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.