Interpretation
The increase in the use of C-section in Indonesia may reflect
availability and acceptability of this health technology, which are
associated with health system development and social environment change.
Indonesia has increased investment in health infrastructure and training
health professionals.8,15,16,17 The government of
Indonesia has encouraged cooperation with private institutions. In the
past two decades, inpatient beds in both public and private hospitals as
well as primary health centers have increased, while the distribution
and quality of health facilities has shown significant geographical
disparity across regions.8,6,18 In this study, we
observed a dramatic decrease in homebirth over time and an increase in
the use of both public and private services for childbirth. We found
higher C-section rates in urban areas and the relatively developed
western region. However, there was no significant disparity in the use
of C-section after adjusting for women’s demographic and socio-economic
characteristics.
It has been argued that maternal request for C-section rather than
medical indication contributes to the rise of C-section rate in many
settings worldwide. In previous studies, the most common reasons for
maternal request for C-section included fear of labor pain or trauma and
perceived benefits to the mother, such as a feeling of control or
mitigation of pelvic floor injury among
others.5,19,20,21 It is not surprising that C-section
rate is high among those who are willing and able to pay for the
services rather than medical indications. Consistent with other studies
in Southeast Asian countries and other developing countries, we found
that women who were well educated, from wealthy households and
primiparous were more likely to have
C-section.22,23,24,25,26 However, there is a growing
body of evidence on increased risks of unnecessary C-section to newborns
and mothers.2 It also has a negative impact on health
system efficiency in terms of value-based health services delivery and
equity in health.1,4
In 2014, the government of Indonesia launched the national health
insurance scheme (JKN), aiming for universal population coverage. The
national health insurance scheme provides a case-based payment for
C-section in both public and private hospitals. The total cost of
C-section and its related hospital services varied by hospital facility
class and severity of complications, but was often higher than the
amount covered by JKN.13 Tariff payments from public
insurance to cover the cost of the operation range from $295 USD in an
ordinary class 3 facility with few complications to $513 USD in a class
1 VIP facility with heavy complications.14 Women have
to pay the cost beyond the health insurance coverage
out-of-pocket.13,27 Previous analysis from the
Indonesian Family Life Survey reported 13.6% of all JKN users suffered
from catastrophic delivery expenditure in 2019.28 Long
hospital stays, pregnancy complications, and upgrades to more luxurious
facilities were major contributors to high out-of-pocket
payments.13,27 There is a positive association between
health insurance coverage and pre-labor planned C-section use in
Indonesia.29
Inconsistent with findings in other developing countries, Indonesian
C-section rate by public services was higher than that by private
services in 1998-2012.24,25,30,31 The low rate of
C-section in private services may be partially due to the large numbers
of births occurring in private clinics only attended by midwives, as we
found in this study. However, C-section rate by private services
increased rapidly over time with a decrease in the percentage of midwife
services, which may indicate the increase of availability and
accessibility to private obstetric hospital services over time. In our
study, the C-section rates among the richest women increased almost the
same in private and public services. In Indonesia, the central
government provides the salary of health professionals and operational
costs to run public health facilities. However, most public health
facilities and still need to rely on user fees for financial and
institutional sustainability, promoting profit-maximizing
behavior.8,9 In this study, we found the difference in
C-section rate in public health facilities enlarged between the poorest
and the richest wealth quintiles between 2008 and 2017, showing a
decrease in C-section rate among the poorest group while a significant
increase among the richest group. This may suggest childbirth care
facilities are pursuing profits through performing C-section for those
who are able to pay in public health facilities as is the case in other
countries.5,32 Profit maximizing behavior could reduce
the accessibility of C-section to socially disadvantaged women without
suffering from catastrophic payment.