Determinants of high cesarean section rates in resource-constrained healthcare system, Peshawar, Pakistan.

Abstract

Objective: To investigate the key determinants of high CS rates in Peshawar’s resource-constrained healthcare system, exploring both demand-side (patient-related) and supply-side (healthcare provider and facility-related) factors. Study Design: Mixed-method approach. Setting: Three Major Hospitals from Peshawar Including Lady Reading Hospital, Hayatabad Medical Complex and Rehman Medical General Hospital. Period: January 2023 to December 2023. Methods: A hospital-based mixed-methods study was conducted across three major public and private facilities (N=221 CS cases). Quantitative data from medical records were analysed using multivariate logistic regression to identify independent predictors. Complementary in-depth interviews with providers (n=15) and mothers (n=15) explored decision-making processes. Results: The CS rate among study facilities was 48.6%, far exceeding WHO recommendations. Key independent predictors included: private hospital delivery (aOR=3.24, 95% CI:1.87-5.61), previous CS (aOR=4.83, 95% CI:2.42-9.65), low-income status (aOR=2.67, 95% CI:1.51-4.72), and primiparity (aOR=2.15, 95% CI:1.25-3.71). Qualitative data revealed three major themes: (1) defensive medical practices in private sectors, (2) inadequate labour monitoring leading to "failure to progress" diagnoses, and (3) socioeconomic perceptions of CS as superior care. Paradoxically, low-income women had higher CS rates despite typically facing access barriers. Conclusion: Multiple modifiable factors drive unnecessary CS in Pakistan's resource-constrained setting, particularly in private facilities and among disadvantaged populations. Targeted interventions should include: VBAC protocol implementation, provider training on labour management, and policy reforms addressing perverse financial incentives. The inverse socioeconomic gradient warrants particular attention in future research and programming.