Caesarean section (C-section) deliveries have risen worldwide with implications for maternal health and household finances. This study aimed to determine the prevalence of Caesarean deliveries in selected districts of Tamil Nadu, identify factors associated with C-section, and evaluate associations between mode of delivery and both out-of-pocket expenditures (OOPE) and health-related quality of life (HRQL).
The investigators noted that institutional deliveries in India are now high and that OOPE for institutional births has increased in recent years. The World Health Organization recommends C-section rates of 10–15% as optimal to prevent maternal mortality; by contrast, Tamil Nadu has reported substantially higher rates in routine surveys. The study sought to address gaps in evidence on indications such as high-risk pregnancy and sterilization, and to include wider economic impacts beyond direct OOPE, as well as HRQL in an Indian context.
A community-based cross-sectional survey was conducted from 15 April 2023 to 30 June 2023. The sample comprised 475 post-partum mothers randomly selected from three districts of Tamil Nadu (Kanyakumari, Tuticorin, and Pudukkottai) chosen to represent low, moderate and high multidimensional poverty index (MPI) levels. Eligible mothers were aged 18 years or older, had an institutional delivery between 1 April 2022 and 31 March 2023, and provided informed consent. Mothers with self-reported mental health conditions, those who experienced stillbirth or infant death, and those who did not consent were excluded.
The target sample size was computed assuming 50% anticipated C-section prevalence, 95% confidence, 5% precision and a design effect of 1.0; the initial estimate of 384 was inflated for 20% non-response to reach 475 participants. A multi-stage stratified cluster random sampling approach was used: one district from each MPI stratum was randomly selected, each district was stratified into urban and rural areas, and one primary health centre (PHC) from urban and one from rural strata were sampled, yielding six clusters. From PHC birth registries, births during 1 April 2022–31 March 2023 were line-listed and 77–81 mothers per PHC were randomly selected.
Data were collected via structured questionnaire. Mode of delivery was self-reported. Obstetric history items included gravida, place of antenatal care, episiotomy, and female sterilization. Indications for considering a pregnancy high-risk were predefined and included severe anaemia, preeclampsia, gestational diabetes, hypothyroidism, young primigravida/elderly gravida, multiple pregnancy, malpresentation, previous C-section, placenta previa, previous bad obstetric history, Rh negative, short stature, obesity, and systemic illness; a mother was classified as having a high-risk pregnancy if she reported at least one such indication. Intrapartum complications captured included breech presentation, prolonged labour, and excessive bleeding.
Economic outcomes included OOPE for delivery and related items; the authors also considered broader economic impacts such as wage loss to caregivers and indicators of financial distress (borrowings or asset sales) though detailed numeric breakdowns are reported in the study data files. Health-related quality of life was measured using the 12-Item Short Form Survey (SF-12), capturing physical and mental component scores.
Binary logistic regression was applied to estimate adjusted odds ratios (AORs) and 95% confidence intervals for factors associated with C-section deliveries and for associations between C-section and outcomes (OOPE and HRQL). Covariates included demographic and obstetric variables and place of delivery (public versus private).
In this sample of 475 post-partum mothers, 52.60% reported delivery by C-section. Two principal factors were strongly associated with C-section: reporting a high-risk pregnancy was associated with markedly increased odds of C-section (AOR = 17.21, 95% CI = 7.57–39.13, p < 0.001), and delivery in a private healthcare facility was also associated with higher odds of C-section (AOR = 3.02, 95% CI = 1.62–5.65, p = 0.001).
After adjustment for covariates, C-section delivery was significantly associated with greater financial burden: mothers who delivered by C-section had higher odds of incurring substantial OOPE compared with those who had vaginal deliveries (AOR = 2.05, 95% CI = 1.22–3.47, p = 0.007). The study highlights that OOPE for institutional deliveries has been increasing in recent years in India and Tamil Nadu and that mode of delivery contributes to cost differences. The authors also captured related economic consequences such as wage loss and financial distress; specific numeric breakdowns and itemized costs are available in the study’s supplementary data.
C-section delivery was associated with poorer postpartum physical HRQL. In adjusted analysis, C-section was linked to lower odds of good physical HRQL (AOR = 0.31, 95% CI = 0.18–0.55, p < 0.001). The SF-12 instrument was used to assess physical and mental component scores; the reported significant association pertained to the physical component. The paper references prior studies showing lower physical and mental scores after C-section in other settings, and places the current findings in that context.
Among the sampled post-partum mothers in three Tamil Nadu districts, approximately one in two deliveries were by C-section. C-section deliveries were strongly associated with reported high-risk pregnancies and with delivery in private facilities. Importantly, C-section was independently associated with higher out-of-pocket expenditures and with poorer physical HRQL in the postpartum period. The authors conclude that strategies are needed to reduce unwarranted C-sections to limit financial burden and adverse impacts on quality of life.
The underlying study data are available as S2 File linked in the original article. The authors reported no specific funding for the work and declared no competing interests. Detailed tables and supplementary material with additional estimates and stratified results are provided in the source article.