Discussion

This study addresses the spatial, maternal, and socio-demographic variables associated with the probability of Indonesian women having CS method for their latest delivery.

Spatial Variables

Many studies have demonstrated spatial inequalities of CS deliveries across regions within a country, such as in Egypt (Khawaja, Kabakian-Khasholian, & Jurdi, 2004), rural China (Klemetti et al., 2010), Bangladesh (Kamal, 2013), and Nepal (Prakash & Neupane, 2014). Higher CS rate in urban areas has also been shown in previous studies (Arrieta, 2011; Collin, Anwar, & Ronsmans, 2007; Kamal, 2013; Magadi, Agwanda, Obare, & Taffa, 2007; Prakash & Neupane, 2014; Ronsmans, Holtz, & Stanton, 2006). Contrary to previous literature, however, the present study does not indicate significant spatial inequalities in CS delivery both across regions and between urban and rural areas. In terms of region, Java region was chosen as the reference category due to its large population size (Statistics Indonesia, 2010). Women residing in the residing in Sumatera region have a higher probability of CS delivery compared to those living in Java region. It is observed that CS deliveries in other regions were not statistically different from that in the reference region. In terms of place of residence, the probability of CS in urban women is not significantly higher than that in rural women.

Maternal Variables

Maternal Age

In terms of maternal age, previous literature finds that maternal age is positively associated with likelihood of having CS as method of delivery (Arrieta, 2011; Bragg et al., 2010; Hsu, Liao, & Hwang, 2008; Khawaja et al., 2004; Klemetti et al., 2010; Liu, Chen, Tsai, & Lin, 2007; Ma, Norton, & Lee, 2010; Magadi et al., 2007; Maharlouei, Moalaee, Ajdari, Zarei, & Lankarani, 2013; Neuman et al., 2014; Nilsen, Ostbye, Daltveit, Mmbaga, & Sandoy, 2014; Prakash & Neupane, 2014; Ribeiro et al., 2007). In this study, maternal age was classified into five categories with women aged 20 to 24 years was used as the reference group (Bragg et al., 2010). It is observed that teenage birthing (<20 years of age) is associated with lower probability of CS delivery compared to their reference counterpart. This is consistent with the previous finding (Bragg et al., 2010).
Moreover, women who gave birth at the age between 25 and 29 have a higher probability of CS delivery compared to those in the reference category. Women who gave birth at the age between 30 and 34 also have a higher probability of CS delivery compared to those who gave birth at the age between 20 to 24 years. Lastly, women who were aged 35 years and over when giving birth have a higher probability of CS delivery compared to women in the reference category. These are coherent with what previous studies suggest (Arrieta, 2011; Klemetti et al., 2010; Liu et al., 2007).

Parity

In this study, parity was operationalised in a three-category variable following that of Bragg and others’ study in 2010 (Bragg et al., 2010) where women who had no children prior to their latest delivery acts as the reference category. Bragg et al. (2010) demonstrated that multiparous women with (no) history of CS delivery have higher (lower) odds of undergoing CS procedure than nulliparous women. Similarly, this study observed that multiparous women with (no) history of CS delivery have a higher (lower) probability of CS delivery compared to reference women. These findings are consistent with that of previous studies as it has been shown that women with previous CS delivery are more likely to have another one (Liu et al., 2007; Ma et al., 2010).

Prenatal Complication

Existing studies agree that women with prenatal complications are at higher risk of CS delivery (Bragg et al., 2010; Ma et al., 2010). The result of this study is in line as it is observed that women who reported having any complications during their pregnancy have a higher probability of CS delivery than those who reported having none.

Prenatal Care Visits

The number of PNC visits was classified into four categories with none as the reference category. It is claimed that more PNC visits are associated with higher likelihood of CS delivery among women (Khawaja et al., 2004; Neuman et al., 2014). It is observed that women who reported having PNC visits for 1 to 3 times have a higher probability of CS delivery compared to those who reported having none. But it is not statistically significant at all conventional levels of significance (p = 0.149). Moreover, women who reported having PNC visits for 4 to 7 times have a higher probability of CS delivery compared to those who reported having none. Lastly, women who reported having PNC visits for 8 times or more have a higher probability of CS delivery compared to those who reported having none.

Private Health Facility Delivery

The last maternal variable in this study was birthing in private facility. It is claimed in previous literature that women who gave birth in a private health facility are more likely to have CS as their method of delivery than women who gave birth in a public health facility or at home (Ma et al., 2010; Mendoza-Sassi, Cesar, Silva, Denardin, & Rodrigues, 2010; Neuman et al., 2014; Ribeiro et al., 2007). In this study, it is found that women giving birth in a private health facility were of a higher probability of undergoing CS for their last delivery compared to those who gave birth in public health facility or at home. This is consistent with the findings of previous studies.

Sociodemographic Variables

Maternal Education

Most previous studies found a positive association between education and likelihood of having CS as a mode of delivery (Collin et al., 2007; Klemetti et al., 2010; Magadi et al., 2007; Mendoza-Sassi et al., 2010). However, other studies have suggested the opposite, namely that low-educated women are at higher risk of CS delivery (Hsu et al., 2008; Nilsen et al., 2014); or found no association (Kottwitz, 2014) when access to hospital care is taken into account. In this study, it is observed that education of mother is significantly and positively associated with the probability of CS delivery. For every one year increase in formal education of mother, the probability of getting CS for her latest delivery increases.

Health Insurance

It is observed that women with private health insurance cover have a higher probability of CS compared to those with no cover. This is fairly consistent with previous literature. A study on CS in rural China has shown indication of the positive and significant effect of health insurance cover on the probability of CS delivery (Long et al., 2012). Studies of CS in Taiwan also found a positive relationship, albeit statistically not significant, between health insurance cover and CS delivery (Hsu et al., 2008; Liu et al., 2007).

Household Wealth

In general, the association between wealth and CS delivery in the literature is positive (Arrieta, 2011; Collin et al., 2007; Cresswell, Assarag, Meski, Filippi, & Ronsmans, 2015; Kamal, 2013; Prakash & Neupane, 2014; Ronsmans et al., 2006). The results of the present study confirm previous studies, where being in higher wealth quintiles (second, third, fourth, and highest quintiles) corresponds to the higher probability of CS delivery compared to being in the lowest wealth quintile. A previous study on CS delivery in Indonesia suggests that wealth index is not only associated with the likelihood of CS delivery but also on the trends in rates of CS in women in the wealthiest quintile (Hatt et al., 2007).

Strengths and Limitations of the Study

This study has several strengths. First, the data used is nationally representative. Second, the questionnaire in the survey is internationally standardised and hence comparable to multiple countries. Third, the large sample size of IDHS means larger statistical power. However, this study was not free from limitations. One of which is the cross-sectional form of IDHS. Another limitation is that information sourced from IDHS are mostly retrospective and self-reported. Moreover, elective CS cannot be separated from emergency CS. Given these limitations, causal inference is not warranted.