Purpose: To explain the strong wealth gradient in the incidence of cesarean births in India and identify opportunities for policy interventions.
Method: Using data from the 2005-06 National Family Health Survey (NFHS), we employ multivariate regression methods to identify sources of variation in cesarean births, by wealth.
Result: The rate of cesarean births rises sharply with wealth and is 27 percentage points higher in the richest quintile of household wealth than in the poorest quintile in the urban sample; the difference in the rural sample is 23 percentage points. These differences are much higher than the 10 – 15 percent rate of cesarean births recommended by the WHO and cannot be fully explained by risk factors for a cesarean birth; less than half of the gradient is driven by factors such as maternal age, birth order, multiple pregnancy, and birth weight. Further investigation reveals that an additional 33 – 35 percent of the gradient is driven by delivery in private facilities, whether the woman and her partner have more than a high school education, and whether the woman has independence in making financial decisions. Even after accounting for these factors about 15 percent of the gradient remains unexplained (Figure 1).
Conclusion: Since risk factors that justify a cesarean birth account for less than half of the wealth gradient, our findings point towards a significant scope for policy interventions to address the misallocation in cesarean rates that vary by household wealth in India. 
See more of: The 33rd Annual Meeting of the Society for Medical Decision Making