Reducing maternal mortality remains a major challenge for healthcare systems worldwide. Indonesia has achieved the fourth target of the Millennium Development Goals, to reduce child mortality, but has yet to reach the fifth target, to improve maternal health by reducing the maternal mortality ratio and achieving universal access to reproductive health (Schröders et al, 2015). Problems with maternal and child healthcare are still prevalent in Indonesia. The government has carried out various programmes to improve maternal and child healthcare, one of which requires childbirth to be assisted by competent health personnel (Mahendradhata et al, 2017). This is an effort to achieve the sustainable development goal target of reducing the global maternal mortality rate to less than 70 per 100 000 live births by 2030 (World Health Organization (WHO), 2016a). Type of delivery, including caesarean section, can reduce maternal and infant mortality and delivery complications. However, a caesarean section is generally only performed according to planned medical situations that indicate its necessity, in an emergency setting or electively.
The rate of caesarean section is currently increasing around the world, in both low- and high-income countries (Vogel et al, 2015; Dusabe et al, 2018). Indonesia has the highest rate of caesarean sections globally, according to the Association of Southeast Asian Nations (Badan Kependudukan dan Keluarga Berencana Nasional et al, 2017). The rate of caesarean section is highest (up to 22.5%) among urban women in Indonesia (Verma et al, 2020). The rate of caesarean section deliveries increased considerably between 2007 and 2017, from 7% to 17% (Betran et al, 2016). The high rate of caesarean section deliveries in Indonesia exceeds the WHO conservative recommendation of 10–15% in a region (Betran et al, 2016). Caesarean section delivery can save the lives of mothers and children when vaginal delivery is not possible (Jenabi et al, 2019). However, it carries the risk of surgery and increases the risk of complications for both the baby and the mother, such as future pregnancy problems. Previous studies have found that caesarean delivery was associated with increased incidence of asthma (Thavagnanam et al, 2008) and type 1 diabetes (Cardwell et al, 2008) in mothers.
Caesarean deliveries take place globally, are performed both with and without medical indications and their use is increasing among health services (Konlan et al, 2019). However, more mothers are choosing a caesarean section without any prior complications or when it is not medically indicated (Jenabi et al, 2019). A caesarean section can have short- and long-term effects, such as bleeding, postpartum infection, delayed breastfeeding because of anesthesia and postoperative pain and future ectopic pregnancies (Rahmawati et al, 2016). There is a reported misunderstanding among some mothers that performing a caesarean section without medical indication is safe (Weeks et al, 2020).
Lazasniti et al (2020) reported on a study of Indonesian women that factors influencing the decision to perform a caesarean section include level of education, income, work status, an agreement between spouse or family, anxiety, knowledge and the 100% health financing method. In low-to middle-income countries, high-risk sociodemographic characteristics have been reported to increase the incidence of caesarean section. These characteristics include family income, area of residence, mother's level of education, birth order and maternal age at delivery (Gebremedhin, 2014; Long et al, 2015; Vieira et al, 2015; Bayou et al, 2016). The aim of this study was to assess the prevalence of and sociodemographic characteristics associated with caesarean sections in Indonesia.
Methods
Study design
A cross-sectional study design was used to conduct this study using secondary data from the 2017 Indonesian Demographic Health Survey (National Population and Family Planning Board and ICF, 2018).
Data source
The 2017 survey was carried out by the National Population and Family Planning Board, Central Statistics Agency of Indonesia and the Ministry of Health. The government of Indonesia funded the survey, which took place from 24 July to 30 September 2017. The Inner-City Fund provided technical assistance under the Demographic Health Surveys Program, which is funded by the United States Agency for International Development.
Sample
The survey sample was representative at national and provincial levels and included urban and rural areas across 34 provinces. The inclusion criteria were married women of reproductive age (15–49 years) in 49 250 households. The total survey sample was 12 789 mothers.
Variables
The dependent variable in this study was a caesarean section, either planned or decided on before the onset of labour pain. The analysis unit in this study was all births in the 5 years prior to the survey.
The independent variables in this study were maternal age, maternal level of education, place of residence, economic status, number of antenatal care visits, proximity to a health facility, birth order and husband's level of education. The antenatal care clinics are run by midwives and obstetricians.
Mothers' age was divided into three groups (15–19 years, 20–34 years, 35–47 years). The reference category was the youngest age group (15–19 years). This uneven distribution of ages in the categories was based on Indonesian age categories (Health Ministry of Republic Indonesia, 2009).
The distribution of education levels intended to determine the differences in the behaviour of women with the lowest level of education (none) up to the highest education (university) to determine if this influenced the selection of delivery type.
Residential areas were classified as urban or rural, based on the existence of and access to medical facilities.
Economic status was measured by ownership of durable goods in households and divided into five groups, ranging from the poorest to the richest, with the poorest as the reference category. This was based on the survey's classification of economic status, and the categorisations were determined based on principal component analysis (Vyas and Kumaranayake, 2006; Arifin et al, 2022).
The frequency of antenatal care visits during pregnancy was divided into four categories: none, one, 2–4 visits, or additional examinations after the fourth visit.
The distance to a health facility was divided into two categories: ‘big problem’ and ‘not a big problem’. This categorisation was based on the respondent's perception of whether they had problems accessing healthcare when they fell sick (Croft et al, 2018; Kusnanto et al, 2020).
Birth order referred to the order of the last child born by caesarean section (for example, birth order 2 means the last child a woman gave birth to by caesarean section was her second child).
Data analysis
Software for statistic and data science (version 14.0) was used to analyse the data, including checking for completeness. The chi-squared test and a binary logistic regression were performed to assess determinants of caesarean deliveries in Indonesia. The strength of the association between the independent and dependent variables was assessed using an odds ratio with a 95% confidence interval. Variables were considered significant at a P value of 0.05 or less with a 95% confidence interval.
Ethical considerations
The 2017 Indonesian Demographic Health Survey obtained ethical approval from the National Institute for Health Research and Development of the Indonesian Ministry of Health. All respondents' identities were deleted from the data, and the respondents gave written approval for their involvement in the research. Permission to use the 2017 survey in this study was obtained from ICF International. The data were authorised by the ICF International's Institutional Review Board (No. FWA00000845). In accordance with 45 Code of Federal Regulations 46, ‘Protection of Human Subjects’, the project adhered to all applicable standards. The survey acquired informed consent from all individuals and oversaw the study's execution. For individuals under the age of 16, informed consent to participate was acquired from their parents.
Results
A caesarean section was conducted for 2269 (17.7%) of the 12 789 mothers who gave birth during the 5 years before the survey. The majority of the births were by women aged 20–34 years (73.61%), those who were living in rural areas (50.94%), those who had a secondary level of education (59.17%), those whose order of children born by caesarean section was 2–3 (54.14%), those who had more than four antenatal care visits during pregnancy (91.73%), those who gave birth in a government hospital or clinic (50.30%), those who did not have a difficult distance to travel to the health facility (88.95%), and those whose husband's level of education was secondary (58.55%) (Table 1).
Table 1. Participants' sociodemographics characteristics
| Variables | Frequency, n=12 789 (%) | |
|---|---|---|
| Mother's age at birth (years) | 15–19 | 1212 (9.48) |
| 20–34 | 9414 (73.61) | |
| 35–47 | 2163 (16.91) | |
| Residence | Rural | 6514 (50.94) |
| Urban | 6275 (49.06) | |
| Mother's education | None or primary | 3387 (26.49) |
| Secondary | 7567 (59.17) | |
| Higher | 1835 (14.35) | |
| Wealth index | Poorest | 2445 (19.12) |
| Poorer | 2650 (20.72) | |
| Middle | 2689 (21.03) | |
| Richer | 2607 (20.39) | |
| Richest | 2398 (18.75) | |
| Number of antenatal care visits | None | 277 (2.17) |
| 1 | 117 (0.92) | |
| 2–3 | 664 (5.19) | |
| ≥4 | 11 731 (91.73) | |
| Birth order | 1 | 4231 (33.08) |
| 2–3 | 6924 (54.14) | |
| 4–5 | 1344 (10.51) | |
| ≥6 | 290 (2.27) | |
| Frequency of watching TV | Not at all | 427 (3.34) |
| Less than once a week | 1412 (11.04) | |
| At least once a week | 10 950 (85.63) | |
| Distance to health facility | Big problem | 1414 (11.05) |
| Not a big problem | 11 375 (88.95) | |
| Husband's age (years) | <20 | 47 (0.37) |
| 20–34 | 6347 (49.63) | |
| 35–99 | 6395 (50.01) | |
| Husband's education | None | 122 (0.95) |
| Primary | 3527 (27.57) | |
| Secondary | 7487 (58.55) | |
| Higher | 1653 (12.92) | |
| Husband's work status | Unemployed | 77 (0.60) |
| Employed | 12 712 (99.40) | |
In bivariate analysis, almost all the variables showed a significant association (P<0.05) with caesarean section delivery, except husband's work status (Table 2).
Table 2. Bivariate analysis of determinants of caesarean delivery
| Variable | Delivery by caesarean section | X2 | P value | ||
|---|---|---|---|---|---|
| Yes, n=10 520 (%) | No, n=2269 (%) | ||||
| Mother's age at birth (years) | 15–19 | 1084 (8.48) | 128 (1.00) | 90.81 | <0.001 |
| 20–34 | 7780 (60.83) | 1634 (12.78) | |||
| 35–47 | 1656 (12.95) | 507 (3.96) | |||
| Residence | Rural | 5699 (44.57) | 815 (6.37) | 245.53 | <0.001 |
| Urban | 4821 (37.69) | 1454 (11.37) | |||
| Mother's education | None or primary | 3057 (23.91) | 330 (2.58) | 452.37 | <0.001 |
| Secondary | 6242 (48.81) | 1325 (10.36) | |||
| Higher | 1221 (9.55) | 614 (4.8) | |||
| Wealth index | Poorest | 1661 (12.99) | 784 (6.13) | 658.06 | <0.001 |
| Poorer | 2045 (15.99) | 605 (4.73) | |||
| Middle | 2275 (17.79) | 414 (3.24) | |||
| Richer | 2300 (17.98) | 307 (2.40) | |||
| Richest | 2240 (17.51) | 158 (1.24) | |||
| Number of antenatal care visits | None | 273 (2.13) | 4 (0.03) | 27.88 | <0.001 |
| 1 | 113 (0.89) | 4 (0.03) | |||
| 2–3 | 602 (4.71) | 62 (0.48) | |||
| ≥4 | 9532 (74.53) | 2199 (17.20) | |||
| Birth order | 1 | 3395 (26.55) | 836 (6.54) | 106.10 | 0.001 |
| 2–3 | 5726 (44.77) | 1198 (9.37) | |||
| 4–5 | 1141 (8.92) | 203 (1.58) | |||
| ≥6 | 258 (2.02) | 32 (0.26) | |||
| Frequency of watching TV | Not at all | 381 (2.98) | 46 (0.36) | 16.60 | 0.007 |
| Less than once a week | 1179 (9.22) | 233 (1.82) | |||
| At least once a week | 8960 (70.06) | 1990 (15.56) | |||
| Distance to health facility | Big problem | 1266 (9.89) | 148 (1.16) | 56.60 | <0.001 |
| Not a big problem | 9254 (72.37) | 2121 (16.58) | |||
| Husband's age (years) | <20 | 45 (0.35) | 2 (0.02) | 13.74 | 0.028 |
| 20–34 | 5281 (41.29) | 1066 (8.33) | |||
| 35–99 | 5194 (40.62) | 1201 (9.39) | |||
| Husband's education | None | 112 (0.88) | 10 (0.08) | 366.71 | <0.001 |
| Primary | 3194 (24.97) | 333 (2.60) | |||
| Secondary | 6069 (47.46) | 1418 (11.09) | |||
| Higher | 1145 (8.95) | 508 (3.97) | |||
| Husband's work status | Unemployed | 60 (0.47) | 17 (0.13) | 1.04 | 0.318 |
| Employed | 10 640 (81.79) | 2252 (17.61) | |||
In multivariate analysis, a backward stepwise logistic regression method was used to assess the association between the independent and dependent variables. Mother's age, level of education, residence, wealth index, number of antenatal care visits, distance to health facility, and birth order were found to have significant associations with caesarean section. Women aged 35–47 years at the time of the birth were 2.92 times more likely to give birth by caesarean section than women aged 15–19 years (P<0.001). Urban women were 1.31 times more likely to give birth by caesarean section than women living in rural areas (P<0.001). Highly educated women were 2.27 times more likely to give birth by caesarean section than women with primary or no education (P<0.001). Women of the poorest wealth index families were 3.19 times more likely to give birth by caesarean section than women from the richest wealth index families (P<0.001). Women who had four or more antenatal care visits during pregnancy were 7.70 times more likely to give birth by caesarean section than women who did not visit antenatal care (P<0.001). Women who reported that they did not have a big problem with the distance to a healthcare facility were 1.42 times more likely to give birth by caesarean section than women who lived far from a healthcare facility (P=0.003). Women who gave birth to their first child were 1.80 times more likely to have a caesarean section than women who had six or more children (P=0.013) (Table 3).
Table 3. Multivariate analysis of determinants of caesarean delivery
| Variable | Adjusted odds ratio (95% confidence interval) | P value | |
|---|---|---|---|
| Mother's age at birth (years) | 15–19 | Ref | - |
| 20–34 | 1.53 (1.18–1.98) | 0.001 | |
| 35–47 | 2.92 (2.16–3.96) | <0.001 | |
| Residence | Rural | Ref | - |
| Urban | 1.31 (1.13–1.53) | <0.001 | |
| Mother's education | None or primary | Ref | - |
| Secondary | 1.39 (1.17–1.65) | <0.001 | |
| Higher | 2.27 (1.84–2.81) | <0.001 | |
| Wealth index | Poorest | 3.19 (2.84–4.12) | <0.001 |
| Poorer | 2.53 (1.98–3.25) | <0.001 | |
| Middle | 1.82 (1.44–2.29) | <0.001 | |
| Richer | 1.53 (1.21–1.92) | <0.001 | |
| Richest | Ref | - | |
| Number of antenatal care visits | None | Ref | - |
| 1 | 2.01 (0.53–7.63) | 0.306 | |
| 2–3 | 5.00 (1.76–14.22) | 0.003 | |
| ≥4 | 7.70 (2.84–20.90) | <0.001 | |
| Birth order | 1 | 1.80 (1.13–2.00) | 0.013 |
| 2–3 | 1.28 (0.82–2.00) | 0.271 | |
| 4–5 | 1.05 (0.67–1.65) | 0.829 | |
| ≥6 | Ref | - | |
| Distance to health facility | Big problem | Ref | - |
| Not a big problem | 1.42 (1.13–1.78) | 0.003 | |
Discussion
In this study, determinants related to caesarean sections in Indonesia were discovered by examining maternal and environmental factors. Mothers aged 35–47 years were more likely to have a caesarean section than mothers aged 15–19 years. Complications during pregnancy and childbirth increase significantly with increasing maternal age; therefore, it is likely that a caesarean section is performed out of consideration of the safety of the mother and the fetus. Several related studies have shown that older women have a greater risk of developing pre-eclampsia, placenta previa and gestational diabetes (Ogawa et al, 2017; Claramonte Nieto et al, 2019). Being older is related to a decrease in physiological and hormonal functions that can lead to pregnancy complications (Ogawa et al, 2017; Claramonte Nieto et al, 2019). Therefore, older women are advised to deliver by caesarean section to lessen the urgency of the delivery process and reduce the risk of potential pregnancy complications.
Women who lived in cities were more likely to give birth by caesarean section than women who lived in rural areas. This is consistent with research in Vietnam, which showed that mothers who lived in urban areas were more likely to give birth by caesarean section as a result of the existence of and access to many private and public hospitals, each of which can provide delivery assistance services that are suitable for pregnant women (de Loenzien et al, 2019). Urban areas have health facilities that are better equipped to assist childbirth and promote a safer delivery. Other studies have also shown that women who lived in metropolitan areas had high social welfare, chose to give birth by caesarean section in a private hospital (Takegata et al, 2020) and their residential status corresponded with a higher social status/class (Liamputtong and Naksook, 2003; Liamputtong, 2005). In line with this, the present study showed that women who lived closer to a health facility were more likely to deliver by caesarean section than women who lived further from a health facility. The majority of maternal mortalities can be avoided by access to affordable, qualified facilities.
Maternal education was also a significant determinant of caesarean section delivery. Highly educated women were more likely to deliver via caesarean section compared with women who had a lower level of education. Gynecological obstetricians are known to offer caesarean sections to pregnant women who are private patients (Faisal-Cury et al, 2017; Manyeh et al, 2019; Sadiq et al, 2019). Pregnant women with a higher level of education may more easily receive and absorb information about caesarean section, and may seek information about having a quick and painless labour, making caesarean delivery a preferential choice for these women. Qualitative research in Norway showed that the decision to have a caesarean section more often resulted from a pregnant mother's request than obstetric indications and this decision was made when considering avoiding trauma experienced from a previous labour (Eide et al, 2019). Healthy psychological conditions during the birthing process are necessary for proper maternal health later in the puerperium and infant care, meaning that caesarean sections are becoming a more popular choice in millennial mothers.
Women in the poorest wealth quintile were more likely to deliver by caesarean section. The cost of delivery may not be a factor, because in Indonesia all types of deliveries are free of charge or covered by the Indonesian National Health Insurance, including caesarean sections (Consumer News and Business Channel Indonesia, 2021) as long as they are medically indicated rather than a personal request. This is in line with the sustainable development goal of developing universally accessible healthcare. This makes it surprising that a caesarean section is associated with a lower wealth quintile, as it is likely to be those of a higher quintile who can afford to request one, even if it is not medically indicated. However, previous research has indicated that pregnant women with low economic quintiles have a greater likelihood of developing labour complications. This can happen because of a lack of knowledge, as well as inadequate intake of nutrients during pregnancy (Larson, 2007; Bakken et al, 2008). Therefore, women from lower socioeconomic means with high-risk pregnancies may be more likely to give birth by caesarean section, to ensure the health of the mother and child.
Mothers who visited antenatal care more than four times were more likely to have a caesarean section. This is consistent with research in Mexico that showed that women who had more than four antenatal care visits planned a caesarean section rather than a vaginal delivery (Heredia-Pi et al, 2014; Guendelman et al, 2017). This was because of problems during pregnancy that required frequent antenatal care visits, resulting in the decision to have a caesarean section. Providing successful and effective antenatal care could prevent and detect potential causes of obstetric complications and avoid the death of newborns and stillbirths (WHO, 2016b). The results of the present study indicated that more than 90% of the participants had more than four antenatal care visits. In Indonesia, there is a health insurance regulation where if a mother routinely undergoes antenatal care visits at a government health facility at the start of their pregnancy, the cost of childbirth will be covered, improving attendance. It is likely that increased attendance allows concerns to be identified earlier in a pregnancy, and caesarean section may be recommended as a result to preserve the health and wellbeing of the mother and the baby.
Second- and higher order births had lower odds of being delivered via caesarean section compared with first-order births. This is in line with research in Ghana, where health facility records showed that women who gave birth to more than four children were less likely to give birth via caesarean section (Seidu et al, 2020). In another study, it was found that mothers elected to have a caesarean section for their first child because they were concerned about the successful delivery of the child, as well as having a general fear of childbirth (Toohill et al, 2014). In addition, first-time expectant women experience more anxiety and fear of labour pain during birth, and therefore opt to give birth by caesarean section (Haines et al, 2012; Størksen et al, 2015). In previous studies, more first-time expectant women in Indonesia gave birth by caesarean section than multiparous women and subsequently decreased in overall multiparity (Sihombing et al, 2017).
Women who had a ‘not difficult’ distance to travel to a health facility were more likely to choose a caesarean section. The Indonesian government mapped the distribution of health facilities to mean that most women have access to one (Mahendradhata et al, 2017). Additionally, first-rate health facilities in Indonesia are able to provide caesarean section either by medical indication or according to individual request. Previous studies have stated that with the close proximity of a health facility, the choice to give birth by caesarean section is more likely to be made, out of consideration of the health and safety of the mother and child (Amaral et al, 2013; Vieira et al, 2015). For this reason, the ease of access to these facilities, particularly in rural areas, needs to be considered by the Indonesian government.
Strength and limitations
This research has determined factors associated with caesarean section, including education and antenatal care visits. This research provides national statistics from data taken across all regions in Indonesia. Thus, it can provide an interpretation of the determinants of caesarean sections across the whole of Indonesia.
The policy and equitable distribution of facilities in rural areas of Indonesia need to be taken into account, so that people who live far from urban areas have the option of a safe delivery process via caesarean section. In addition, this research showed that characteristics of a mother (maternal age>35 years, urban residence, high level of education, poorest wealth index, more than four visits to antenatal care centres, no problems accessing health facilities and first-time birth) have an important role in the selection of the birth process.
The limitations of this study are that other factors, such as those from a husband or other family members and the influence of culture and beliefs, were not included and require further exploration to provide more detailed information on the determinants of the decision to choose a caesarean section. Additionally, no information was gathered on the indications for caesarean section, meaning it is not possible to elucidate whether one was undertaken for medical reasons or by maternal request.
Conclusions
Overall, the number of caesarean deliveries in Indonesia was found to be 17.7%. In Indonesia, a caesarean section was more likely to occur for older women (35–47 years), those with a high level of maternal education, those living in a urban area, those who visited antenatal care four or more times, those who live in close proximity to a health facility and those who were giving birth for the first time. In addition, women from the poorest wealth quintile were more likely to have a caesarean section. Further monitoring and evaluation of the increasing number of caesarean sections without medical indication and the severity of labour in Indonesia is needed. Continuous health education for pregnant women is important to reduce the risk of pregnancy complications and ensuring a normal, healthy birth.
Key points
- The prevalence of caesarean sections in Indonesia was found to be 17.7%.
- A total of 12 789 mothers participated in the 2017 Indonesian Demographic Health Survey and were analysed for determinants of birth by caesarean section.
- Demographic data should be considered during caesarean section delivery in Indonesia as multiple factors were associated with increased likelihood of caesarean section, including higher education and more antenatal care visits.
- A monitoring and evaluation program should be initiated by the Indonesian government.
CPD reflective questions
- Do you think the prevalence of caesarean sections will continue to rise globally?
- What effect are higher numbers of caesarean sections likely to have?
- Why do you think mothers are more frequently choosing to give birth by caesarean section, despite the risk of short- and long-term effects?