---
title: "Caesarean Deliveries in Tamil Nadu: Prevalence, Costs, and Postpartum Quality of Life"
id: "plos-one-13-caesarean-deliveries-and-their-impact-on-financial-burden-and-quality-of-life"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-13-caesarean-deliveries-and-their-impact-on-financial-burden-and-quality-of-life"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358778"
published_at: "2026-09-22T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Caesarean Deliveries in Tamil Nadu: Prevalence, Costs, and Postpartum Quality of Life
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-13-caesarean-deliveries-and-their-impact-on-financial-burden-and-quality-of-life
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358778)
- **Published At:** 2026-09-22T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This community-based cross-sectional study surveyed 475 randomly selected post-partum mothers in three districts of Tamil Nadu between April and June 2023 to examine **Caesarean (C-section)** prevalence, determinants, out-of-pocket expenditures (OOPE) and health-related quality of life (HRQL). - The observed C-section prevalence was 52.60% of all births in the sample. Data were collected on demographic and obstetric characteristics, indications for high-risk pregnancy, intrapartum complications, and expenditures; HRQL was measured using the **SF-12** instrument. - Sampling used multi-stage stratified cluster random sampling across districts chosen to represent low, moderate and high multidimensional poverty index (MPI) levels; eligibility required institutional birth between 1 April 2022 and 31 March 2023, maternal age ≥18 years, and consent. Mothers with self-reported mental health conditions, stillbirths, or infant deaths were excluded. - Key factors associated with C-section delivery included reporting a **high-risk pregnancy** (AOR 17.21, 95% CI 7.57–39.13) and delivering in a **private healthcare facility** (AOR 3.02, 95% CI 1.62–5.65). - C-section delivery was significantly associated with higher likelihood of incurring substantial **OOPE** (AOR 2.05, 95% CI 1.22–3.47) and with poorer physical HRQL (AOR 0.31, 95% CI 0.18–0.55); the study examined broader economic impacts including wage loss and financial distress though detailed numeric breakdowns beyond the reported associations are in the source data files. - The authors conclude that about one in two deliveries in this Tamil Nadu sample were C-sections and that these were linked to greater financial burden and reduced postpartum physical quality of life, arguing for strategies to reduce unwarranted C-sections in this setting. - Data underlying the study are available as S2 File; the authors reported no specific funding and no competing interests.
## Clinical Analysis & Structured Key Points
Caesarean deliveries and their impact on financial burden and quality of life among post-partum mothers in Tamil Nadu, India | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Introduction Caesarean section (C-section) deliveries are on the rise globally, often with significant health and economic consequences. This study investigates the prevalence and factors associated with C-section deliveries, and their association with out-of-pocket expenditures (OOPE) and health-related quality of life (HRQL) among post-partum mothers in Tamil Nadu, India. Methods A cross sectional study among 475 randomly selected post-partum mothers was conducted during April-June 2023. Data on demographic and obstetric characteristics and OOPE were collected using a structured survey questionnaire. HRQL was assessed using the 12-Item Short Form Survey (SF-12). Binary logistic regression analysis was used to compute Adjusted Odds Ratios (AOR) to identify the factors associated with C-section deliveries, and identify the association between C-section deliveries with OOPE and HRQL. Results C-section deliveries accounted for 52.60% of all births. High-risk pregnancies (AOR = 17.21, 95% CI = 7.57–39.13, p 90% of mothers undergoing institutional deliveries incurred out of pocket expenses (OOPE) [ 3 ]. In five years from 2015–16–2019–21, the OOPE associated with institutional deliveries increased by 26.5% [ 4 , 5 ]. In Tamil Nadu alone, the OOPE associated with institutional deliveries in public hospitals increased by 21% [ 4 , 5 ]. In India, households pay around Indian Rupees (INR).10,000/- per institutional delivery [ 6 ]. Also, the cost of delivery is known to vary according to the mode of delivery (i.e., Caesarean Section [C-section]/Vaginal Birth), place of delivery (public vs private), health status of the mother and child, and treatment duration [ 7 ]. While the World Health Organization (WHO) recommends the a judicious use of C-section procedure at levels of 10–15% to be optimum to prevent maternal mortality [ 8 ]. C-sections account for over 20% of all deliveries in India [ 2 ]. Tamil Nadu reported a C-section prevalence of 44.9% in 2019−20, which is substantially higher than the C-section rates in developed economies like the United States (US) and the United Kingdom (UK) [ 2 ]. From 2015 to 2021, the prevalence of C-sections in public hospitals in Tamil Nadu increased by 36.9% compared to a 24.4% relative increase in the private hospitals [ 5 ]. C-section rates are strongly associated with place of delivery, social norms, high risk pregnancies, and fertility preferences [ 9 , 10 ]. In addition to incurring higher costs, mothers undergoing C-section have poorer health related quality of life (HRQL) [ 11 ]. A longitudinal study from Australia reported that women who delivered by C-section had poorer physical and mental health scores [ 12 ]. Another study from New Delhi, India reported that women undergoing C-section had significantly poorer scores across the domains of physical functioning, role physical, bodily pain, vitality, social functioning and mental health [ 13 ]. Previous studies conducted based on the National Family Health Surveys (NFHS) 2015−16 (round 4) and 2019−21 (round 5) established the association between C-section deliveries and high out of pocket expenses (OOPE), and a high odds of financial distress among households of women undergoing C-section in private healthcare facilities [ 7 , 14 ]. However, these studies were primarily focussed on OOPE estimates. Evidence on the role of high-risk pregnancies and female sterilization as indications for C-section remains to be studied, specifically in the contexts like Tamil Nadu with a high prevalence of high-risk pregnancies, close to 100% institutional deliveries, fertility rates below replacement levels, and a focussed policy target to reduce MMR. Moreover, earlier studies comparing C-section and Vaginal deliveries predominantly focussed on OOPE, while other economic aspects such as wage loss to family caregiver and financial distress involving borrowings or sale of assets to pay OOPE were not studied. While there a few studies on C-section’s impact on HRQL, they are also limited by the volume of evidence in Indian settings, small sample size, and predominant focus on mothers during the post-natal period. We conducted this study (i) to assess the prevalence and factors associated with C-section deliveries in Tamil Nadu, and (ii) compare the out-of-pocket expenditures and health related quality of life among mothers undergoing C-section and vaginal deliveries. Materials and methods Study design and study setting We conducted a community based cross-sectional survey of post-partum mothers from 15 th April 2023–30 th June 2023. The survey was conducted among a randomly sampled mothers from three districts (i.e., Kanyakumari, Tuticorin, and Pudukkottai) of Tamil Nadu. These three districts were selected to represent three distinct multidimensional poverty index(MPI) levels (i.e., low, moderate, and high respectively) and had C-section prevalence ranging from 43.1% to 67.6% [ 4 , 15 ]. Sampling The sample size was estimated using OpenEpi version 3.01 ( https://www.openepi.com/SampleSize/SSPropor.htm ) based on the formula An initial sample of 384 was estimated at an anticipated prevalence (p) of C-section deliveries of 50%, with confidence level at 95%, an absolute precision (d) of 5%, and a design effect (DEFF) of 1.0. Further, considering a non-response rate of 20% the sample was inflated to 461, and rounded to a final sample size of 475 post-partum women. Sampling was conducted employing multi-stage stratified cluster random sampling approach. Given that maternal healthcare utilization is impacted by socio-economic and development indicators [ 6 , 7 , 16 ], we used the MPI levels to categorize the districts in Tamil Nadu into low, moderate, and high based on the MPI India report published by NITI Aayog, Government of India [ 15 ]. MPI is a composite index of 12 indicators across three dimensions (Health [including Nutrition, Child & adolescent mortality, Maternal Health], Education, and Standard of Living) capturing deprivations that individuals/households experience simultaneously [ 15 ]. One district from each MPI group were randomly sampled as the primary sampling units. Each district was further stratified into urban municipalities, and rural panchayats. From the list of the primary health centers (PHCs) in the district, one PHC from the urban municipalities and one PHC from the rural panchayats were randomly sampled resulting in six clusters [3 urban and 3 rural]. From each sampled PHC, the birth registries were accessed and line-list of institutional births between 1 st April 2022–31 st March 2023 was prepared. From the line-list of births, 77–81 post-partum mothers per PHC were randomly sampled using a computer programme. A total of 156, 160, and 159 mothers were sampled from Kanyakumari, Tuticorin, and Pudukkottai districts respectively. Each potential participant was approached and screened for inclusion. Eligibility criteria included mothers aged 18 years and above who had an institutional delivery and whose most recent childbirth occurred between 1 April 2022 and 31 March 2023. Mothers with self-reported mental health conditions were excluded. In addition, women who had experienced a stillbirth or infant death, as well as those who did not provide consent, were considered ineligible for inclusion in the study. A total of 510 mothers were approached to attain the sample size of 475, with most [n = 34] of the excluded mothers refusing consent to participate. Data collection The survey was conducted between 15 th April 2023–30 th June 2023. Caesarean section was captured as a self-reported response to the item “ With respect to the birth of your recent child, what was the mode of delivery?” . The items for obstetric history included gravida, place of antenatal care (ANC) visits, episiotomy during delivery, and female sterilization. Further, the survey questionnaire also captured details on the indications for high-risk pregnancy and intrapartum complications. The indications for high-risk pregnancy included severe anaemia, preeclampsia, gestational diabetes, hypothyroidism, young primigravida/elderly gravida, twin/multiple pregnancy, malpresentation, previous C-section delivery, placenta previa, previous bad obstetric history, Rh negative, short stature, obesity, and history of systemic illness. A mother was considered to have a high-risk pregnancy if she reported to have at least one of these indications during her pregnancy. The intrapartum complications included breech presentation, prolonged labour, and excessive bleeding. The OOPE incurred towards institutional delivery was captured as a total of indirect costs incurred towards transportation, paid-caregivers, food & accommodation; and direct costs including OOPE for hospital stay, tests, medicines and other expenses. The data on mode of delivery and obstetric history were captured based on self-report and verified by mother and child protection card and/or hospital discharge summery. The data on OOPE was primarily self-reported. The HRQL was measured using a 12-Item Short Form Health Survey (SF-12) questionnaire developed for the Medical Outcomes Study [ 17 ]. It captures HRQL under eight domains “i) physical functioning, ii) role-physical, iii) bodily pain, iv) general health perceptions, v) vitality, vi) social functioning, vii) role-emotional, viii) general mental health” , with the former four capturing the physical component summary (PCS) and later four capturing the mental component summary (MCS) [ 17 ]. SF-12 has been shown to have a significant internal consistency and structural validity to measure HRQL among post-partum mothers [ 18 ]. In this study, SF-12 had an acceptable internal reliability with Cronbach’s alpha (α) measured at 0.85. The questionnaire was translated into vernacular version (Tamil), and back translated to English to check for the consistency of translations. Translations and back translation of the questionnaire was done by the first author a native speaker ensuring to account for cultural nuances in translated versions of the questionnaire. Further, the translated versions were checked with another native speaker not part of study team to ensure consistency of interpretation. Content and face validity of the questionnaire was established prior to undertaking the study through a review of the questionnaire by the research team, and two independent experts. The survey was conducted in Tamil, and data were collected as self-reported responses. Data cleaning and analysis The data entry, cleaning, and analysis was conducted using International Business Machine’s (IBM) Statistical Package for Social Sciences (SPSS) version 27 and Stata version 13 (StataCorp, College Station, TX, USA). Based on a prior analysis of NFHS-4 which reported the mean OOPE for institutional deliveries in Tamil Nadu as 10,063 [ 19 ], and NFHS-5 estimates of average cost of institutional deliveries in Indian settings [ 7 ], we categorized the OOPE paid towards institutional deliveries into two categories ≤INR.10000/- (approximately 120 USD), and>INR.10000/-. The HRQL variables, i.e., PCS & MCS were computed as continuous scores with higher PCS & MCS scores representing better HQRL in physical and mental health components respectively. The PCS and MCS questions of SF-12 were coded following the standardized procedures, by clearing the out-of-range values, followed by reverse coding of four negative questions (SF1, SF8, SF9, SF10), creating the indicator items, applying specific weights, and finally standardizing the PCS and MCS scores by using constants [ 17 , 20 ]. The PCS and MCS scores were transformed to categorical variables with a PCS & MCS score of 50 and above being categorized as good, and below 50 was categorized as poor [ 17 , 21 , 22 ]. We computed the percentage prevalence and 95% confidence interval (CI) of the C-section deliveries, and indications for high-risk pregnencies. A descriptive comparison of the indications of high-risk pregnancies and intrapartum complications among vaginal and C-section deliveries were made. The descriptive estimates and bivariate comparisons of OOPE for delivery, cost of postnatal care and treatment, wage loss to family caregiver, amount received as financial assistance, financial distress, and HRQL variables of PCS & MCS between the vaginal and C-section deliveries was undertaken. The Mann-Whitney U test and Chi-Square test were used to assess the statistical significance of the difference in these estimates by mode of delivery. We developed logistic regression models to (i) identify the factors associated with C-section deliveries, (ii) ascertain the association of C-section deliveries with out-of-pocket expenditure, (iii) assess the association of mode of delivery with physical component summery of HRQL, and (iv) on the mental component summery of HRQL. Given the dependent variables in each of the regression models were dichotomous, we used binary logistic regression. The independent variables comprised of socio-demographic characteristics (i.e., district, place of residence, wealth index, and education), obstetric history (high risk pregnancy, intra partum complications, gravida), place of delivery, and mode of delivery. These variables were included based on prior published evidence on institutional deliveries [ 12 , 13 , 19 , 23 – 27 ], and bivariate associations observed in the data. Adjusted odds ratios (AOR) were computed to adjust for the confounding effect of independent variables in the regression models. Variance inflation factor (VIF) was computed to assess for multicollinearity between independent variables, and a VIF of up to 3.00 was considered acceptable. Area under receiver operating characteristic curves (AUROC) were calculated to evaluate the discriminative ability of the logistic regression models. Sensitivity analyses were performed using clustered robust standard errors, excluding women with previous C-sections from analysis, and by log transformation of OOPE as outcome variable ( S1 File , Tables 4–7). Ethics statement We conducted the study complying with the relevant ethical guidelines including the Declaration of Helsinki. The Institutional Human Ethics Committee of the Central University of Kerala (Ref.No. IHEC/CUK/2023/23) approved the study. Additionally, permissions to collect data were obtained from the Director of Public Health and Preventive Medicine, Tamil Nadu. Informed consent in writing was obtained from all the study participants. Privacy and confidentiality of the study participants were maintained at all stages of the study. Results Sample characteristics We surveyed 475 post-partum mothers from three districts in Tamil Nadu. Among the study sample more than 60% of the mothers delivered within six-months prior to the survey. Majority (65.5%) delivered in a public facility, more than half had a caesarean section, 44.8% (n = 213) were primigravida, and 55.2% (n = 262) were multigravida mothers ( Table 1 ). Download: PNG larger image TIFF original image Table 1. Characteristics of the study sample (n = 475). https://doi.org/10.1371/journal.pone.0358778.t001 Prevalence and indications of C-section deliveries The C-sections accounted for more than half of all deliveries (52.6%, 95%CI = 48.1–57.1). Among the mothers who had vaginal delivery (n = 225), 18.2% (95%CI = 13.6–23.6) had a high-risk pregnancy, whereas among the mothers who underwent a C-section (n = 250), 67.2% (95% CI = 60.3–72.0) had a high-risk pregnancy. Among these mothers, previous C-section delivery was a major indication of high-risk pregnancy (41.2%, 95%CI = 35.2–47.4), followed by preeclampsia (12.4%, 95%CI = 8.7–16.9) and hypothyroidism (7.6%, 95%CI = 4.7–11.3) ( Table 2 ). Download: PNG larger image TIFF original image Table 2. Distribution of high-risk pregnancy indications and intrapartum complications by mode of delivery. https://doi.org/10.1371/journal.pone.0358778.t002 Factors associated with C-section deliveries Mothers with a high-risk pregnancy had significantly higher odds (AOR = 17.21, 95% CI = 7.57–39.03, p < 0.001) of C-section deliveries. Similarly, mothers delivering in a private healthcare facility (AOR = 3.02, 95% CI = 1.62–5.65, p < 0.001), and primigravida mothers (AOR = 3.76, 95% CI = 1.96–7.20, p < 0.001) have higher odds of C-section deliveries ( Table 3 ). The logistic regression had an acceptable model fit (Hosmer-Lemeshow test, p = 0.712). Download: PNG larger image TIFF original image Table 3. Factors associated with caesarean section deliveries (n = 475). https://doi.org/10.1371/journal.pone.0358778.t003 Association of mode of delivery with household finances and HRQL 50.4% of mothers with C-section reported household experienced distress financing (i.e., taking loans or selling assets to pay OOPE), compared to 30.2% of mothers with vaginal delivery (χ 2 = 19.955, df = 1, p < 0.001). Further, mother who underwent a C-section incurred higher OOPE (p < 0.001), and had poorer health related quality of life scores in PCS (p < 0.001) and MCS (p = 0.001) domains ( Table 4 ). Download: PNG larger image TIFF original image Table 4. Financial implications and health related quality of life (HRQL) among vaginal and C-section deliveries: a comparison (n = 475). https://doi.org/10.1371/journal.pone.0358778.t004 The multivariate binary logistic regression found a significant variation in OOPE (Hosmer-Lemeshow test, p = 0.386) for institutional deliveries across districts, with those residing in Kanyakumari having an AOR of 5.73 (95%CI = 4.07–8.06, p < 0.001) for incurring OOPE over INR.10000/- compare
## Related Clinical Research

- [Jehovah’s Witnesses permit blood-derived products but keep ban on whole-blood transfusions](https://medichelpline.com/clinical-feed/stat-news-0-jehovah-s-witnesses-allow-blood-derived-products-but-keep-ban-on-whole-blood.md)
- [Roche expands Boston presence with new research center — biotech roundup](https://medichelpline.com/clinical-feed/stat-news-0-stat-roche-expands-its-boston-footprint-with-new-research-center.md)
- [Men with Multiple Long-Term Conditions and Disability in the Game of Stones Weight Management Trial](https://medichelpline.com/clinical-feed/bmj-open-2-mens-experiences-of-multiple-long-term-conditions-and-or-disability-in-the-uk.md)
- [Ecological momentary assessment of stress during a 6‑month behavioral weight loss program: study p](https://medichelpline.com/clinical-feed/plos-one-17-intensive-longitudinal-assessment-of-stress-and-stress-related-concepts-across.md)
- [Folic Acid for Women of Reproductive Age: Prevention of Neural Tube Defects and Other Risks](https://medichelpline.com/clinical-feed/womens-mental-health-0-essential-reads-why-all-women-of-reproductive-age-should-take-folic-acid.md)

## Navigation
- [← Back to General Feed](https://medichelpline.com/clinical-feed/general.md)
- [← All Clinical Specialties](https://medichelpline.com/clinical-feed.md)
## Medical & Regulatory Disclaimer

> [!CAUTION]
> MedicHelpline content is structured for research, educational, and professional discovery purposes. It does not constitute individual medical advice, clinical diagnosis, or treatment recommendations.
> Always verify dosing, contraindications, and regulatory alerts against official product labeling and primary regulatory sources before clinical decision-making.