Socioeconomic, geographic and health system factors associated with rising C-section rate in Indonesia: a cross-sectional study using the Indonesian demographic and health surveys from 1998 to 2017.

Introduction Caesarean section (C-section) has been a public health concern globally. This study investigated the change in C-section rate in 1998–2017 in Indonesia and explored the socioeconomic, geographic and health system factors associated with the use of C-section. Methods We analysed data from demographic health surveys in 2002–2003, 2007, 2012 and 2017 in Indonesia. We included women who reported giving birth within 5 years of each round of the survey (n=56 462) into the analysis. Cross-tabulation was used to examine change of C-section rate by year. We conducted bivariate and multivariate logistic regressions to study the determinants of C-section use. Results In Indonesia, the C-section rate increased from 4.0% in 1998 to 18.5% in 2017. In 2017, the C-section rate in urban areas (22.9%) was almost two times that in rural areas (11.8%). It was almost three times among the richest wealth quintile (36.5%), compared with the poorest wealth quintile (12.9%). Between 2008 and 2017, the difference in the C-section rate by public services enlarged between the poorest and the richest groups. The absolute increase of the C-sections by private services was more than public services over time. In 2013–2017, the C-section rates by public and private services were 22.5% and 23.1%, respectively. After adjusting for all variables, higher education, higher household wealth, primiparity and use of public childbirth services were positively associated with C-section. Conclusions The C-section rate increased steadily in the past two decades in Indonesia. Women’s socioeconomic status and health system factors were associated with the increased use of C-section.