State-wise variation and inequalities in caesarean delivery rates in India: analysis of the National Family Health Survey-5 (2019–2021) dataResearch in context

Abstract

Summary: Background: India’s caesarean delivery (CD) rate of 21.5% suggests adequate national access to CD but may mask significant disparities. We examined variation in CD rates across states (geography), wealth, and health care sector (public versus private). We also aimed to determine relative inequality in CD rates across wealth quintiles. Methods: The current study was a cross-sectional analysis of CD rates from the National Family Health Survey-5 (2019–2021) disaggregated by asset-based household wealth quintiles for each state and by healthcare sector (public versus private). Data from 724,115 women aged 15–49 years across 28 states and eight union territories were analysed. Women who reported their most recent live birth within the past five years were included. Relative inequality was measured by comparing CD rates in the richest versus the poorest quintiles. Findings: Disaggregating the national CD rate of 21.5% showed substantial variation in CD rate across states, ranging from 5.2% in Nagaland to 60.7% in Telangana and across wealth quintiles, ranging from 0% to 76.7% (Assam). CD facility rates were higher in private than public facilities across all wealth quintiles. Over two-thirds of states (69%) had at least twice the CD rate in the richest wealth quintile versus the poorest quintile. Relative inequality in CD rates between the richest and poorest was 5.3 nationally and was higher in public (4.0) versus private (1.4) facilities. Interpretation: The national CD rate in India masks complex geographical, wealth, and sector-related inequalities in CD utilisation. Accounting for these variations is imperative when interpreting national-level rates to better assess the equity in the distribution of CD services. Funding: None.

Keywords

• Cesarean section delivery
• India
• NFHS-5
• Private sector
• Inequality