The C-Section Epidemic in Pakistan

Intervention of caesarean section (C-section) is crucial in Pakistan where maternal and neonatal mortality is high. However, its use exceeds World Health Organisation recommendations, suggesting that Pakistan is part of a trend worldwide of having C-sections for non-medical reasons. Private health facilities in the country may be more accommodating of C-sections for nonmedical reasons than public ones. To test this hypothesis, we used data from the Pakistan Demographic and Health Survey 2012-13 on the most recent birth for women giving birth 2007-2012. Controlling for medical indications (birth order, age at delivery, pregnancy complications, previous termination, previous Csection, antenatal visits), we examined whether the odds of having a C-section were higher in private health facilities. Since women in Pakistan do not have an equal chance of delivering at a health facility, we modelled delivering at a health facility and having a C-section as a two-step process. In the first or selection equation, place of delivery was a function of the aforementioned medical indications and various sociodemographic and community factors (N=7,354). Women who delivered at a health facility (N=3,886) were included in the second or outcome equation, where C-section was a function of medical indications and a binary variable for type of facility served as predictors. Medical indications for a C-section, being more educated, and living in socioeconomically advantaged households and communities were associated with higher odds of delivering at a health facility, and, after taking into account medical indications for having a C-section, the odds of having one were higher for delivery at a private facility. Findings suggest that the private maternal health sector in Pakistan may be over-medicalising childbirth.