Rising C-section use and the private maternal health care sector in Pakistan: evidence from the 2012-13 and 2017-18...

Pakistan is part of a global escalation in cesarean section (C-section) rates, raising concerns that medically unnecessary procedures are being performed-particularly within the private maternal health care sector. Some studies have shown that C-section rates are higher in private than in public health facilities, possibly due to timesaving and profit-driven incentives among private-sector physicians. Consequently, Pakistan's private health facilities may be more likely to perform nonessential C-sections than its public facilities. Building on these concerns, this paper examines how delivery at a private versus public facility in Pakistan affects the likelihood of a C-section, and how this likelihood has evolved over time.

We used data from the 2012-13 and 2017-18 Pakistan Demographic and Health Surveys. Unlike previous studies, we employed a conceptual framework to identify predictors and used a Heckman probit model to adjust for selection bias-recognizing that access to facilities offering C-sections varies across sociodemographic groups. The model conceptualized childbirth as a two-step process: determining, first, the place of delivery (home versus facility), and second, the mode of delivery (vaginal versus C-section).

Accounting for selection bias and controlling for medical factors, women who delivered at private facilities were more likely to have a C-section. This likelihood increased from 3.6 to 14.2%-points between surveys. The larger gap in 2017-18 reflected an increase in the probability of a C-section in private facilities and a decrease in the probability of one in public facilities.

These findings suggest that C-sections are increasingly performed for nonmedical reasons, especially in private facilities where financial incentives and weak regulation may influence decisions. Considering community misconceptions and varied attitudes toward childbirth, culturally sensitive public education is needed. Targeted workshops and media campaigns can provide women and families with clear information on the risks and long-term consequences of unnecessary C-sections.