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We used the data of all women who delivered at the Kasturba Maternity Hospital (KMH), a hospital managed by SEWA Rural, a voluntary, not-for-profit organization. KMH has been providing maternal and neonatal health services in this area since 1980 along with community-based services in surrounding areas [24]. The hospital functions in Jhagadia block of Bharuch in the western Indian state of Gujarat. The total population of Jhagadia block is around 185,000, of which 70% is tribal [11]. The hospital provides free clinical services to pregnant women and newborns. The hospital works as a first referral unit and is the largest provider of maternal health care in the Bharuch district and nearby areas. The study is based on secondary analyses of data which was primarily collected for delivery and monitoring of services at the hospital. The data is part of the hospital program to provide quality health services to the remote and tribal areas of Gujarat. The ethical approval for the use of this data has been obtained from SEWA Rural Institutional Ethics Committee (IEC). The SEWA Rural IEC reviewed this data and allowed its use for analyses and publication. The IEC have also waived the need for the informed consent of the patient, given that the anonymity of the patient will be maintained. Any personal information of the patient was removed from the datasets before analysis. We used the data of all women who delivered at the Kasturba Maternity Hospital (KMH), a hospital managed by SEWA Rural, a voluntary, not-for-profit organization. KMH has been providing maternal and neonatal health services in this area since 1980 along with community-based services in surrounding areas [24]. The hospital functions in Jhagadia block of Bharuch in the western Indian state of Gujarat. The total population of Jhagadia block is around 185,000, of which 70% is tribal [11]. The hospital provides free clinical services to pregnant women and newborns. The hospital works as a first referral unit and is the largest provider of maternal health care in the Bharuch district and nearby areas. The tribal population native to the study area is known as Vasava, and belongs to the Bhil tribe. As with other tribal communities, Vasava tribe has its own language and customs which are different from the mainstream culture; though this is changing as they are increasingly connected with the mainstream culture. Agriculture is the primary occupation with a large percentage of the population working as landless labourers [25]. KMH is a 200-bed tribal-friendly first referral unit providing CEmONC care to surrounding villages. The CEmONC services at the hospital include services from full-time clinicians including obstetricians, anaesthetists and internists. Along with the clinician, the hospital has a functional operation theatre, blood storage centre, ultrasound, and inpatient facility [24]. The mission of the hospital is to serve the most underprivileged tribal patients. Therefore, it is an empanelled provider for the government sponsored health insurance schemes to facilitate almost free or highly subsidized services to the poor.
Data sources and sample size: The hospital maintains a prospective registry for all admissions that is maintained by care providers and subsequently digitized by trained staff. A team of care providers including gynaecologists ensured the accuracy of the entire dataset, including that of indications and outcomes of all deliveries. Women who delivered from April 2010 to March 2016 were included in the study. The definition of tribal is as per the specifications from the government of India [26]. The description of admission and outcomes is shown in Fig 1.
Figure data removed from full text. Figure identifier and caption: 10.1371/journal.pone.0189260.g001 Number of deliveries and caesarean sections in KMH (2010–16), Bharuch, Gujarat. The deliveries were categorized as caesarean section and vaginal deliveries, and are the primary dependent variables. The potential determinants of caesarean section were maternal age, parity, maternal education, gestational week, haemoglobin status, government scheme, distance from the health facility and child’s gender. The adverse outcomes of deliveries examined for this analyses were still birth, low birth weight (less than 5.5 lbs/2500 grams), survival status of the neonate at the time of discharge from the hospital (case fatality rate) and birth asphyxia (no cry after delivery).
Rate, indication and outcomes of caesarean section were represented by percentages and counts comparing tribal and non-tribal women. Still birth rate and neonatal death rate are expressed per 1000 total (live + still) deliveries and per 1000 live births respectively. Logistic regression was used to estimate the odds ratio caesarean section by background characteristics as potential determinants. The odds ratio was adjusted for Mother’s age, Mother’s education, Parity, Mother’s haemoglobin, Gestational week, Child’s gender, Number of ANC visits by mother and Distance from the health facility. The odds ratio of caesarean section was estimated for tribal and non-tribal women. Decomposition analysis was done to decompose the differences in the rates of caesarean section between tribal and non-tribal women. Fairline modification of Blinder-Oaxaca decomposition for the logit models was used [27]. Various indications for caesarean section among tribal women were compared with non-tribal women. The odds ratio of each pregnancy outcome of caesarean section and vaginal deliveries was calculated. The odds ratios were separately calculated for caesarean section and vaginal deliveries comparing tribal and non-tribal women. All of the odds ratios were reported with 95% confidence interval. Strobe guidelines were followed for reporting the results. Microsoft Excel 2007 was used to compile the data and STATA Version 12.0 was used for statistical analyses [28].
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