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.