Page 77 - IJPS-7-1

Rajaa, et al.

China, and South India have also emphasized the above findings (Ming et al., 2019; Mohan et al., 2019). This reinforces the
hypothesis that CS rates are highly influenced by income and health-seeking behavior of the wealthy people.
Our study described that gestational diabetes mellitus was a significant risk factor for CS, in unadjusted analysis.
Similar study done in Indian context to understand the risk factors for CS have also established the same (Poobalan et al.,
2009). Our study established that mothers who delivered through CS had 5 times more odds of having Malpresentation
(breech/transverse lie, etc.,) as a risk factor. We also found that among the mothers who underwent CS had 30 times, more
odds of having undergone a LSCS in their previous pregnancy. Similar findings were reported in a cohort study conducted
in Denmark which reported serious and explosive risk associated with these risk factors and the type of delivery (Wehberg
et al., 2018). These figures question the practice of trial of labor after CS (TOLAC) or vaginal birth after cesarean (VBAC)
after previous LSCS. There is enough evidence around the world supporting trial of labor as a safe option for women
following previous LSCS. Studies have showed that the success rates of TOLAC to be around 60-80% provided the
candidates are appropriately selected (favorable bishop score and spontaneous onset of labor) (Soni et al., 2015). Thus,
encouraging VBAC or TOLAC among women with favorable factors would enable the health systems to combat this
epidemic of rising CS rates. However, an individualized approach is necessary assessing every woman taking the existing
circumstances and facilities into consideration.
Our study in multivariable logistic regression analysis showed that previous LSCS, malpresentation, and belonging to
middle and upper socioeconomic class emerged as independent risk factors for CS even after adjusting for all other variables
in the model. This shows the importance of clinician’s decision-making in determining the indication of CS among the
pregnant women. It is very difficult to follow a protocol with a set of indications in determining CS as mostly these decisions
are taken in an individualized approach, inside the labor room based on the intrapartum condition of the mother and the fetus.
Our study had several strengths. We employed a case–control design to find the risk factors associated with increased
CS in an urban setting. We age and period matched the cases and controls to match the characteristics and risk factor
profile of the study participants. Although we picked only 70 matched pairs, matching for age and period increased the
power of the study. We collected the information through personal interviews from the mothers themselves. We verified
the information obtained, through the discharge slips available with the mothers. Our study also adds to the existing
literature for evidence-based decision-making in choosing CS as a mode of delivery. We used the same reference period
for both cases and controls to reduce misclassification bias. To reduce interviewer bias, identical probes were used and
effort was made to ensure approximately similar interview time for both cases and controls.
Our study also had certain limitations. Although we had a recall period of 3 years to reduce the recall bias, it was
unavoidable. The assessment of risk factors could have been subjected to recall bias when the discharge slips were not
available with the participants. Furthermore, we got a limited sample size of 70 matched cases and controls, the results
are less likely robust, especially for some very large odds ratios, making our study lacked sufficient power to detect an
association for known risk factors such as gestational hypertension, cardiovascular diseases, and elderly gravida. In
addition, we have only utilized the variables that were readily available in the ANC cards, thus, we could have missed
other significant associates of CS. Studies with larger sample size are clearly warranted to establish more reliable findings.

5. Conclusions
Our study showed that socioeconomic class, previous LSCS, and malpresentation were found to be independent risk
factors for CS in urban Puducherry. We recommend a further review of the health-care delivery system, to halt the rise
in CS rates in the nation. We also call for policymakers to formulate and set up national guidelines reviewing various
indications for CS, thereby minimizing the rates of unnecessary CS.

Acknowledgments

We would like to acknowledge the staff of the primary health center and the interns of 2013 batch for their immense
contribution and continuous technical support for completing the study.

Funding
No funding was received for this study.

Conflict of interest
None declared.

International Journal of Population Studies | 2021, Volume 7, Issue 1 71