Introduction

Background on caesarean sections in India

Caesarean section (CS) rates in India have been steadily increasing over the past decades, mirroring global trends. Based on findings from National Family Health Survey (NFHS)-5 (2019-21), the national CS rate in India has risen to 21.5%, a significant increase from 17.2% in NFHS-4 (2015-16) [1]. The percentage of deliveries conducted through cesarean section in public health facilities within Gajapati district has increased to 16.5% according to NFHS-5, compared to 10.6% as reported in NFHS-4 [1]. This trend raises concerns about the potential over-medicalization of childbirth and associated risks, while also highlighting improvements in access to emergency obstetric care.

The rise in CS rates is not uniform across India's diverse population. Urban areas consistently report higher rates compared to rural regions, and significant inter-state variations exist. These disparities are often attributed to differences in healthcare infrastructure, socioeconomic factors, and cultural practices surrounding childbirth [2].

Importance of studying tribal vs. non-tribal differences

The share of India’s total population that belongs to tribal group is 8.6% [3], often experience unique health challenges and disparities in healthcare access. Studying CS patterns in tribal versus non-tribal populations is crucial for several reasons:

1. Health Equity: Understanding disparities in CS rates and indications can highlight potential inequities in obstetric care access and quality between tribal and non-tribal communities [4].
2. Cultural Competence: Tribal populations may have distinct cultural practices and beliefs surrounding childbirth, which can influence healthcare-seeking behaviors and acceptance of interventions like CS [5,6].
3. Healthcare Planning: Identifying specific patterns and needs in tribal populations can inform targeted interventions and resource allocation to improve maternal and neonatal outcomes [6,7].
4. Epidemiological Insights: Comparative analysis may reveal unique risk factors or protective elements in tribal populations, contributing to our understanding of obstetric health determinants [8,9].

Research objectives

This study aimed to conduct a comprehensive analysis of cesarean section (CS) patterns, indications, and outcomes among PVTG and non-PVTG populations at a district headquarters hospital in a tribal-dominated district of Odisha, India. The specific objectives are:

1. To compare CS rates and primary indications between PVTG and non-PVTG women.
2. To analyze the differences in APGAR scores of neonates born via CS in both populations.
3. To examine the distribution of CS cases across the Robson Classification groups in PVTG and non-PVTG women.
4. To investigate the impact of maternal age on CS rates in both populations.
5. To assess temporal patterns in CS delivery between tribal and non-tribal groups

Methodology

The current study, designed as a prospective observational investigation, took place at the 161-beded District Headquarter Hospital, Paralakhemundi, Gajapati district, India, which is the only First referral Unit (FRU) of the tribal dominated district. The study encompassed a comprehensive analysis of caesarean section (CS) data collected over a 13-month period, from October 2023 to October 2024.

Study Design

The data collection instruments were specifically designed with the existing hospital records in mind, and the study employed a prospective observational design. By collecting data without manipulating variables, this methodology allows for a broader examination of CS patterns and related factors in clinical practice.

Setting

The present study was conducted at the District Headquarter Hospital, Paralakhemundi, Gajapati District of Odisha State, India. This facility is the only FRU serving the entire district, which includes both PVTG and non-PVTG populations, hence offering a rare chance of looking into differences in obstetric assessment between these two groups. According to the 2011 census, the district’s population comprises 577,817 individuals, with a significant proportion of approximately 54.31% identified as members of PVTGs.

Data Collection

The data collection process was meticulously structured to extract relevant information from hospital records, ensuring strict adherence to patient privacy protocols, while minimizing any disruption to ongoing patient care. The extraction was performed contingent upon the availability and completeness of the records.

Sample Size and Population

The study analyzed a total of 1,374 caesarean sections performed during the specified period. The samples were then stratified into two groups.

1. Tribal population: n = 177 (12.88%)
2. Non-tribal population: n = 1,197 (87.12%)

This stratification allowed for a comparative analysis between the two populations with an adequate sample size to detect statistically significant differences.

Variables Studied

The following variables were extracted from the medical records and analyzed.

1. Indications for C-sections: Categorized according to standard obstetric classifications, including but not limited to cephalopelvic disproportion (CPD), oligohydramnios, postdatism, fetal distress, and previous CS.
2. APGAR scores: Collected 1 minute and 5 minutes subsequent to the delivery. providing an assessment of neonatal outcomes. The scores were categorized as 5, 6, 7, 8, 9, and 10.
3. Robson classification: Cases of CS were classified using the Ten-Group Robson Classification system, which categorizes women based on their obstetric characteristics.
4. Maternal age: Recorded in years and analyzed both as a continuous variable and in age groups to identify age-related trends in CS rates.
5. Time of delivery: Categorized into five shifts (A,B,C,D, and E) corresponding to different time periods throughout the day and night.

Statistical Analysis Methods

The dataset was analyzed through IBM SPSS Statistics (version 26.0), establishing a statistical significance criterion of p-value < 0.05, and the strength of associations was quantified using appropriate effect size measures, such as Cramer's V for chi-square tests. Sensitivity analyses, including an examination of outliers and the impact of missing data, were performed to ensure the robustness of the findings. Additionally, 95% confidence intervals (CI) were calculated for the key outcome measures to provide a range of plausible population values.

Ethical Consideration:

The Institutional Review Board (IRB) of the Jodhpur School of Public Health has given ethical authorization for this study with approval identifier: JSPH/IRB/2024/04/06, dated April 27, 2024.

Results

Indications for C-sections (Table 1)

Most common indications in both groups

The analysis of caesarean section (CS) indications revealed notable patterns across tribal and non-tribal populations. In both groups, the most prevalent indications were as follows:

a) Previous Caesarean section: This was the leading indication, accounting for 29.9% (n=53) of tribal and 39.3% (n=471) of non-tribal CS cases. This high prevalence underscores the significant impact of prior CS on subsequent delivery modes.

b) Presumed Fetal Distress/IUGR/Abnormal CTG: This category represented 20.9% (n=37) of tribal and 21.0% (n=251) of non-tribal CS cases, indicating a consistent concern for fetal well-being across both populations.

c) Oligohydramnios: This condition accounted for 12.4% of CS in both the tribal (n=22) and non-tribal (n=149) groups, suggesting a uniform approach to managing this obstetric complication.

Significant differences between tribal and non-tribal populations

Although there were points of similarity, it was evident that several noteworthy distinctions existed:

Malpresentation/Unstable Lie: The tribal population exhibited a higher proportion of CS due to this indication (4.0%, n=7) compared to the non-tribal group (1.0%, n=12). This disparity may suggest differences in antenatal care or genetic factors that influence fetal positioning.

Long Period of Infertility: This indication was exclusive to the non-tribal population (1.8%, n=21), potentially reflecting disparities in access to fertility treatments or the reporting of infertility issues.

Previous Poor Obstetric Outcome (BOH): The tribal population showed a higher rate of CS due to this indication (4.5%, n=8) compared to the non-tribal group (1.3%, n=15), suggesting potential differences in obstetric history or risk assessment practices.

The statistical evaluation conducted through Pearson's Chi-Square test (χ² = 112.000, df = 104, p = 0.279) and Fisher's Exact Test (p = 1.000) indicated no statistically significant differences in the indications for CS between the two groups under investigation. However, the Linear-by-Linear Association test (χ² = 12.259, df = 1, p < 0.001) suggested a significant trend in the distribution of indications across groups.

APGAR Scores

Distribution of scores at 1 and 5 minutes

The APGAR score distribution revealed interesting patterns:

At 1 minute:

• Score 10: 8.3% in both tribal (n=36) and non-tribal (n=334) newborns
• Score 9: 8.3% in both groups (tribal n=103, non-tribal n=633)
• Score 8: 8.3% in both groups (tribal n=35, non-tribal n=217)
• Score 6: 8.3% in both groups (tribal n=4, non-tribal n=5)

At 5 minutes:

• Score 10: 8.3% in both groups (tribal n=178, non-tribal n=1166)
• Score 9: 8.3% in both groups (tribal n=1, non-tribal n=11)
• Score 8: 8.3% in both groups (tribal n=3, non-tribal n=7)
• Score 6: 8.3% in non-tribal group (n=1), not observed in tribal group

Comparative Analysis of Newborns: PVTGs Versus Non-PVTGs

The distribution of APGAR scores appears remarkably parallels between newborns of PVTG and Non-PVTG, with identical percentages across most score categories. However, the absolute numbers differed substantially owing to the larger non-tribal sample size.

Statistical analysis using Pearson's Chi-Square test (χ² = 84.000, df = 56, p = 0.009) and Fisher's Exact Test (p = 0.010) indicated notable statistical disparities observed in the distribution of APGAR scores across the two populations. The Linear-by-Linear Association test (χ² = 10.909, df = 1, p = 0.001) further supported a significant trend in the score distribution across the groups.

Robson Classification (Table 3)

Distribution across Robson groups

Examination of CS cases using the Robson Classification yielded the following distribution:

a) Robson Group 1 (Nulliparous Women, single cephalic presentation, gestational age ≥37 weeks, spontaneous onset of labor): Predominant in both populations, accounting for 44.8% (n=82) of tribal and 44.9% (n=534) of non-tribal CS cases.

b) Robson Group 5 (History of Previous CS, single cephalic fetus, Gestational Age ≥37 weeks): second most common, representing 28.4% (n=52) of tribal and 41.0% (n=488) of non-tribal CS cases.

c) Robson Group 3 (Multiparous Women with No Prior CS, single cephalic presentation, Gestational age ≥37 weeks, spontaneous labor Onset): More prevalent in the tribal population (13.1%, n=24) compared to non-tribal (5.3%, n=63).

Key differences between PVTGs and non-PVTGs C-sections

Several notable differences were observed:

a) Robson Group 5: The incidence of CS within this cohort was markedly elevated in the non-PVTG group, accounting for 41.0%, in contrast to the PVTG population, which exhibited a rate of 28.4%, suggesting a higher rate of repeat CS in the non-tribal group.

b) Robson Group 3: The tribal population showed a higher proportion of CS in this group (13.1%) in comparison to the non-PVTG population (5.3%), indicating potential differences in labor management for multiparous women without previous CS.

c) Robson Group 7 (Multiparous, breech): A notably increased prevalence was recorded within the PVTG population, reflecting 2.7% (n=5), in comparison to the non-PVTG cohort, which demonstrated a significantly lower rate of 0.2% (n=2), suggesting potential differences in breech presentation management or detection.

Statistical analysis using Pearson's Chi-Square test (χ² = 63.333, df = 56, p = 0.234) and Fisher's Exact Test (p = 1.000) did not reveal statistically significant overall differences in Robson Classification distribution between the two populations. However, the Linear-by-Linear Association test (χ² = 8.344, df = 1, p = 0.004) indicated a significant trend in distribution across the groups.

Maternal Age Distribution (Table 4)

Age-wise frequency of C-sections

The analysis of maternal age distribution revealed a complex pattern of CS frequencies across different age groups:

a) Peak CS frequency:

• Tribal population: Age 24 (11.9%, n=21)
• Non-tribal population: Age 23 (11.7%, n=137)

b) Age range with highest CS incidence:

• Tribal: Ages 18-24 (59.4%, n=105)
• Non-tribal: Ages 21-25 (47.5%, n=557)

c) Adolescent CS rates (≤19 years):

• Tribal: 16.4% (n=29)
• Non-tribal: 11.5% (n=135)

d) Advanced maternal age (≥35 years):

• Tribal: 3.4% (n=6)
• Non-tribal: 2.1% (n=24)

Comparison of age patterns in PVTG Versus Non-PVTG women

Several notable differences in age-related CS patterns were observed:

a) Early childbearing: The tribal population exhibited a higher proportion of CS in younger age groups (18-20 years: 23.2%, n=41) compared to the non-tribal population (19.3%, n=226).

b) Peak childbearing age: The non-tribal population showed a more concentrated peak in CS rates around ages 22-23 (23.1%, n=271), whereas the tribal population had a broader distribution across ages 22-24 (28.3%, n=50).

c) Advanced maternal age: Both populations showed declining CS rates after age 30, but the tribal population maintained a slightly higher proportion in the 30-34 age range (11.3%, n=20) compared to the non-tribal population (8.8%, n=102).

Statistical analysis using Pearson's Chi-Square test (χ² = 350.000, df = 308, p = 0.050) and Fisher's Exact Test (p = 0.004) indicated statistically significant differences in the overall distribution of maternal ages between the two populations. The Linear-by-Linear Association test (χ² = 20.177, df = 1, p < 0.001) further supported a significant trend in the age distribution across the groups.

Time of Delivery

Discussion

Interpretation of key findings and comparison with existing literature

Implications of differences in C-section indications

a) Previous CS predominance: The high prevalence of repeat CS (29.9% tribal and 39.3% non-tribal) underscores the cascading effect of primary CS on subsequent deliveries. This trend aligns with global concerns about rising CS rates stated by Harihar et al. [10] and Betrán et al. [11], and emphasizes the need for judicious use of primary CS and promotion of vaginal birth after caesarean (VBAC) when appropriate.

b) Fetal distress concerns: The consistent rate of CS due to presumed fetal distress/IUGR/abnormal CTG (20.9% tribal and 21.0% non-tribal) suggests uniform vigilance in fetal monitoring [12]. Nonetheless, it simultaneously prompts inquiries regarding the specificity of existing diagnostic criteria and the potential for overintervention, which contrasts with the findings of Li et al.[13], who reported a correlation between CS rates and lower APGAR scores.

c) Malpresentation disparities: The high CS incidence due to malpresentation is more prevalent in the tribal population (4.0% vs. 1.0%) and warrants investigation into potential contributing factors such as nutritional status, pelvic anatomy variations, or differences in antenatal care practices.

d) Infertility-related CS: The exclusive presence of long-period infertility as a CS indication in the non-tribal group (1.8%) highlights potential disparities in access to fertility treatments or reporting of infertility issues, as observed by Contractor et al. [14] in their study of tribal maternal health in Odisha.

Analysis of APGAR score patterns

a) Uniformity in score distribution: The identical percentages of APGAR scores across most categories for both populations (8.3% for scores 6-10 at 1 and 5 minutes) suggest a standardized approach to neonatal assessment. However, this uniformity is atypical and warrants careful examination of scoring practices, in contrast to the findings of Li et al. [13], who reported greater variability in the APGAR scores.

b) Absence of low APGAR scores: The lack of reported scores below six in both populations is noteworthy. This could indicate excellent perinatal care or, alternatively, the potential underreporting of adverse outcomes. Further investigations of neonatal resuscitation practices and documentation procedures are advisable.

c) Improvement at 5 minutes: The shift towards higher scores at 5 minutes, particularly the increase in score 10 (from 36 to 178 in tribal, 334 to 1166 in non-tribal), aligns with the expected patterns of neonatal adaptation. However, the magnitude of the improvement warrants further validation.

Significance of Robson classification variations

a) Nulliparous term singleton vertex (NTSV) prevalence: The high proportion of Robson Group 1 in both populations (44.8% tribal, 44.9% non-tribal) aligns with the global trends reported by Vogel et al.[15], but exceeds the WHO recommendations. This suggests a need for interventions to reduce primary CS rates in low-risk pregnancies.

b) Previous CS impact: The markedly higher rate of Robson Group 5 in the non-tribal population (41.0% vs. 28.4% tribal) indicates a more entrenched cycle of repeat CS. This disparity necessitates targeted efforts to promote VBAC and reduce primary CS rates in the non-tribal group, this observation aligns with the results reported by Vogel et al.[15].

c) Multiparous spontaneous labor: The higher proportion of Robson Group 3 in the tribal population (13.1% vs. 5.3% non-tribal) suggests potential differences in labor management or the threshold for intervention in multiparous women without previous CS.

Impact of maternal age on C-section rates

a) Early childbearing in the tribal population: The higher proportion of CS in younger age groups among tribal women (23.2% vs. 19.3% in ages 18-20) highlights the need for targeted antenatal care and obstetric services for young tribal mothers, similar to the findings of Cavazos-Rehg et al. [16] on maternal age and adverse birth outcomes.

b) Concentrated childbearing period in the non-tribal population: The more pronounced peak in CS rates around ages 22-23 in the non-tribal group (23.1%) suggests a narrower window of prime reproductive years, potentially influenced by socioeconomic factors or family planning practices, as observed in the study by Cavazos-Rehg et al. [16].

c) Advanced maternal age considerations: The slightly higher proportion of CS in the 30-34 age range among tribal women (11.3% vs. 8.8% non-tribal) warrants attention to the unique obstetric needs of older tribal mothers, thus contributing to the literature on maternal age and obstetric outcomes [17-19]

Relevance of delivery timing differences

a) Daytime predominance: While both groups showed a highest preference for daytime CS (A shift), the non-tribal population exhibited a stronger tendency (69.0% vs. 56.9% in tribal). This suggests potential differences in healthcare-seeking behavior, provider availability, or elective CS scheduling practices, partially aligning with the findings of Snowden et al. [20] on temporal patterns in CS.

b) Evening surgeries: The tribal population had a notably higher proportion of CS during the B shift (38.5%) compared to the non-tribal population (28.1%). This may indicate delayed presentation to healthcare facilities or differences in the natural progression of labor.

c) Nocturnal CS prevalence in tribal women: The elevated rate of nighttime CS in the tribal population (4.1% vs. 1.4% non-tribal during D and C shifts combined) raises concerns about access to 24-hour obstetric services and potential delays in care-seeking or referral [21,22] contributing to the limited literature on time-of-day effects in obstetric care.

These findings collectively highlight the intricate interactions of biological, sociocultural, and health system factors [23] that influence CS patterns in tribal and non-tribal populations. The observed disparities highlight the need for tailored interventions addressing the unique obstetric needs of each group, with particular attention to reducing unnecessary primary CS, promoting VBAC, enhancing antenatal care for young tribal mothers, and improving round-the-clock access to quality obstetric services for tribal communities [24-28]

Conclusion

This study revealed significant disparities in CS patterns between the PVTGs and non-PVTG populations in Gajapati, India. Key findings include higher rates of CS due to malpresentation and among younger mothers in the tribal population and increased prevalence of repeat CS in the non-tribal group. Robson Classification analysis highlighted differences in CS distribution, particularly in Group 5. Temporal variations, notably higher nocturnal CS rates among tribal women, suggest disparities in 24-hour access to obstetric care.

These results emphasize the need for:

1. Enhanced, culturally sensitive antenatal care for tribal women

2. Targeted VBAC promotion strategies

3. Improved round-the-clock obstetric services in tribal areas

4. Standardized CS decision-making protocols

While providing valuable insights, the study's single-center, retrospective design limits causal inferences and generalizability. Future multi-center, longitudinal research is warranted to elucidate the underlying factors and evaluate the long-term intervention impacts.

Addressing these disparities requires a multifaceted approach combining targeted clinical interventions, strengthening the health system, and contextually relevant public health interventions aimed at enhancing maternal and neonatal health outcomes in this diverse population.

Conflict of Interest

The authors declare that they have no competing interests.

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