title: Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal.
abstract: OBJECTIVE
  To describe the prevalence and determinants of births by caesarean section in private and public health facilities in underserved communities in South Asia.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  81 community-based geographical clusters in four locations in Bangladesh, India and Nepal (three rural, one urban).
  
  
  METHODS
  45,327 births occurring in the study areas between 2005 and 2012.
  
  
  METHODS
  Proportion of caesarean section deliveries by location and type of facility; determinants of caesarean section delivery by location.
  
  
  RESULTS
  Institutional delivery rates varied widely between settings, from 21% in rural India to 90% in urban India. The proportion of private and charitable facility births delivered by caesarean section was 73% in Bangladesh, 30% in rural Nepal, 18% in urban India and 5% in rural India. The odds of caesarean section were greater in private and charitable health facilities than in public facilities in three of four study locations, even when adjusted for pregnancy and delivery characteristics, maternal characteristics and year of delivery (Bangladesh: adjusted OR (AOR) 5.91, 95% CI 5.15 to 6.78; Nepal: AOR 2.37, 95% CI 1.62 to 3.44; urban India: AOR 1.22, 95% CI 1.09 to 1.38). We found that highly educated women were particularly likely to deliver by caesarean in private facilities in urban India (AOR 2.10; 95% CI 1.61 to 2.75) and also in rural Bangladesh (AOR 11.09, 95% CI 6.28 to 19.57).
  
  
  CONCLUSIONS
  Our results lend support to the hypothesis that increased caesarean section rates in these South Asian countries may be driven in part by the private sector. They also suggest that preferences for caesarean delivery may be higher among highly educated women, and that individual-level and provider-level factors interact in driving caesarean rates higher. Rates of caesarean section in the private sector, and their maternal and neonatal health outcomes, require close monitoring.
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Melissa
authors.initials: M
authors.lastname: Neuman
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Glyn
authors.initials: G
authors.lastname: Alcock
authors.affiliation: Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh.
authors.forename: Kishwar
authors.initials: K
authors.lastname: Azad
authors.affiliation: Perinatal Care Project, Diabetic Association of Bangladesh, Dhaka, Bangladesh.
authors.forename: Abdul
authors.initials: A
authors.lastname: Kuddus
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: David
authors.initials: D
authors.lastname: Osrin
authors.affiliation: Society for Nutrition, Education and Health Action (SNEHA), Urban Health Centre, Maharashtra, India.
authors.forename: Neena Shah
authors.initials: NS
authors.lastname: More
authors.affiliation: Ekjut, Jharkhand, India.
authors.forename: Nirmala
authors.initials: N
authors.lastname: Nair
authors.affiliation: Ekjut, Jharkhand, India.
authors.forename: Prasanta
authors.initials: P
authors.lastname: Tripathy
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Sikorski
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Naomi
authors.initials: N
authors.lastname: Saville
authors.affiliation: Mother and Infant Research Activities (MIRA), Kathmandu, Nepal.
authors.forename: Aman
authors.initials: A
authors.lastname: Sen
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Tim
authors.identifier: http://orcid.org/0000-0002-6917-6552
authors.initials: T
authors.lastname: Colbourn
authors.affiliation: Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Tanja A J
authors.initials: TA
authors.lastname: Houweling
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Nadine
authors.initials: N
authors.lastname: Seward
authors.affiliation: Mother and Infant Research Activities (MIRA), Kathmandu, Nepal.
authors.forename: Dharma S
authors.initials: DS
authors.lastname: Manandhar
authors.affiliation: Mother and Infant Research Activities (MIRA), Kathmandu, Nepal.
authors.forename: Bhim P
authors.initials: BP
authors.lastname: Shrestha
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Audrey
authors.initials: A
authors.lastname: Prost
mesh_terms: D000293:Adolescent; D000328:Adult; D001459:Bangladesh / Q000453:epidemiology; D002585:Cesarean Section / Q000706:statistics & numerical data; D002608:Charities; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000379:methods* / Q000706:statistics & numerical data; D004522:Educational Status; D005260:Female; D006268:Health Facilities; D006297:Health Services Accessibility; D006801:Humans; D007194:India / Q000453:epidemiology; D009390:Nepal / Q000453:epidemiology; D011247:Pregnancy; D011248:Pregnancy Complications; D015995:Prevalence; D017149:Private Sector; D017150:Public Sector; D012111:Residence Characteristics; D012424:Rural Population; D014505:Urban Population; D055815:Young Adult
keywords: OBSTETRICS; PUBLIC HEALTH