C:\Users\User\Documents\41 no 2 129 ABSTRACT UNIVERSA MEDICINA Highest economic status increases risk of cesarean section in women of childbearing age Haerawati Idris1*and Rini Anggraini1 BACKGROUND Cesarean section (CS) rates that are higher than the WHO recommendation may pose morbidity and mortality risks for both mother and child. In recent years, the number of CS deliveries has been increasing in developed and developing countries. The aim of the present study was to determine the rate of CS delivery and socioeconomic and demographic factors as risk factors of cesarean delivery in women of childbearing age. METHODS This cross-sectional study used data from the 2017 Indonesian Health Demographic Survey (IDHS). The research subjects were 14,724 women of childbearing age aged 15-49 years who had given birth and met the inclusion criteria. The rate of CS was determined and the associations between independent and dependent variables were explored using logistic regression. RESULTS The CS rate was 17.9%. Variables that had a significant relationship with cesarean delivery were geographic region, economic status, occupation, education, birth attendant, insurance ownership and antenatal care visits. The most dominant influencing variable was the highest economic status (OR 3.566; 95% CI: 2.857-4.452). Respondents with the highest economic status had a 3.5 times greater risk of having a cesarean delivery than subjects with the lowest economic status after controlling for the other variables. CONCLUSION This study demonstrated that the highest economic status increased the risk of CS delivery in women of childbearing age. The current epidemiological findings and evidence suggest adopting and implementing some strict guidelines in the health system to avoid unnecessary delivery by CS. Keywords: Cesarean section, demographic health survey, economic status, women of childbearing age ORIGINAL ARTICLE pISSN: 1907-3062 / eISSN: 2407-2230 DOI: http://dx.doi.org/10.18051/UnivMed.2022.v41.129-138 Copyright@Author(s) - https://univmed.org/ejurnal/index.php/medicina/article/view/1306 May-August 2022 Vol.41- No.2 1Faculty of Public Health, Sriwijaya University, Palembang Correspondence: Haerawati Idris Faculty of Public Health, Sriwijaya University, Raya Palembang-Unsri KM 32 Indralaya Street, Ogan Ilir, South Sumatra, Indonesia, 30862 Email: haera@fkm.unsri.ac.id ORCID ID: 0000-0002-3483-6717 Date of first submission, February 27, 2022 Date of final revised submission, June 6, 2022 Date of acceptance, June 10, 2022 This open access article is distributed under a Creative Commons Attribution- Non Commercial-Share Alike 4.0 International License Cite this article as: Idris H, Anggraini R. Highest economic status increases risk of cesarean section in women of childbearing age. Univ Med 2022;41: 1 2 9-3 8 . doi: 10 .18 051/ UnivMed. 2022.v41.12 9-13 8. 130 Idris, Anggraini Cesarean section in women of childbearing age INTRODUCTION The World Health Organization (WHO) recommends that the average number of cesarean sections should range from 10% to 15% as the maximum -target limit in an effort to avoid the risks of this mode of delivery to mother and baby.(1) However, it turns out that the cesarean section rate (CSR) continues to increase and to exceed the WHO recommended average. Betran et al.(2) reported that based on their studies from 1990 to 2014 in 121 countries, mean CSR increased by 12.4% (from 6.7% to 19.1%). Some countries with higher CSR than the WHO standards are the Latin American and Caribbean countries with the highest CSR of 40.5%, Europe with 25%, and Asia 19.2%, whereas Africa with 7.3% is still below the recommended average.(2) On the other hand, the CSR in some areas of Pakistan ranges from 47% to 65%. The number of mothers who are giving birth by cesarean section also continues to increase in Indonesia; acc ording to the Indonesian Demographic and Health Survey (IDHS) data, the CSR in Indonesia was 5%, then it rose to 12% in 2012 and increased again to 17.0% in 2017.(4) As the proportion of births increased in health facilities in Indonesia, in the last 30 years Indonesia’s CSR has also increased considerably, from 1.6% in 1991 to 17.6% in 2017.(5) Even the study of Oktarina et al.(6) in government and private hospitals in Jakarta, Indonesia, reported that the trend of cesarean section (CS) deliveries is very high, reaching 70%, especially in private hospitals. Currently CS is a life-saving intervention for mothers and children during childbirth, but this procedure can also have short-term and long-term health effects for women and children. The prevalence of maternal morbidity and mortality is higher after CS compared to vaginal delivery. Cesarean section has been shown to increase the risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth and premature delivery.(7) Cesarean delivery also affects the child’s sensory perception, sensory integration ability, and neuropsychiatry, and the relationship between mother and child.(8) Exclusive breastfeeding is especially important for the baby’s growth and development, but CS can reduce the chances of continued breastfeeding.(9) Breast milk production is strongly influenced by the release of the hormones oxytocin and prolactin.(10) In cesarean delivery, maternal anxiety due to postoperative pain and also the effects of anesthetics/drugs may delay the onset of breastfeeding.(11) Based on previous studies, it was reported that the majority of mothers who gave birth by the cesarean method stopped breastfeedin g after 12 weeks of delivery.(12) Research in Niger by Hitachi et al. (13) also reported that many mothers who had cesarean section did not give exclusive breastfeeding, and even stopped breastfeeding after 1 week of giving birth. Medically, the most common indication for CS is cephalopelvic disproportion (CPD) or narrow pelvis. (1 4.1 5) Other indications are obstructed labor, multiple pregnancies, non- reassuring fetal heart rate pattern (NRFHRP), failed induction and augmentation of labor, malpresentation and malposition, and antepartum hemorrhage.(16) Sungkar and Basrowi (17) also stated that sociodemographic factors, namely advanced maternal age, high socioeconomic status, higher education, living in urban areas and ownership of health insurance were also found to be associated with the incidence of cesarean delivery. Cesarean section procedures aim to save lives when there are medical indications for delivery, but CS can pose a higher risk of morbidity and mortality when performed without medical indications.(5) Ironically, according to Sandall et al.(7) the rate of cesarean delivery continues to increase, especially in cases without medical indications, even though this procedure can have short-term and long-term health effects on women and children. In addition, it turns out that a high CSR of more than 10% is also not associated with a decrease in maternal and neonatal mortality.(17.18) 131 Based on this description, it can be concluded that there is a large risk that threatens the mother and child due to CS without medical indications which contributes greatly to the high CSR but is proven not to be associated with a decrease in maternal and neonatal mortality. A study in Ghana involving 4948 research participants revealed that CS delivery is associated with maternal age, level of education, occupation, parity and antenatal care (ANC) visits.(19) Women’s socioeconomic status and health system factors were associated with the increased use of CS.(20) In contrast, a Bangla desh study found that the logistic regression analysis has traced no significant variation in CS rate among mothers of varying educational levels as compared to the reference group (mothers with no education) (p>0.05). Similarly, mothers’ religious status, age at first childbirth, age at first marriage, working status, exposure to media, including wanted indexed child and husband’s educational level, resulted in no significant difference in CS rate among various groups as compared to their corresponding reference groups.(21) Because the results of previous studies that found an association of socioeconomic and demographic factors, working status, and age with CS, are still inconsistent, therefore the association of socioeconomic and demographic factors, working status, and age with CS delivery are still to be determined. This study aimed to raise the importance of investigating the causes of high CSR, especially in Indonesia, which is useful in developing strategies for optimizing the use of appropriate CS. The objective of this study was to determine the socioeconomic and demographic factor as risk factors of CS in Indonesia. METHODS Research design This was a cross-sectional study using secondary data from the 2017 Indonesian Health Demographic Survey (IDHS), which is a survey data jointly carried out by the Central Statistics Agency (BPS), the National Population and Family Planning Agency (BKKBN), and the Ministry of Health (Kemenkes) from 24 July to 30 Se ptember 2017. Survey funding was provided by the Government of Indonesia, assisted by the United States Agency for International Development (USAID). Study Subjects The population of this study comprised all respondents in 34 provinces of Indonesia who were successfully interviewed by the IDHS t e a m. T he s a mpl e f o r t he p r es e n t s t ud y amounted to 14,724 respondents who were selected based on one inclusion criterion, namely women of childbearing age in the range of 15- 49 years who had given birth in the last 5 years at the time of the interview and two exclusion criteria consisting of missing data and invalid data. Main outcomes The main outcome was cesarean delivery a n d wa s ca t e go r i ze d i nt o s ub j e c t s wh o underwent cesarean delivery (coded as 1) and otherwise (coded 0). Main exposure variables The main exposure variables in this study were education, occupation, economic status, region, insurance ownership, birth attendant, and ANC visits. Educational level was divided into three categories, namely low if respondent had no education or had attended elementary school, intermediate if respondent had attended junior high school or senior high school, and high if respondent had studied for diploma degree or attended college. Economic status was based on the economic quintile owned by a household. Households were scored based on the number and type of items they had, from television sets t o bi c yc l e s o r c ar s, a n d on h ou s in g characteristics, such as drinking water sources, toilet facilities, and main building materials for the floor of the house. This score was calculated using principal component analysis. National economic quintiles were arranged based on Univ Med Vol. 41 No 2 132 Idris, Anggraini Cesarean section in women of childbearing age A B hou sehold scor es for each pers on in the household and then divided into five quintiles, namely lowest, low, middle, high and highest. Statistical methods Data were analyzed by univariate analysis and by bivariate analysis using the simple logistic regression test to determine the relationship between the independent variable and the dependent variable. Multivariate analysis was by means of logistic regression test with predictive model to analyze the independent variable with the most dominant effect on the dependent variable. The significance level set at p<0.05. Ethical clearance Ethical clearance was obtained for the 2017 IDHS from the National Ethics Committee. The respondents’ identities have all been deleted from the dataset. Respondents provided written consent for their involvement in the study. The researchers have obtained permission to use the data for the purposes of this study through the following website: https://dhsprogram.com/data/ new-user-registration.cfm. This study was appro ved by the Health Research E thics Committee of the Faculty of Public Health, Sriwijaya University, under No. 217/UN9.FKM/ TU.KKE/2022. RESULTS From Table 1 it can be seen that around 17.9% of respondents gave birth by cesarean section. The majority of respondents (58.6%) had secondary education, 58.8% had insurance, 57.6% resided on Java/Bali, 51.5% were e mpl oyed , 4 1.4% h ad mi ddl e t o h igh es t economic status, 86.3% gave birth assisted by hea lth wor ke rs a nd 91.7% had c ompl ete antenatal care visits. Based on the results of the simple logistic regression analysis in Table 2, it was found that all independent variables namely education, occupation, economic status, geographic region, insurance ownership, birth attendants, and ANC visits have a significant relationship with incidence of cesarean delivery. All of the independent variables studied also have an OR of >1, which means that there is an association in the form of increasing the risk of an outcome (i.e. a risk factor for cesarean delivery). Based on the OR value, respondents with the highest economic status have a 6.3 times gre ater probability of having a cesarean delivery compared to respondents with the lowest ec onomic s ta tu s ( 95% CI: 5 .2 43 -7. 733) . Respondents with complete ANC visits have a 3 times greater probability of having a cesarean d e l i ve r y c o mpa r e d t o r e s po nde n t s wi t h incomplete ANC visits (95% CI: 2.413-3,926). Table 1. Socio-demographic characteristics of the study participants (n= 14,274) *Education: Low: no education or elementary school; inter- mediate: junior high school or senior high school; high: di- ploma or college; ANC : antenatal care Variable n % Education High 2,188 14.9 Middle 8,634 58.6 Low 3,902 26.5 Insurance policy ownership Yes 8,661 58.8 No 6,063 41.2 Region Sumatra 3,282 22.3 Java/Bali 8,477 57.6 East Indonesia 2,965 20.1 Employment status Employed 7,585 51.5 Unemployed 7,139 48.5 Economic status Highest 2,829 19.3 High 3,054 20.7 Middle 3,053 20.7 Low 2,980 20.2 Lowest 2,808 19.1 Childbirth attendant Health workers 12,702 86.3 Non-health workers 2,022 13.7 ANC visits Complete 13,501 91.7 Incomplete 1,223 8.3 Cesarean section delivery Yes No 2,632 12,092 17.9 82.1 133 Univ Med Vol. 41 No 2 Respondents with a higher educational level have a 4.6 times greater probability of having a cesarean delivery compared to respondents with a low level of education (95%CI: 3.944-5.562). The results of the simple logistic regression selection analysis show that the independent variables have a p-value <0.25. Based on the results, it can be concluded that the variables of education, geographic region, insurance policy ownership, occupation, economic status, birth attendant, and ANC visits can be included in the multivariate analysis modeling. Based on the results of the multivariate analysis in Table 3, which shows the most influential variable as indicated by the adjusted odds ratio is the highest economic status variable (AOR= 3.566; 95% CI: 2.857-4.452). This means that re spondents with t he highest economic status have a 3.5 times gre ater probability of having a cesarean delivery when compared to respondents with the lowest economic status after controlling for the variables of education, geographic region, insurance ownership, birth attendant and ANC visits. DISCUSSION The cesarean delivery rate in Indonesia has continually increased, from 1.6% in 1991 to 17.6% in 2017.(5) The present study, which used IDHS 2017 data, also reported that Indonesia’s CSR was 17.9%. This figure exceeds the range of CSR recommendations from WHO, which is 10%-15%.(1) Medically, the study by Aprina and Puri reported on the factors that could influence the occurrence of cesarean delivery, namely severe preeclampsia, placenta previa, fetal Table 2. Crude odds ratios of determinants of CS delivery Notes: ANC: antenatal care; Education: Low: no education or elementary school; intermediate: junior high school to senior high school; high: diploma or college; OR: odds ratio Variable CS delivery OR(95% CI) p value Yes (n,%) No (n,%) Region Sumatra 649 19.8 2633 80.2 1.655 (1.418 -1.930) 0.000 Java/Bali 1899 18.9 6878 81.1 1.561 (1.346 -1.809) 0.000 East Indonesia 384 13.0 2581 87.0 1 - Economic status Highest 911 32.2 1917 67.8 6.367 (5.243-7.733) 0.000 High 691 22.6 2363 77.4 3.918 (3.215-4.775) 0.000 Middle 483 15.9 2569 84.1 2.524 (2.072-3.074) 0.000 Low 351 11.8 2629 88.2 1.788 (1.457-2.195) 0.000 Lowest 195 6.9 2613 93.1 1 - Childbirth attendant Health workers 2508 19.7 10194 80.3 3.746 (2.940-4.772) 0.000 Non-health workers 125 6.2 1897 93.8 1 - ANC visits Complete 2547 18.9 10954 81.1 3.078 (2.413-3.926) 0.000 Incomplete 86 7.0 1137 93.0 1 - Education High 735 33.6 1453 22.4 4.684 (3.944-5.562) 0.001 Intermediate 1517 17.6 7117 82.4 1.974 (1.703-2.287) 0.003 Low 380 9.7 3522 90.3 1 - Insurance policy ownership Yes 1854 21.4 6807 78.6 1.850 (1.651-2.071) 0.000 No 778 12.8 5285 87.2 1 - Employment status Employed 1455 19.2 6130 80.8 1.201 (1.080-1.336) 0.000 Unemployed 1178 16.5 5961 83.5 1 - 134 Idris, Anggraini Cesarean section in women of childbearing age sub-Saharan Africa shows the diversity of CSR in public health facilities that ranges from 3% in Burkina Faso to 15.6% in Ghana. The results of the present study show that the highest CSR in women of high educational status is around 33.6% and in working women is about 19.2%, which is greater than the 16.5% of non-working women. This finding is also in line with previous research and the global trend of CSR in general. The factors of urban residence and high educational status influence the occurrence of CS in other developing countries as well, such as in South and Southeast Asia.(25) Mumtaz et al.(26) reported that the prevalence of CS in Pakistan among working mothers tended to increase in the following three survey periods, namely 16.6% (DHS 1990), 24.7% (DHS 2006) and 25% (DHS 2012). Women with high educational status tend to choose to work, so there is a similar pattern of relationship of educational factors and occupational factors with the incidence of CS. Hea lt h pre f e re n c es of wome n wi th h igh position abnormalities, and delayed parturition.(22) Several predictors of CS in Pakistan according to Murtaza et al.(23) were multiparity, breech position, fetal distr ess, oligohydramnios, preeclampsia, and previous uterine scars. In Indonesia, the variety of CSR in each ge ogr a p h ic r e gio n i s c a us e d b y sociodemographic factors. The disparity in CSR between one region and another, which is influenced by the diversity of the regions, education, and occupation in Indonesia, is similar to the world trend.(5) Sumatra, which is the western part of Indonesia, has a CSR of 19.8%, followed by Java/Bali with 18.9% and East Indonesia with 13%, all of which are greater than the 10% recommended by the WHO. In addition, pregnant women residing in Sumatra are 1.6 times more likely to have a CS procedure than those in East Indonesia. The CSR in Pakistan varies by province, being 40% in Khyber Pakhtunkhwa and Punjab, 43% in Islamabad, 4 9% i n Sin dh a n d 51 % i n Aza d J a mmu Kashmir.(23) The study of Yaya et al.(24) on CS in Table 3. Adjusted odds ratios of determinants of CS delivery Note : ANC: antenatal care; Education: Low: no education or elementary school; intermediate: junior high school to senior high school; high: diploma or college; AOR: adjusted odds ratio Variable AOR 95 % CI p value Education 1.646 - 2.433 1.095 – 1.507 0.000 0.002 High 2.001 Intermediate 1.285 Low 1 Region 1.257 - 1.694 0.990 - 1.314 0.000 0.068 Sumatra 1.459 Java/Bali 1.140 East Indonesia 1 Insurance policy ownership 1.349 - 1.710 0.000 Yes 1.519 No 1 Economic Status 2.857 - 4.452 2.195 - 3.366 1.575 - 2.393 1.216 - 1.860 0.000 0.000 0.000 0.000 Highest 3.566 High 2.718 Middle 1.941 Low 1.504 Lowest 1 Childbirth attendant 1.701 - 2.799 0.000 Health worker 2.182 Non-health worker 1 ANC visits 1.497 - 2.431 0.000 Complete 1.907 Incomplete 1 135 educational status are generally higher than those of women without formal education.(27) High formal education has a strong relationship with women’s decision-making autonomy in making choices.(28) In addition, women with high formal education may believe that CS is safer and does not interfere with their workload.(29) The WHO recommends ANC to provide a positive pregnancy experience, the minimum recommendation in 2006 being 4 ANC visits, followed by the minimum of 8 ANC contacts (in 2016) with a trained ANC service provider. T he s e e f f or ts a r e t h e ma n a ge me nt of complications during pregnancy that are likely to lead to CS procedures.(30) However, the results of the present study showed a different finding, in that 18.9% of mothers had cesarean delivery and 91.7% had complete ANC visits. The latter percentage is much higher than in the group of mothers who did not receive complete ANC services, which is around 7%. A secondary analytical study in Pakistan using DHS 2012- 2013 data reported that mothers who received ANC care more than four times were more likely to give birth to children through CS procedures. In women who reported complications of pregnancy, gynecological risk avoidance was the reason for the choice of cesarean section.(31) Pregnant women who attend antenatal care are more likely to give birth in health facilities and follow postnatal care,(32) such that they have safe deliveries by health workers. The high prevalence of ANC of 91.7% is also followed by a high trend of birth attendance with health personnel, namely 86.3% (Table 1). In addition to the fact that the prevalence of cesarean delivery is still relatively high among mothers who underwent complete ANC, it is note-worthy that the prevalence of cesarean delivery is also quite high in the group of mothers whose birth attendants are health workers, namely 19.7%. Even though the CSR in government-owned hospitals is around 30%-40%, there are private hospitals whose CSR can reach 70%.(6) The percentage of women with cesarean delivery in Pakistan is high at 13.6%. According to Amj ad et al. (3 1) Pakistani wome n who experience pregnancy complications, have high ANC utilization and deliver in private hospitals have a higher probability of obtaining a CS procedure. Therefore decisive action is needed such as detailed medical indications from doctors for CS and awareness of pregnant women to reduce the chances of pregnancy complications. Cesarean section delivery costs many times more than vaginal delivery, such that the f a mi l y’s e c on omi c a bi l i t y b e c o me s a consideration in choosing the CS method of delivery.(35) This can be seen from the results of the study which showed that the economic s t a t us va ri a bl e w a s t h e mo s t d o mi n a n t. Respondents with the highest economic status have a 3.5 times greater probability of having a cesarean delivery than do respondents with the lowest economic status after controlling for other variables. Economic factors are also seen in CSR patterns in other countries, where the percentage of CS births in Ghana ranges from 5% in very poor women to 27.5% in very rich women.(34) The CSR in Brazil is particularly high among wealthier women or those in maternity hospitals in the private sector.(35) In developing countries, economic inequality factors influence the pattern of cesarean delivery rates, which may be due to inadequate access to emergency obstetric care in the very poor and the poor, in co ntra st w ith the high ra tes of ce sare an deliveries without medical indication in the very rich group.(36) The data show that insurance ownership is related to the incidence of cesarean delivery. The percentage of cesarean deliveries in the group of women who have insurance is relatively high, namely 21.4% (Table 2). These results are in line with the research of Jenabi et al.(37) who reported that the factors of educational level, socioeconomic status, place of residence and insurance ownership were significantly related to the mother’s choice of cesarean delivery. The link between insurance and cesarean delivery rates in Indonesia can be seen from the National Health Insurance- Healthy Indonesian Card Univ Med Vol. 41 No 2 136 Idris, Anggraini Cesarean section in women of childbearing age Quality Control and Cost Control Team Report, that in the period of 2014-2018 around 57% of J a mi n an Ke se ha t an Nas i o na l - Kar t u Indonesia Sehat (JKN-KIS) participants who gave birth chose the CS method. According to Widjayanti,(38) the CSR for JKN participants even reached 79.21%. Se ve r a l f a c t or s o ut s i de o f sociodemographic and midwifery variables such as women’s choice, women’s fear, psychological factors and doctor’s preference also contribute to high CSR.(23,39) Severe fear of childbirth in women causes them to be at higher risk for emergency CS and to be more likely to choose elective CS, mostly due to non-obstetr ic indications.(40) Solanki et al.(41) examined 6,542 births in South Africa, of which 4,815 were cesarean births, causing the CSR to reach 73.6%. Most of the CS were emergency CS (39.7%), followed by elective CS (39.5%). Weak regulations concerning hospitals that offer CS service packages (profit-oriented) as well as regulations that encourage moral hazard in doctors, thus allowing CS requests without adequate medical indications, also contribute to high CSR.(6) Therefore, adequate awareness, appropriate prenatal and perinatal counseling, fetomaternal monitoring, monitoring of vaginal bir th a fter ces ar ean (VBAC) eff ort s and promotion of institutional delivery (in health facilities with trained birth attendants) can minimize obstetric complications and CSR.(23,39) The present study has its limitations, such as the use of cross-sectional data that cannot determine a causal relationship, and the fact that there are several variables that have not been explored due to limited data regarding age, parity, maternal physical activity during pregnancy, delivery complications and the demand for cesarean delivery. On the other hand, it becomes difficult to limit the autonomy of women, especially those with higher income to demand or to suggest cesarean delivery. The government should consider this factor for controlling the cesarean delivery rate in Indonesia. Further study should expand this study by adding other variables related to cesarean delivery with a better design like cohort study. CONCLUSIONS The current investigation based on the Indonesian Health Demographic Survey-2017 data has revealed that the prevalence of CS delive ry in Indonesia is higher than that recommended by the WHO. Economic status is the dominant variable in the prevalence of cesarean delivery in Indonesia. CONFLICT OF INTEREST The authors declare no competing interest ACKNOWLEDGEMENT We gratefully acknowledge the use of secondary data from the 2017 IDHS. 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