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.