Introduction
Caesarean section (C-section) is a life-saving operation for women with pregnancy or delivery-related complications.1 However, C-section, like any surgery, is also associated with risks of short-term and long-term adverse maternal and neonatal outcomes, with 100 times higher risk in developing countries.2 Rapid increase in the C-section rate globally is a rising public health concern. Between 1990 and 2014, C-section rates increased from 6.7% to 19.1% globally, with a 4.2% rise in less developed countries and a 12.7% rise in more developed countries. 3 Complex social, cultural, economic, and health system factors are known drivers of C-section use. The co-existence of underuse and overuse of C-section in many low- and middle-income countries represent challenges for the health systems from perspectives of equity and efficiency.1,4,5
In Indonesia, the C-section rate has grown from 2% in 1991 to 16% in 2012. A previous study in Indonesia reported that rich and well-educated women were most likely to have C-section, at rates of 11.2% and 20.0% respectively in 2012.6 The most commonly cited reason for C-section in Indonesia from reporting hospitals in 2005 was malpresentation, representing 5.5% of all births, while maternal request without medical indication represented 2.2% of all births.7
The Indonesian health system has undergone transition over the past 20 years. Health services delivery has a mixture of public and private providers. Public health services have been decentralized in administration with central, provincial, and district government responsibility. The Ministry of Health is in charge of financial and human resource distribution.8,9 There is a range of private providers including not-for-profit and for-profit providers as well as individual doctors and midwives who engage in dual practice in both public and private health facilities.10,11,12 In 2014, the government of Indonesia introduced the national health insurance scheme (JKN), which covers childbirth care provided by both public and private providers. The national health insurance scheme provides payment determined by group-based cases for C-section. Payment is determined by region, hospital level, luxury service class, and severity of health complications.8,13,14
This study investigated the change of C-section rate by location, women’s socio-demographic characteristics, and childbirth service use from 1998 to 2017 in Indonesia. We examined the factors associated with the use of C-section and analyzed implications of socioeconomic and health system development on the use of C-section in Indonesia.