.78***[0.66–0.93]
Place of delivery
Public sector health facility®6.55.3
NGO or trust hospital/clinic20.60.98 [0.78–1.23]15.01.06 [0.84–1.33]
Private sector health facility22.60.91***[0.87–0.96]18.21.11***[1.05–1.17]
Total9.47.6
® reference; *P < 0.10, **p < 0.05, ***p < 0.01.
Age of mothers at first birth is playing an important role to prefer the delivery by C-section in India. The result portrays that a higher proportion of mother at maternal age group 35–49 years (33%) were significantly 1.9 times (p < 0.001) more likely to scheduling birth by C-section by choice. It was found that a significant proportion of women changed their preferred mode of delivery after their first childbirth, as birth order increases, the prevalence of voluntary C-section delivery decreases. The result of the logistic regression analysis does not deviate from this fact that with the increase in the birth order, the chances of cesarean deliveries reduces significantly.
In case of emergency C-section, about 7.6% women reported delivery by C-section after onset of labor pain in India. It was observed that those women are residing in rural areas, belonging to OBC caste and poorest quantile were significantly more likely to go for emergency C-section. Table 2 also portrayed that the women who had gone for 4 + ANC services were more to plan their caesarian delivery by choice (16%) and also for any medical reason (12%). The results of the logistic regression analysis revealed that women who had gone for full ANC were significantly 1.10 (p < 0.001) times more likely to have an emergency cesarean section. Size of the child at birth is a significant medical risk factor behind C-section delivery. Findings reveal that women with the larger size of the child at birth were 1.3 (p < 0.001) times more likely to go for voluntary C-section, although prevalence of C-section delivery is higher in both the situation either it is by choice or emergency. It is worth mentioning to note that the role of private health facilities is crucial in perform C section delivery in both the situations. It is observed that the C-section delivery is significantly higher in private sector in both conditions. The rate of voluntary C-section in the private health sector was higher than the emergency (18%) and there was a noticeable gap between the rates of public health sector (7%) and the private health sector (23%).
Socioeconomic inequalities concerning for voluntary c-section deliveries refer to the degree to which prevalence of delivery by voluntary C-section differ between more and less economically advantaged groups. In this study, economic inequality concerning voluntary C-section was measured using the poor-rich ratio (poorest/richest wealth quintile) and concentration index. The value of the poor-rich ratio (0.092) and concentration index (0.031), significantly revealed that voluntary C-section before the onset of labor pain is more concentrated among richest in India (Table 3). Socioeconomic inequalities concerning the voluntary C-section before the onset of labor pain varied considerably across the states and geographical regions in India. In all of the states except Kerala, the value of poor -rich ratio below one and positive value of concentration index indicating that voluntary C-section deliveries mostly performed among women who belongs to the affluent class of households in India. The result shows that Kerala is the only states where the poor-rich ratio is greater that one and concentration index is −0.005 suggests that voluntary C-section deliveries is more concentrated among poor socio-economic families. It was also observed that the value of poor-rich ratio is higher in emergency C-section deliveries (0.164) than the voluntary C-section (0.092). Further, a negative value of concentration index (−0.036) reveals that c-section deliveries after the onset of labor pain are disproportionately concentrated among poor to middle socio-economic families in India.
Table 3Poor-rich ratio and concentration index for voluntary C-section, India (2015-16).
StatesBefore onset of labor pain (Voluntary C-section)After onset of labor pain (Emergency C-section)
PR ratioConcentration indexPR ratioConcentration index
India0.0920.0310.164−0.036
North
Jammu and Kashmir0.159−0.0060.1600.026
Punjab0.6360.0390.000−0.047
Uttaranchal0.0610.0850.149−0.080
Haryana0.2460.0010.2860.002
Delhi0.0000.00030.0000.022
Rajasthan0.0910.0060.111−0.002
Central
Chhattisgarh0.0620.060.151−0.043
East
Bihar0.0840.0310.152−0.020
Jharkhand0.0580.0750.133−0.060
Orissa0.1290.0390.174−0.031
West Bengal0.0790.0540.189−0.065
West
Goa0.0000.0630.000−0.069
Gujarat0.1150.0370.223−0.040
Maharashtra0.1250.0060.170−0.008
South
Karnataka0.3400.0120.331−0.012
Kerala1.151−0.0051.2730.007
North east
Tripura0.0140.0740.096−0.105
Manipur0.0490.0760.165−0.124
Meghalaya0.0700.0030.0890.028
Mizoram0.0450.0340.134−0.106
Nagaland0.0140.0650.019−0.064
Sikkim0.2890.0210.000−0.057
Assam0.0330.0650.103−0.060
Note: PR= Poor-Rich ratio.

## 4. Discussion

Different analytical methods used in this study have been organized to answer the key questions relating to the nature and pattern in socio-economic inequalities in C-section deliveries in India along with its major drivers. The findings, which are based on total of 51,511 deliveries taken place during five years preceding the 2005-06 NFHS-3 among a total of 124,000 women age 15–49 included in the nationally representative sample and 2,59,627 deliveries taken place during five years preceding the 2015-16 NFHS-4 from a nationally representative sample of 699,686 women age 15–49 portray a drastic increase in the prevalence of C-section deliveries in India. However, this pattern does not stand alone for India but globally the increasing rate of cesarean deliveries has become a serious concern for public health professionals, health programme managers and policy makers. Numerous medical and non-medical factors including maternal characteristics, socio-demographics, delivery complications, are found to be responsible for this upsurge. Usually, the rate of cesarean section defines the fraction of women who adopted the cesarean section procedure for delivery among total childbirths in a specific period in a particular geographic area. And the prevailing models and estimates of the cesarean rate in a specific geographic area are appropriate under the assumption that in the selected area almost all deliveries took place in medical institutions.
• Verma V.
• Nath D.C.
Prevalence of the caesarean section in India.
Nationally, the prevalence of C-section deliveries has considerably increased from 2005-06 (8.5%) to 2015-16 (17%). Although the prevalence has increased in each socioeconomic and cultural characteristic, C-section deliveries are found to be more among women age 25–34 years, higher educated, residing in urban areas, and belonging to general caste and Christian religion in 2015-16. The rate of C-section is higher in urban areas than rural areas. This may be because of better access to medical institutions and their standards of living make the urban mothers more likely to have a C-section. Higher rates in urban areas may be a reflection of the combination of factors, advanced health facilities to take care of risk factors, higher levels of women's choice, and wide prevalence of the private sector in healthcare, with the focus on profit.
• Ghosh S.
Increasing Trend in Caesarean Section Delivery in India: Role of Medicalisation of Maternal Health.
,
• Choudhury C.R.
Caesarean Births: The Indian Scenario.
Our findings regarding the higher prevalence of Caesarean section among urban women are similar to the findings of a number of studies in other developing countries. A study conducted using demographic and health survey in Pakistan has reported a rising trend of C-section deliveries in urban areas.
• Nazir S.
Determinants of Cesarean Deliveries in Pakistan.
A positive association has emerged between the economic status of the household and deliveries by C-section. This finding suggests that chances of cesarean deliveries are more among mothers from high-income families. Many researchers have proved that the mothers belonging to higher socio-economic status had higher chances of Caesarean Section.
• Kaur J.
• Singh S.
• Kaur K.
Current trend of caesarean sections and vaginal births.
,
• Patel R.V.
• Gosalia E.V.
• Deliwala K.J.
• Vasa P.B.
• Pandya V.M.
Indications and trends of caesarean birth delivery in the current practice scenario.
The finding of the study also confirms the results of the other studies conducted in Asia and Africa.
• Cavallaro F.L.
• Cresswell J.A.
• França G.V.
• Victora C.G.
• Barros A.J.
• Ronsmans C.
Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa.
This variation could be explained by the reason that people with higher-socioeconomic status usually choose private medical facilities where C-section deliveries are more common whereas, poorer household fails to pay for the surgery and the extra cost associated with C-section.
• Montagu D.
• Yamey G.
• Visconti A.
• Harding A.
• Yoong J.
Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data.
,
• Khan M.N.
• Islam M.M.
• Shariff A.A.
• Alam M.M.
• Rahman M.M.
Socio-demographic predictors and average annual rates of caesarean section in Bangladesh between 2004 and 2014.
Further, mother's age at birth is playing a considerable role in make a selection for C-section over the last decade in India. A recent study conducted in Bangladesh and other developing countries stated that women's advanced maternal age are more likely to suffer from obstetric and maternal complications than women in middle maternal age, and this may subsequently contribute to the increasing rate of C section deliveries.
• Khan M.N.
• Islam M.M.
• Shariff A.A.
• Alam M.M.
• Rahman M.M.
Socio-demographic predictors and average annual rates of caesarean section in Bangladesh between 2004 and 2014.
• Bayrampour H.
• Heaman M.
Advanced maternal age and the risk of cesarean birth: a systematic review.
• Collin S.M.
• Anwar I.
• Ronsmans C.
A decade of inequality in maternity care: antenatal care, professional attendance at delivery, and caesarean section in Bangladesh (1991–2004).
• Yoshioka-Maeda K.
• Ota E.
• Ganchimeg T.
• Kuroda M.
• Mori R.
Caesarean section by maternal age groupamong singleton deliveries and primiparous Japanese women: a secondary analysis of the WHO Global Survey on Maternal and Perinatal Health.
There was a negative relationship found between birth order and C-section deliveries. It may be due to the fact that the increase in the birth order implies the women are getting more experienced regarding delivery procedures and the chances of having serious complications get reduced.
• Choudhury C.R.
Caesarean Births: The Indian Scenario.
The result of the study also supports the similar circumstance that with the increase in the birth order, the chances of C-section deliveries reduces significantly.
Findings of the study revealed that the prevalence of C-section deliveries was more among women who had four or more antenatal care visits in both the survey and the percentage has increased from 2005-06 to 2015-16. A study conducted in South Asian countries has also been reported a similar finding; there is a substantial increase in the occurrence of cesarean deliveries in the private health sector from 28% in 2005-06 to 41% in 2015-16. Other studies have confirmed that there is an evident disparity between the two types of health-care services, with greater prevalence of cesarean deliveries in the private sector.
• Ghosh S.
Increasing Trend in Caesarean Section Delivery in India: Role of Medicalisation of Maternal Health.
,
• Neuman M.
• Alcock G.
• et al.
Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.
,
• Vieira G.O.
• Fernandes L.G.
• de Oliveira N.F.
• Silva L.R.
• de Oliveira Vieira T.
Factors associated with cesarean delivery in public and private hospitals in a city of northeastern Brazil: a cross-sectional study.
,
• Maktha V.K.
• Ghatam A.
• Ravulakol A.
Prevalence and factors associated with caesarean section: a community based cross sectional study in rural parts of Rangareddy district, Telangana, India.
The decision to perform a cesarean section is based primarily on the question of what is best for or may save the lives of the mother and child. The indications for the cesarean section can, therefore, be divided into absolute and relative indications. Elective cesarean section performed solely at the wish of the mother, without any medical indication, is considered a separate indication.
• Mylonas I.
• Friese K.
Indications for and risks of elective cesarean section.
It is evident from the findings of voluntary C-section that nationally, 9% of the women reported that they decided to delivery by voluntary C-section. The finding of the study conclude that mother's education is an essential predictor behind both the condition, either it is a choice of scheduling a C-section without any medical reason, or it is choice of emergency C-section. These findings are accredited to the significant increment in women's education in the recent years, as higher educated women have more knowledge about benefits of the use of maternal health care services.
• Kamal S.M.
Factors affecting utilization of skilled maternity care services among married adolescents in Bangladesh.
Education is likely to enhance women's autonomy such as women develop greater confidence and compatibility to make decisions about their health.
• Kamal S.M.
Factors affecting utilization of skilled maternity care services among married adolescents in Bangladesh.
,
• Caldwell J.C.
Maternal education as a factor in child mortality.
Further, the findings of the study revealed that the prevalence of voluntary C-section is higher in urban areas. It may be the lifestyle factors of women residing in urban areas that are playing an important role. Lack of activity, late conception, and babies conceived through assisted reproductive techniques resulting in twins or triplets are also contributing to the rise in the rate of Caesarean sections in the urban population.
• Kamal S.M.
Preference for institutional delivery and caesarean sections in Bangladesh.
It may be the fact that C-section among women residing in urban areas has the easy accessibility of government and non-government medical health facilities.
• Kamal S.M.
Preference for institutional delivery and caesarean sections in Bangladesh.
The findings of the study observed that affluent class of women were more likely to have voluntary C-section deliveries than their other counterparts. It indicates that the affordability of the C-section is an important predictor. Many Indian doctors have also said that most of the women belong to the affluent class who are opting for the surgery because of late pregnancies and lifestyle conditions such as diabetes or high blood pressure.
• Hindustan Times
Why women are opting for C-sections.
The increase in maternal age appears to have a substantial role in increasing the cesarean rates. It may be due to fact that pregnancy complications are higher at older ages at the time of delivery. Similarly, the finding of the study also consistent with the results of several studies which reveal that C-section delivery is more likely to occur among older mothers compared to younger mothers below 20 years.
• Bayrampour H.
• Heaman M.
Advanced maternal age and the risk of cesarean birth: a systematic review.
,
• Essex H.N.
• Green J.
• Baston H.
• Pickett K.E.
Which women are at an increased risk of a caesarean section or an instrumental vaginal birth in the UK: an exploration within the M illennium Cohort Study.
,
• Bragg F.
• Cromwell D.A.
• Edozien L.C.
• et al.
Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study.
Antenatal care (ANC) and delivery care services are the key components of safe motherhood. ANC services help pregnant woman and her family to interact with the formal health care system. This study concludes that women who had gone for full ANC are significantly more likely to have an emergency cesarean section. This may not because of the ANC that cesarean is more, but it may be because those having more number of ANC visits may be more likely to have delivery related complications and hence substantially larger proportion of them might have gone for voluntary or emergency C section deliveries in India.
• Choudhury C.R.
Caesarean Births: The Indian Scenario.
It is evident from the findings of this study that the rate of voluntary C-section was higher in the private health sector than the public health sector. Several studies conducted in South Asian countries have raised concerns about high caesarean rates in private health facilities, and a recent analysis of demographic health survey revealed that the recent increase in C-section rates in South-Asian countries could be driven by higher rates of institutional deliveries in private health facilities.
• Cavallaro F.L.
• Cresswell J.A.
• França G.V.
• Victora C.G.
• Barros A.J.
• Ronsmans C.
Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa.
,
• Neuman M.
• Alcock G.
• et al.
Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.
,
• Ajeet S.
• Nandkishore K.
The boom in unnecessary caesarean surgeries is jeopardizing women's health.
,
• Koblinsky M.
• Anwar I.
• Mridha M.K.
• Chowdhury M.E.
• Botlero R.
Reducing maternal mortality and improving maternal health: Bangladesh and MDG 5.
Several studies also indicated that increases in C-section deliveries are shaped by supply and demand pressure which often have financial incentives to intervene surgically, and affluent class of women are also more likely to opt for C-section.
• Neuman M.
• Alcock G.
• et al.
Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.
,
• Leone T.
• Matthews Z.
Community factors affecting rising caesarean section rates in developing countries: an analysis of six countries.
,
• Mazzoni A.
• Althabe F.
• Liu N.H.
• et al.
Women's preference for caesarean section: a systematic review and meta‐analysis of observational studies.
The value of the poor-rich ratio and concentration index concludeed that voluntary C-section before the onset of labor pain is more concentrated among the richest quintile of households in India. Socioeconomic inequalities with respect to voluntary c-section before the onset of labor pain varied considerably across the states and geographical regions in India. The result shows that Kerala is the only states where the value of concentration index suggests that C-section deliveries before the onset of labor pain are more the concentrated among poor socio-economic families.

## 5. Conclusions

The finding concluded that C-section deliveries is still higher than the WHO recommendations of 5–15% threshold in C-section prevalence in India. Older women, higher educated mothers, residing in urban areas and, belonging to high socio-economic status are the ones who opt for voluntary C-section deliveries and seek instructional delivery. Women from higher socio-economic status and, wealth quintile have autonomy and can take the decision for their health care. Rising institutional deliveries may be the reason for increased cesarean deliveries in India during the last decade, as we see amplifying increment in institutional deliveries increased from 41% in 2005-06 to 79% in 2015-16. Evidence suggests that risk factors like mother's high age at birth, the size of the child at birth, women having full ANC influence the decision of women to opt for C-section. Place of delivery has come up to be the strongest predictor, influencing the cesarean section deliveries. As it can be drawn from the findings that women are voluntarily, choosing C-section deliveries are from the sample in private health facilities than in public health facilities. The analysis of socioeconomic inequalities reveals that C-section deliveries are more concentrated among the affluent class of women in all the Indian states except Kerala. Although the Union Health Ministry of India has asked states to curb “needless” Caesarean section surgeries, after a health survey pointed a sharp rise in such operations in the private sector, there is an urgent need to strengthen the regulatory protocol for private health facilities in the country by government of India. One of the regulatory protocols for all private hospitals should be displaying the name of doctors along with number of C-section deliveries conducted by them every month on their web sites as well as notice board.

## Conflicts of interest

The authors of this paper have no financial or other conflict of interest to declare. The authors of this papers are thankful to the DHS USAID for providing the data. The paper did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

## Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Data for this study is available in public domain, so there is no need of ethical approval for this study.

## Acknowledgement

The authors of this study are thankful to DHS USAID for providing the data for this study.

## Acronyms

CS
Caesarean section
MDGs
Millennium development goals
SDGs
Sustainable Development Goals
WHO
World Health Organizations

## References

• Mylonas I.
• Friese K.
Indications for and risks of elective cesarean section.
Deutsches Ärzteblatt International. 2015 Jul; 112: 489
• Gayathry D.
• Guthi V.R.
• Bele S.
A study of maternal morbidity associated with caesarean delivery in tertiary care hospital.
International Journal Of Community Medicine And Public Health. 2017 Apr 24; 4: 1542-1547
• World Health Organization
WHO Statement of caesarean section rates.
(April. WHO/RHR/15.02)
• Betrán A.P.
• Ye J.
• Moller A.B.
• Zhang J.
• Gülmezoglu A.M.
• Torloni M.R.
The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014.
PLoS One. 2016 Feb 5; 11e0148343
• Nierenberg C.
Vaginal Births vs. C section. Live science contributor.
• Hannah M.E.
Planned elective cesarean section: a reasonable choice for some women?.
Cmaj. 2004 Mar 2; 170: 813-814
• Campbell O.M.
• Graham W.J.
Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works.
The lancet. 2006 Oct 7; 368: 1284-1299
• Lumbiganon P.
• Laopaiboon M.
• Gülmezoglu A.M.
• et al.
Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08.
The Lancet. 2010 Feb 6; 375: 490-499
• Wilmink F.A.
• Hukkelhoven C.W.
• Lunshof S.
• Mol B.W.
• van der Post J.A.
• Papatsonis D.N.
Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry.
Am J Obstet Gynecol. 2010 Mar 1; 202 (250-e1)
• Maine D.
Monitoring Emergency Obstetric Care: A Handbook.
World Health Organization, 2009
• Mishra U.S.
• Ramanathan M.
Delivery-related complications and determinants of caesarean section rates in India.
Health Policy Plan. 2002 Mar 1; 17: 90-98
• Hobbs A.J.
• Mannion C.A.
• McDonald S.W.
• Brockway M.
• Tough S.C.
The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum.
BMC Pregnancy Childbirth. 2016 Dec; 16: 90
• Pérez-Ríos N.
• Ramos-Valencia G.
• Ortiz A.P.
Cesarean delivery as a barrier for breastfeeding initiation: the Puerto Rican experience.
J Hum Lactation. 2008 Aug; 24: 293-302
• Rowe‐Murray H.J.
• Fisher J.R.
Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding.
Birth. 2002 Jun; 29: 124-131
1. National Family Health Survey 2015-16 Report. International Institute of population Sciences and ICF, 2017
• O'Donnell O.
• Van Doorslaer E.
• Wagstaff A.
• Lindelow M.
Analyzing Health Equity Using Household Survey Data.
The World Bank, Washington DC: USA2007
• Verma V.
• Nath D.C.
Prevalence of the caesarean section in India.
in: Presented in Population Association of America. 2018
• Ghosh S.
Increasing Trend in Caesarean Section Delivery in India: Role of Medicalisation of Maternal Health.
Institute for Social and Economic Change, Bangalore2010
• Choudhury C.R.
Caesarean Births: The Indian Scenario.
Population Association of America, 2008: 1-8
• Nazir S.
Determinants of Cesarean Deliveries in Pakistan.
Pakistan Institute of Development Economics, 2015 (April. PIDE Working Papers No. 122)
• Kaur J.
• Singh S.
• Kaur K.
Current trend of caesarean sections and vaginal births.
Adv Appl Sci Res. 2013; 4: 196-202
• Patel R.V.
• Gosalia E.V.
• Deliwala K.J.
• Vasa P.B.
• Pandya V.M.
Indications and trends of caesarean birth delivery in the current practice scenario.
Int J Reprod Contracept Obstet Gynecol. 2014; 3: 575-580
• Cavallaro F.L.
• Cresswell J.A.
• França G.V.
• Victora C.G.
• Barros A.J.
• Ronsmans C.
Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa.
Bull World Health Organ. 2013 Aug 9; 91 (914-22D)
• Montagu D.
• Yamey G.
• Visconti A.
• Harding A.
• Yoong J.
Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data.
PLoS One. 2011 Feb 28; 6e17155
• Khan M.N.
• Islam M.M.
• Shariff A.A.
• Alam M.M.
• Rahman M.M.
Socio-demographic predictors and average annual rates of caesarean section in Bangladesh between 2004 and 2014.
PLoS One. 2017 May 11; 12e0177579
• Bayrampour H.
• Heaman M.
Advanced maternal age and the risk of cesarean birth: a systematic review.
Birth. 2010 Sep; 37: 219-226
• Collin S.M.
• Anwar I.
• Ronsmans C.
A decade of inequality in maternity care: antenatal care, professional attendance at delivery, and caesarean section in Bangladesh (1991–2004).
Int J Equity Health. 2007 Dec; 6: 9
• Yoshioka-Maeda K.
• Ota E.
• Ganchimeg T.
• Kuroda M.
• Mori R.
Caesarean section by maternal age groupamong singleton deliveries and primiparous Japanese women: a secondary analysis of the WHO Global Survey on Maternal and Perinatal Health.
BMC Pregnancy Childbirth. 2016 Dec; 16: 39
• Neuman M.
• Alcock G.
• et al.
Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.
BMJ open. 2014 Dec 1; 4e005982
• Vieira G.O.
• Fernandes L.G.
• de Oliveira N.F.
• Silva L.R.
• de Oliveira Vieira T.
Factors associated with cesarean delivery in public and private hospitals in a city of northeastern Brazil: a cross-sectional study.
BMC Pregnancy Childbirth. 2015 Dec; 15: 132
• Maktha V.K.
• Ghatam A.
• Ravulakol A.
Prevalence and factors associated with caesarean section: a community based cross sectional study in rural parts of Rangareddy district, Telangana, India.
International Journal of Community Medicine And Public Health. 2017; 3: 2054-2057
• Kamal S.M.
Factors affecting utilization of skilled maternity care services among married adolescents in Bangladesh.
Asian Popul Stud. 2009 Jul 1; 5: 153-170
• Caldwell J.C.
Maternal education as a factor in child mortality.
InWorld health forum. 1981; 2: 75-78
• Kamal S.M.
Preference for institutional delivery and caesarean sections in Bangladesh.
J Health Popul Nutr. 2013 Mar; 31: 96
• Hindustan Times
Why women are opting for C-sections.
(Available at:)
• Essex H.N.
• Green J.
• Baston H.
• Pickett K.E.
Which women are at an increased risk of a caesarean section or an instrumental vaginal birth in the UK: an exploration within the M illennium Cohort Study.
BJOG An Int J Obstet Gynaecol. 2013 May; 120: 732-743
• Bragg F.
• Cromwell D.A.
• Edozien L.C.
• et al.
Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study.
Bmj. 2010 Oct 6; 341: c5065
• Ajeet S.
• Nandkishore K.
The boom in unnecessary caesarean surgeries is jeopardizing women's health.
Health Care Women Int. 2013 Jun 1; 34: 513-521
• Koblinsky M.
• Anwar I.
• Mridha M.K.
• Chowdhury M.E.
• Botlero R.
Reducing maternal mortality and improving maternal health: Bangladesh and MDG 5.
J Health Popul Nutr. 2008 Sep; 26: 280
• Leone T.