The results reveal a drastic increase in caesarean deliveries among Pakistani women from 3.2% in 1990 to 19.6% in 2018. Further studies conducted in Pakistan reveal that foetal distress, prolonged labour pain, wound sepsis, previous caesarean history and rupture of placenta are the most common medical factors of caesarean section deliveries in the hospitals in Pakistan [16, 17]. The high cost of caesarean delivery is sometimes considered as a higher social status symbol. Such perception might be adding to the increasing trend of caesarean deliveries. Nevertheless, in Pakistan and other developing countries, where patients are rarely given an option to choose the mode of delivery, the doctor’s referrals for caesarean delivery can be a possible reason behind the increasing trend of caesarean deliveries .
The age of mothers at the time of delivery emerged as one of the contributing factors, as there is a strong relationship between the age of the mother and the mode of delivery (caesarean or vaginal). Many studies revealed that older mothers have a higher likelihood of caesarean deliveries [19, 20]. No research has been conducted to show the factors for the increased number of caesarean deliveries in the older mothers. However, it can be assumed that older mothers have more chances of having pregnancy complications that may result in caesarean deliveries . Even in the absence of pregnancy-related complications, older mothers are more inclined to give birth through caesarean section . Women in Pakistan have become more career conscious in terms of acquiring education and choosing a suitable job to earn their livelihood during the last few years . The extensive process of becoming financially independent results into delayed marriages of women and, thus, increases their age for conception . The increased age of a woman at the time of conception tends to have complications in the later period of the pregnancy that can possibly lead to a caesarean delivery . Thus, it could be a possible reason for increased caesarean compared to vaginal deliveries.
Previous studies have revealed that women who reported having medical problems, such as chronic hypertension, chronic infections, heart problems or respiratory diseases, have a higher tendency of caesarean section births . In correspondence to previous studies [24, 25], our results also showed that mothers who reported having complications, such as urinary tract infections, obesity or preeclampsia at any stage of pregnancy, had a higher tendency of caesarean delivery. On the other hand, PDHSs 1990–91 and 2017–18 did not include the questions related to pregnancy complications.
As per findings of previous clinical studies [26, 27], frequent visits to antenatal care facilities, pregnancy complications and the mode of delivering a baby are strongly associated. Considering the importance of antenatal care in the reduction of complications, a new World Health Organization guideline emphasises that every pregnant woman should have at least eight antenatal care visits during each pregnancy . Findings of previous studies also revealed that antenatal care is considered an important component of women’s health during the course of pregnancy that can play a pivotal role in reducing the likelihood of caesarean deliveries [26,27,28]. By contrast, our study reveals a persistent upsurge of caesarean deliveries for mothers with more than four antenatal care visits more. Although there is no clear reason behind this, it can be assumed that women with pregnancy complications, such as obesity, hypertension and diabetes, were asked by the gynaecologists to have frequent antenatal care visits in order to handle any undesirable obstetric risk. While considering the regional demographics, the women from Punjab’s region persistently show a higher tendency towards caesarean deliveries. Feasible access and the availability of health care facilities at private and public hospitals can be traced as one of the factors behind increased caesarean deliveries in the province [4, 28].
Studies conducted in Bangladesh  and India  indicated that mothers belonging to a higher socio-economic class had a higher tendency to opt for caesarean section. In such cases, caesarean delivery seems to be a desire of woman who can afford it rather than the doctor’s referral for a safe childbirth process . Moreover, research conducted in different countries also highlights that caesarean deliveries are more prevalent in women belonging to a higher socio-economic class as they have a misconception that caesarean delivery is the highest quality of obstetric care [6, 32]. Similarly, our study shows that a better socio-economic status is one of the significant factors behind increased caesarean section rates. It is obvious that a higher socio-economic status provides sufficient finances to bear the higher expenditure of caesarean surgery. Thus, caesarean section is more prevalent in women belonging to a higher socio-economic class . On the other hand, women belonging to a lower socioeconomic status might not be able to afford the expenses of caesarean delivery or do not have access to the obstetric care facilities required for caesarean delivery. Therefore, the rate of caesarean deliveries is found to be lower in women having a poor socio-economic status .
Although it has been recognised that caesarean deliveries may support a reduction in the mother and child mortality rate, malpractices linked with caesarean surgery cannot be neglected . A study conducted in India shows that the number of caesarean deliveries in private hospitals are three times higher than in public hospitals . Similarly, the present study reveals that the rate of caesarean deliveries is increasing in private health care centres and hospitals in Pakistan over time. Arguably, the misuse of the surgical incision in private hospitals may involve varied factors. The high expenditure of a caesarean delivery, for example, can be considered as a significant factor that has resulted in increased rates of caesarean deliveries in private hospitals. Considering the situation in private hospitals, the doctors may prefer caesarean delivery over vaginal delivery for financial benefits and time convenience . Additionally, the higher rates of caesarean deliveries in private hospitals tend not only to increase the cost of health care but they increase the health risks of women and newly born babies. However, the PDHSs (1990–2018) for both private and public hospitals lack the relevant information regarding the medical reasons for performing caesarean deliveries.
The literature shows that the low weight of baby at birth or a small size is not strongly associated with the caesarean delivery, as the mothers who were told about the low birth weight or the small size of the newborn at the time of birth had fewer chances to undergo caesarean delivery . Similarly, results of the present study show that the size of the baby is not interlinked with the caesarean delivery, as mothers whose babies had below average size did not have a higher tendency to have a caesarean delivery.
The data from the PDHSs have some limitations that tend to affect the findings of the study. First of all, the cross-sectional design does not allow for causal interpretations. While taking into consideration pregnancy-related variables, the information related to pregnancy termination was not available in 2006–07 and 2012–13. Similarly, PDHS 2017–18 lacks the relevant information about pregnancy complications and, thus, affected the trend analysis of the respective variable in the present study. In addition, the information about birth weight is uncertain. Consequently, we used a combined variable on size and weight at birth to borrow strength. The data in all four PDHSs waves (1990–2018) do not offer relevant information on the nature of pregnancy complications experienced by a mother. Keeping in view the limited availability of data required, the present study is unable to highlight any particular pregnancy complication that led to a caesarean section delivery. The PDHS 1990–2018 data lacked the information to differentiate between medical and non-medical reasons for carrying out caesarean surgery, thus, the study could not discuss the misuse of surgical incision for child delivery as a contributing factor for the increase in the caesarean deliveries. Additionally, the dataset of PDHS 2017–18 does not include the information related to pregnancy complications.