Temporal changes in socio-economic inequality in distress financing for caesarean deliveries in India, 2015-21
1
Department of Population and Development, International Institute for Population Sciences, Mumbai, India
2
Department of Economics, Virginia Tech, Blacksburg, United States
Popul. Med. 2026;8(Supplement Supplement 1):A1320
ABSTRACT
INTRODUCTION:
The global rise in caesarean deliveries has heightened financial risks for poorer populations, particularly in low- and middle-income countries. In India, caesarean rates increased from 17.2% in 2015 to 21.5% in 2021. Using data from the last two rounds of National Family and Health Surveys (NFHS), this paper tests the hypothesis of whether the socio-economic (SES) inequality in distress financing for caesarean deliveries has increased in India.
METHODS:
We analysed 67497 caesarean births using data from the last two rounds of the National Family and Health Survey (NFHS) conducted in 2015–16 and 2019–21. Births for which the out-of-pocket (OOP) payment was met by selling properties/jewellery or borrowing from friends, relatives, and money lenders were labelled distress financing. The independent variables analysed were time, health insurance coverage, OOP payments, wealth status, place of delivery, birth order, mother's age, education, caste, and religion. We have used descriptive statistics, bivariate analyses, and decomposition analyses to understand the changes in socio-economic variations and inequality in distress financing.
RESULTS:
Distress financing declined nationally from 31.2% in 2015-16 to 23.1% in 2019-21 (-8.16 percentage point change; 95% CI: -9.29, -7.03). The decrease in distress financing has been observed across socio-economic groups in the country. The concentration index improved from -0.275 to -0.165, indicating reduced SES inequality in distress financing for caesarean delivery in India. Among all states, Bihar had the highest SES inequality in distress financing for caesarean delivery (CI: -0.327; std. error: 0.032), while Himachal Pradesh had the lowest (CI: -0.050; std. error: 0.020). However, state-level disparities persist. Decomposition analysis shows wealth and maternal education as key drivers of inequality.
CONCLUSIONS:
Rising caesarean rates and persistent interstate inequities suggest uneven policy effectiveness. Targeted reforms to reduce financial hardship and promote equitable access to maternal health services are needed.
The global rise in caesarean deliveries has heightened financial risks for poorer populations, particularly in low- and middle-income countries. In India, caesarean rates increased from 17.2% in 2015 to 21.5% in 2021. Using data from the last two rounds of National Family and Health Surveys (NFHS), this paper tests the hypothesis of whether the socio-economic (SES) inequality in distress financing for caesarean deliveries has increased in India.
METHODS:
We analysed 67497 caesarean births using data from the last two rounds of the National Family and Health Survey (NFHS) conducted in 2015–16 and 2019–21. Births for which the out-of-pocket (OOP) payment was met by selling properties/jewellery or borrowing from friends, relatives, and money lenders were labelled distress financing. The independent variables analysed were time, health insurance coverage, OOP payments, wealth status, place of delivery, birth order, mother's age, education, caste, and religion. We have used descriptive statistics, bivariate analyses, and decomposition analyses to understand the changes in socio-economic variations and inequality in distress financing.
RESULTS:
Distress financing declined nationally from 31.2% in 2015-16 to 23.1% in 2019-21 (-8.16 percentage point change; 95% CI: -9.29, -7.03). The decrease in distress financing has been observed across socio-economic groups in the country. The concentration index improved from -0.275 to -0.165, indicating reduced SES inequality in distress financing for caesarean delivery in India. Among all states, Bihar had the highest SES inequality in distress financing for caesarean delivery (CI: -0.327; std. error: 0.032), while Himachal Pradesh had the lowest (CI: -0.050; std. error: 0.020). However, state-level disparities persist. Decomposition analysis shows wealth and maternal education as key drivers of inequality.
CONCLUSIONS:
Rising caesarean rates and persistent interstate inequities suggest uneven policy effectiveness. Targeted reforms to reduce financial hardship and promote equitable access to maternal health services are needed.
| eISSN: | 2654-1459 |
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