Assessment of Variation in Cesarean Delivery Rates Between Public and Private Health Facilities in India From 2005 to 2016

Key Points Question Are private vs public sector health care facilities associated with increases in cesarean delivery rates among pregnant women in India over time, and what is the avoidable burden of cesarean deliveries in private sector facilities? Findings In this cross-sectional study of 217 976 births at public and private sector institutions in India between 2005 and 2016, the likelihood of having a cesarean delivery in a private facility more than doubled over the period examined. A reduction in the percentage of cesarean deliveries in the private sector to the World Health Organization’s recommended threshold of 15% was associated with a potential cost savings of approximately $321 million. Meaning The study’s findings indicated that private sector facilities were associated with increases in the rate of cesarean deliveries; it is important that policy makers address the increasing number of avoidable cesarean deliveries in India.


Introduction
In the past several decades, a pattern of rapid increases in cesarean delivery rates has been observed worldwide, and this increase has varied across regions. 1 Although these rates have increased at a slow pace in countries within sub-Saharan Africa, 2 they are increasing at a substantial rate in many other countries. For instance, in the US, the cesarean delivery rate reached 30% in 2006, partly owing to the practice of preventive medicine and the threat of litigation. 3 In European countries, the cesarean delivery rates vary from 52.2% in Cyprus to 14.8% in Iceland, with rates in the United Kingdom ranging from 24.6% in England to 29.9% in Northern Ireland. 4 Australia's cesarean delivery rate increased from less than 20% in 1998 to approximately 30% in 2008. 5 Moreover, in Asia, an increase in cesarean delivery rates has been observed in a number of countries, including India, Nepal, China, and Bangladesh. 6 Such a substantial increase in cesarean delivery rates without an indication of benefits for maternal or neonatal health has become a major public health concern. 7 Although cesarean delivery can be a life-saving surgery, this procedure should be performed only when medically indicated, as complications that have adverse consequences for the mortality and morbidity of both the mother and the newborn are well documented in the literature. [8][9][10][11][12][13][14][15][16] Some of the negative health outcomes in infants born via cesarean delivery include childhood obesity, respiratory disorders, type 1 diabetes, acute lymphoblastic leukemia, impaired cognitive development, higher rates of autism, and an increased risk of neurodevelopmental disorders. 15,[17][18][19][20][21][22][23] Cesarean delivery has been reported to be associated with an approximately 4-fold increase in the risk of maternal death. 24 In addition, unnecessary cesarean deliveries may be associated with higher health care costs in many low-income settings. 25 India has also experienced increases in cesarean delivery rates similar to those observed in the rest of the world. Based on our calculations, cesarean delivery rates have more than doubled in India as a whole, from 8% in 2005 through 2006 to 17% in 2015 through 2016. The World Health Organization (WHO) recommends that the percentage of cesarean deliveries should not exceed 10% to 15% in any nation. The present study assessed the variation in cesarean delivery rates in public and private sector health facilities in India to evaluate whether private facilities were associated with increases in cesarean delivery rates and to estimate the burden of avoidable cesarean deliveries in the private sector.

Methods
The data for this cross-sectional study were obtained from the National Family Health Survey (NFHS), which is a nationally representative survey conducted under the stewardship of the Ministry of Health and Family Welfare in India. The International Institute for Population Sciences in Mumbai is designated as the central agency to implement the survey. Although our analysis was mainly based on data from the most current survey, the NFHS-4 (2015-2016), 26 data from previous rounds of surveys, specifically the NFHS- 1 (1992-1993) 27 and the NFHS- 3 (2005-2006), 28 were also used. The

JAMA Network Open | Health Policy
present study calculated the patterns in cesarean delivery rates in India by type of facility and assessed the association of participants' sociodemographic, economic, and health characteristics and their place of delivery with the likelihood of having a cesarean delivery. The study also examined the potential cost savings of reducing the current cesarean delivery rates in the private sector to the thresholds recommended by the WHO. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. Ethical review was not necessary as this study was based on the analysis of secondary survey data, which is available in the public domain, and complied with all requirements of 45 CFR §46.
For comparison, the locations of institutional deliveries were classified into public and private sectors. A dichotomous variable was created based on the location of the live birth. The location was considered public if the delivery occurred in a government hospital, government dispensary, urban health center, urban family welfare clinic, community health center, or primary health center. The location was considered private if the delivery occurred at a private hospital or private clinic. Owing to their small numbers, nongovernmental organizations and trust hospitals were also included in the private sector category.

Statistical Analysis
Geographic maps were developed to visualize the change in spatial distribution of the cesarean delivery rate in India from the NFHS-3 to the NFHS-4. A total of 7 cutoffs for the percentage of cesarean deliveries (3 cutoffs lower and 4 cutoffs higher than the 15% threshold recommended by the WHO) were used to highlight the increase in cesarean delivery rates in various states and union territories of India. In addition, funnel plots were drawn to observe the variation in the percentage of cesarean deliveries according to public vs private facilities in the states. We constructed 95% CI bands in funnel plots to identify states with rates higher than the 95% CI band, which were considered upper outliers with high cesarean delivery rates, and states with rates lower than the 95% CI band, which were considered lower outliers with low cesarean delivery rates. The funnel was plotted using the lower and upper control limits, which were calculated from the aggregated national cesarean delivery percentages and SEs based on state rates.
A multivariate binary logistic regression model was constructed to estimate the increase in the likelihood of cesarean delivery in private vs public health facilities. Cesarean delivery was a binary variable coded as 0 for a vaginal delivery and 1 for a cesarean delivery; thus, an odds ratio (OR) greater than 1 signified that the OR of a cesarean delivery for that particular explanatory variable was higher than that of the reference category. We considered several relevant background characteristics and assessed their associations with the likelihood of having a cesarean delivery. The explanatory variables considered were the size of the child at birth (small, average, or large, as reported by the mother), birth order of the child (1, 2 or Ն3), maternal age at the child's birth (Յ19 years, 20-29 years, or Ն30 years), maternal body mass index (BMI; calculated as weight in kilograms To understand whether there were fundamental differences with respect to medical indications for cesarean delivery among women in public vs private facilities, a simple bivariate analysis was performed. The medical indicators considered were complications during pregnancy, complications during delivery, and preplanned cesarean delivery. A scenario analysis was performed to estimate the economic burden of avoidable cesarean deliveries in the private sector by calculating the cesarean deliveries that could have been avoided and the potential cost savings that could have been achieved under various scenarios. Data regarding household out-of-pocket expenditures for vaginal and cesarean deliveries, which were available for the first time in the NFHS-4, were used for this analysis. All analyses were performed using Stata software, version 13.1 (StataCorp). Data were analyzed from June to December 2019.

Results
The analysis considered only deliveries that occurred at institutional facilities. In the NFHS-  States with cesarean delivery rates beyond these boundaries were considered outliers.
In the NFHS-3, only 2 states, Andhra Pradesh and West Bengal, were observed to be upper outliers with high cesarean delivery rates; in the NFHS-4, the number of upper outliers increased to 13 states. The 2 rounds of the NFHS were also pooled to assess the association of socioeconomic status with the likelihood of cesarean delivery by the place of delivery.   (Figure 3). Our study also found that the likelihood of having a cesarean delivery in the private sector was higher (OR, 1.62 in the NFHS-3; OR, 4.17 in the NFHS-4) than in the public sector. In addition, the difference in the probability of having a cesarean delivery in public vs private sector facilities in both  associations of cesarean delivery with richer wealth quintiles 31,32 and higher educational levels. 33 In addition, other studies' results are consistent with our finding that the place of delivery (ie, public vs private facility) is the most important structural factor in the outcome of birth by vaginal or cesarean delivery. 16,34 Our results also highlight the fact that there were no substantial differences in medical indications for cesarean delivery (eg, pregnancy complications, delivery complications, or the decision to have cesarean delivery before the onset of labor) among women at public vs private facilities. Therefore, other nonmedical factors are likely to play a more substantial role in the increase of cesarean delivery rates in the private sector.
One of the factors documented in the literature that is associated with the increase in cesarean delivery rates is the role of private sector facilities in a number of settings. In many low-and middleincome countries, the introduction of health sector reforms has involved engagement with the private sector in the form of public-private partnerships. A number of such approaches have been successful in addressing the issue of safe motherhood in low-and middle-income countries. 35,36 In India, the private sector has expanded rapidly, and government-sponsored health care programs rely on private hospitals as part of public-private partnerships. 37 In this context, it is important to understand the characteristics of the private sector in India, which provides a range of health care services in both urban and rural areas. 38 Private-sector hospitals range from small family-run general hospitals to facilities providing superspecialty tertiary care. Consultation fees vary because there is no fixed fee schedule, and patients usually pay for services directly (ie, out of pocket). 38 In addition, the private health care sector in India is not well Our study also estimated that, assuming the private sector experienced the mean national cesarean delivery rate, the potential number of avoidable cesarean deliveries would be 1.67 million, with a potential cost savings of $293.36 million. Consistent with our findings, 1 study estimated a potential 0.9 million preventable cesarean deliveries in the private sector in India. 39 Another study estimated that 6.2 million unnecessary cesarean deliveries were performed globally in 2008 at a cost of $2.32 billion. 40 Such avoidable cesarean deliveries consume a large share of national and global resources, have equity implications, and act as a barrier to achieving universal health coverage. 40

Limitations
This study has several limitations. Although cesarean delivery rates were estimated based on NFHS guidelines, all limitations for analyses of sample survey data also applied to our study. In addition, because the study used secondary data, it was not possible to capture the appropriateness of cesarean deliveries performed in public or private facilities. Exploring the underlying factors associated with high cesarean delivery rates in the private sector was beyond the scope of this study.
From our results, it appears that India is in the early stages of an increasing pattern of cesarean deliveries. As seen in the funnel plot, the number of highly populated states with high birth rates is behind the curve with respect to cesarean delivery rates. Therefore, the consequences of higher cesarean delivery rates in India will likely be more noticeable when highly populated states, such as Bihar and Uttar Pradesh, start to experience cesarean delivery rates similar to those in some of the less populated states, such as Andhra Pradesh, Tamil Nadu, Gujarat, and West Bengal. Hence, policy makers in India have a window of opportunity to forestall the increase in cesarean deliveries before it occurs in highly populated states.
A number of approaches can be considered by the government of India to address the problem of high cesarean delivery rates in private sector facilities; these approaches include informing patients of the risks of the cesarean delivery procedure, including the higher probability of subsequent births by cesarean delivery. In Brazil, it is now mandatory for pregnant women to acknowledge the risks of a cesarean delivery before surgery, and this requirement has inspired partnerships with several hospitals to promote vaginal birth. 41 Through public-private partnerships, the government of India could use financial incentives to reimburse private facilities at a uniform rate for childbirth, whether it be birth through vaginal or cesarean delivery. Such a policy would provide financial incentives to encourage vaginal delivery, as has been implemented in Taiwan. 42 Professional associations in many countries have developed guidelines and recommendations for the prevention of primary cesarean deliveries. 43 Because no such guidelines exist in India, the Indian Medical Association could be given the responsibility of developing such guidelines. A movement is currently under way in India to ensure that the cesarean delivery rates of all hospitals are made available to the general public with the aim of calling attention to hospitals with high cesarean delivery rates. Some countries have encouraged midwifery-led units as a way to reduce cesarean delivery rates. 43,44 In addition, for any policy to be successful, cultural factors and local context will need to be considered. 43

Conclusions
This cross-sectional study indicates that there is a substantial discrepancy in cesarean delivery rates between the public and private sectors in India, and that private sector health care facilities are associated with increases in cesarean delivery rates. It appears that India is in the early stages of a pattern of increasing cesarean deliveries. Given the context of India, with its expanding middle class, rapidly expanding private sector, low governmental regulatory capacity, and governmental policy that encourages public-private partnerships, conditions seem favorable for the increase in cesarean delivery rates to occur in highly populated states. Hence, it is important that policy makers in India