Assessing socio-ecological factors on caesarean section and vaginal delivery: an extended perspective among women of South-Punjab, Pakistan

Figures & data

Table 1. Flowchart.

1st stage	Pakistan
2nd stage	Province (South-Punjab)
3rd Stage	Region (Muzaffargarh)
4th stage	Hospitals (private and public)
5th stage	Obstetrics and gynecology department (respondents)

Table 2. Existing and extended SEM model.

Levels	Illustration
Existing SEM model
Interpersonal Intrapersonal Socio-economic Organizational Public policy	Primary groups such as peers, friends, family, social identity Individual characteristics of expectant mother such as personality traits, beliefs, education, family Socio-economic status, norms, social circle, network and standards Organizational policies and laws, informal structures, rules and regulations
Extended SEM model
Biological levels of influence	Federal policies, management, local states and control Health facilities, biological complications such as breech presentations of the baby, fetus with intrauterine growth restriction IUGR, sufficient nutrition, fetal distress, repeated CS, maternal anemia, meconium aspiration syndrome

Table 3. Characteristics, interpersonal, socio-economic, organizational and biological factors for MOD among women of South-Punjab, Pakistan (n = 908).

Characteristics	Total (%)	CS (%)	VD (%)	p Value
Age	26.35 ± 6.428	29.19 ± 4.196	24.24 ± 3.926	.000
16–21	59 (6.49)	29 (3.19)	30 (3.30)	–
22–26	197 (21.69)	116 (12.77)	81 (8.92)
27–31	388 (42.73)	303 (33.37)	85 (9.36)
32–36	215 (23.67)	196 (21.58)	19 (2.09)
Above 36	49 (5.30)	43 (4.73)	6 (0.66)
Education				.031
Non literate	315 (34.69)	229 (25.22)	86 (9.47)	–
Primary	353 (38.87)	273 (30.06)	80 (8.81)
Secondary	166 (18.28)	119 (13.10)	47 (5.17)
Higher	74 (8.14)	42 (4.62)	32 (3.52)
Residence				.003
Rural	322 (35.46)	183 (20.15)	139 (5.23)	–
Urban	586 (65.53)	462 (50.88)	124 (13.65)
Section 1. Interpersonal factors
Enough capacity of VD pain				.000
Yes	518 (57.04)	365 (40.19)	153 (16.85)	–
No	390 (42.95)	310 (34.14)	80 (8.81)
Reliable procedure for mother and fetus				.000
Yes	189 (20.81)	164 (18.06)	25 (2.75)	–
No	719 (79.18)	368 (40.52)	351 (38.65)
Husband and his family preference for CS for male carrier				.167
Yes	198 (21.80)	109 (12.00)	89 (9.80)	–
No	710 (78.19)	447 (49.22)	263 (28.96)
Section 2. Socio-economic factors
Husband’s affordability of CS				.001
Yes	473 (52.09)	338 (37.22)	135 (14.86)	–
No	435 (47.90)	287 (31.60)	148 (16.29)
Employment status of mother				.108
Housewife	816 (89.86)	665 (73.23)	151 (16.62)	–
Employed	92 (10.13)	77 (8.48)	15 (1.65)
Section 3. Organizational factors
Hospital level				.001
Private	435 (47.90)	383 (42.18)	52 (5.72)	–
Public	473 (52.09)	182 (20.04)	291 (32.04)
Doctor suggestion				.000
Yes	379 (41.74)	286 (31.49)	93 (10.24)	–
No	529 (58.25)	226 (24.88)	303 (33.37)
Section 4. Biological factors
Walk or physical activity				.000
Yes	667 (73.45)	321 (35.35)	346 (38.10)	–
No	241 (26.54)	196 (21.58)	45 (4.95)
Optimal maternal diet				.012
Yes	675 (74.33)	387 (42.62)	288 (31.71)	–
No	233 (25.66)	187 (20.59)	46 (5.06)
Fetal distress				.001
Yes	342 (37.66)	207 (22.79)	135 (14.86)	–
No	566 (62.33)	294 (32.73)	272 (29.31)
”Fetus with intrauterine growth restriction (IUGR)				.000
Yes	404 (44.49)	197 (21.69)	207 (22.79)	–
No	504 (55.50)	453 (49.88)	51 (5.61)
Abnormal presentations				.000
Yes	396 (43.61)	277 (30.50)	119 (13.10)	–
No	512 (56.38)	165 (18.17)	347 (38.21)
Maternal anemia				.004
Yes	569 (62.66)	447 (49.22)	122 (13.43)	–
No	339 (37.33)	198 (21.80)	141 (15.52)
Meconium aspiration syndrome				.000
Yes	239 (26.32)	194 (21.36)	45 (4.95)	–
No	669 (73.67)	209 (23.01)	460 (50.66)
Previous cesarean				.000
Yes	655 (72.13)	388 (42.73)	267 (29.40)	–
No	253 (27.86)	121 (13.32)	132 (14.53)

Figure 1. Odd ratio with 95% confidence intervals of biological, demographic, organizational, interpersonal and social factors representation.

Table 4. LR estimates for variables associated with method of delivery among South-Punjab women (sample size 908).

Factors	Covariates	Coefficient (SE)	OR (95% CI)	p Value
Demographic indicators	Age
	16–21	−6.004** (1.480)	0.001 (0.000–0.064)	.001
	22–26	−4.435** (1.108)	0.012 (0.015–0.343)	.001
	27–31	−4.879** (1.020)	0.008 (0.004–0.190)	.001
	32–36	−3.620* (1.226)	0.006 (0.006–0.567)	.011
	Above 36 (RC)	–	–	–
Organizational Indicator	Private	1.407** (0.861)	4.076 (2.223–10.912)	.001
	Public (RC)	–	–	–
	Gynecologist suggested	0.445* (0.682)	1.560 (1.233–6.645)	.037
	Gynecologist not suggested (RC)	–	–	–
Interpersonal and social indicators	CS reliable for mother and fetus			.006
	Yes	1.705** (0.724)	5.514 (1.782–20.392)
	No (RC)	–	–	–
	According to me, I have enough stamina to tolerate VD			.002
	Yes	−5.385** (2.285)	0.005 (0.001–0.240)	–
	No	–	–	–
Biological/clinical indicators	Fetal distress			.012
	Yes	1.021* (0.499)	2.775 (0.247–8.724)
	No (RC)	–	–
	Abnormal presentations			.000
	Yes	2.826** (0.699)	3.767 (3.372–16.124)
	No (RC)	–	–
	Anemia			.001
	Yes	1.300** (0.494)	5.096 (2.769–9.987)
	No (RC)	–	–
	Meconium aspiration syndrome			.001
	Yes	3.362** (0.539)	11.246 (5.108–21.879)
	No (RC)	–	–
	Walk or physical activity (during pregnancy)			.002
	Yes	−2.472** (0.518)	0.183 (0.176–4.570)
	No(RC)	–	–
Constant		5.668 (1.709)	124.362

SE: standard error; OR: odds ratio; CI: confidence interval; RC: reference category.

* p value <.05.

** p value <.01.

Data availability statement

Data, models and code supporting this study’s findings are available from the corresponding author.