Predictors of caesarean intent and effect of unmet health conditions: evidence from Kerala, India.

BACKGROUND

India's rising dependence on institutional childbirth through Caesarean sections has intensified both the health-related risks and the financial pressures experienced by women and their households. The escalating costs of Caesarean deliveries have become a significant source of out-of-pocket spending, with the burden falling most heavily on low-income families in Kerala.

OBJECTIVE

This study aims to identify the cognitive, emotional, and healthcare related predictors that influence women's intentions to opt for elective Caesarean delivery. It seeks to understand the underlying factors that shape this preference, using the theory of planned behavior framework, which emphasizes the role of attitudes, subjective norms, and perceived behavioral control in shaping behavioral intentions.

METHODS

Using a cross-sectional design, a structured household survey was conducted among 1,030 married women in Kerala planning future pregnancies. The main outcome measured was their stated intention to opt for a Caesarean delivery in a subsequent birth. Key predictors included unmet health needs, childbirth-related knowledge, depression severity, attitudes, subjective norms, and perceived behavioral control. Binary logistic regression and propensity score matching (STATA 14.0; p < 0.05) were applied to identify statistically significant associations.

RESULTS

Greater childbirth-related knowledge significantly lowered the likelihood of intending to choose a Caesarean delivery (intermediate knowledge: OR = 0.167; good knowledge: OR = 0.297). Depression severity displayed a nonlinear relationship: moderately severe depression reduced the intention to opt for a C-section (OR = 0.140), whereas severe depression substantially increased it (OR = 4.357). The most influential predictor was unmet healthcare need (OR = 27.876), a result further supported by propensity score matching.

CONCLUSION

Women's intentions to choose elective Caesarean delivery are strongly influenced by their level of knowledge, psychological well-being, and access to healthcare. Strategies that strengthen health literacy, bolster mental health support, and reduce healthcare barriers may help decrease unnecessary C-sections and enhance maternal health outcomes.