Page 73 - IJPS-7-1

Rajaa, et al.

stay, and severe maternal-neonatal morbidity and mortality (Villar et al., 2006). Especially in neonates, this has led to
increased risk of neonatal complications such as pulmonary hypertension, respiratory distress syndrome, and iatrogenic
prematurity (Betran et al., 2021; Wehberg et al., 2018).
In India, there is no national guideline for decision-making among the clinicians in choosing CS. National Family
Health Survey-4 states that the proportion of births delivered by CS in India is 17.2%, which is higher than the WHO
recommendations (Panda et al., 2018). It is disquieting to note that these rates have doubled in the past decade (Srivastava
et al., 2020). A study done among 30 teaching hospitals/medical colleges in South India, comparing the rates between
1993 – 1994 and 1998 – 1999, has shown that the overall CS rates have increased from 21.8% in 1993 – 1994 to 25.4%
during 1998 – 1999. Alarmingly among them, primigravida constituted around 42.4%, and 31% were hailing from rural
areas, which has right now reached 21% at the national level, with a considerable increase specifically in the private
sectors (Kambo et al., 2002; Roy et al., 2021). One such important reason for peaking of these CS rates is the rise in
primary CS followed by proportionate rise in repeat CS as well. Studies done in South India have also shown similar
findings (Bhasker, 1994; Roy et al., 2021).
A cesarean without any indications could result in more harm than good, in fact a low-risk uncomplicated CS has
an 8 times higher risk of mortality and 8 – 12-fold more risk of morbidity than spontaneous vaginal delivery (Boehm &
Graves, 1994). Studies have proven that non-medical indications make up about 1/3 of the global total 18.5 million CS
rd
cases performed annually (Begum et al., 2017; Festin et al., 2009).
Unnecessary cesareans may also result in catastrophic health expenditure at the family level and overburden the
existing health finances at the national level (Lauer et al., 2010). Dismally, taking India’s economic and human resource
constraints into consideration, our health system is hardly equipped to handle such an unprecedented increase in CSs.
This drastic escalation of CS rates has warranted further research to monitor the indications and evaluate the factors
influencing them. There is a paucity of research on clinical indications and factors influencing cesarean deliveries in India,
which is essential for deeper understanding of various strategies to halt this epidemic of CSs. Prior attempts to determine
the risk factors for CS were mostly cross-sectional in nature and were widely done across western settings. Thus, our
study aimed to determine the various sociodemographic risk factors and antenatal complications that influenced cesarean
deliveries among the mothers who delivered during the past 3 years in the selected wards of urban Puducherry, India.
2. Data and methods
2.1. Study design and study setting

Our study was conducted as a matched case control study in Jipmer Institute Urban Health Centre (JIUHC) service area,
health center of a tertiary care institute in Puducherry, India. We adopted this novel study design as matched case–control
studies, as this study design helps us not only to eliminate confounding but also to gain potential benefit in gaining efficiency
when compared to conventional case–control studies. The health center caters a population of about 8000 comprising four
wards, namely, Kurusukkupam, Vazhaikullam, Chinnayapuram, and Vaithikuppam, with around 2000 population each.
The JIUHC (nearest health facility to all four wards ~ 1.2 km) provides comprehensive primary care services to the
people, apart from being an urban health center for undergraduate and postgraduate teaching under JIPMER (Rajaa et al.,
2019). All four wards share similar sociodemographic and cultural factors. The study was conducted during January and
February 2018. A preliminary record review showed that on an average, around 80 – 90 deliveries are registered in the
service area every year. For our study, we included all women who gave birth through CS and reside in our service area,
during the past 3 years (January 2015 – December 2017) as cases and for controls, we enrolled age- and year-matched (for
risk factor comparability) women who had normal vaginal delivery during January 2015 – December 2017.
2.2. Sample size
Sample size was calculated to be 45 matched pairs based on a study done by Wehberg et al. (2018) in Denmark taking
the percentage of exposed (previous lower segment CS (LSCS) in cases as 36% and controls as 8% (normal delivery),
power of 80%, alpha error of 5%, and 95% CI using nMaster 2.0 software). However, we included 70 matched pairs (140
in total, i.e., 70 women who delivered through CS and another 70 who delivered vaginally) as we considered all women
who delivered through CS during the past 3 years of the study.

2.3. Data collection procedure
Three trained doctors were assigned to collect list of mothers who delivered in the past 3 years from the birth register
(giving a total of 241 deliveries) and the total CS deliveries were jotted down. After a preliminarily data analysis, we could

International Journal of Population Studies | 2021, Volume 7, Issue 1 67