International Institute for Population Sciences
Deemed to be University (An Autonomous Organization of Ministry of Health & Family Welfare, Government of India)

Introduction: The global rise in caesarean deliveries has heightened financial risks for poorer populations, particularly in low- and middle-income countries. In India, caesarean rates increased from 17.2% in 2015 to 21.5% in 2021. Objective: Using data from the last two rounds of National Family and Health Surveys (NFHS), this paper tests the hypothesis of whether the socio-economic (SES) inequality in distress financing for caesarean deliveries has increased in India. Methodology: We analysed 67,497 caesarean births using data from NFHS-4 (2015–16) and NFHS-5 (2019–21). Births for which the OOP payment was met by selling properties/jewellery or borrowing from friends, relatives, and money lenders were labelled distress financing. The independent variables analysed were time, health insurance coverage, OOP payments, wealth status, place of delivery, birth order, mother's age, education, caste, and religion. We have used descriptive statistics, bivariate analyses, and decomposition analyses to understand the changes in socio-economic variations and inequality in distress financing. Critical findings: Distress financing declined nationally from 31.2% in 2015-16 to 23.1% in 2019-21. The decrease in distress financing has been observed across socio-economic groups in the country. The concentration index improved from -0.275 to -0.165, indicating reduced SES inequality in distress financing for caesarean delivery in India. Among all states, Bihar had the highest SES inequality in distress financing for caesarean delivery (CI: -0.327), while Himachal Pradesh had the lowest (CI: -0.045). However, state-level disparities persist. Decomposition analysis shows wealth and maternal education as key drivers of inequality. Conclusions: Rising caesarean rates and persistent interstate inequities suggest uneven policy effectiveness. Targeted reforms to reduce financial hardship and promote equitable access to maternal health services are needed.