“Everywhere you see, C-sections are happening”: examining trends and reasons for a rise in cesarean-section deliveries among women in urban informal settlements, Mumbai Metropolitan Region, using a mixed methods approach

Abstract Background Cesarean sections (C-sections) are life-saving surgeries; however, rates exceeding 10–15% are not associated with reductions in maternal and neonatal mortality. In urban India, C-section rates were 32% in 2019-21. Research on C-section deliveries in urban informal settlements and among those primarily accessing public healthcare services has been limited. This study examined trends and underlying reasons for C-sections in informal settlements in the Mumbai Metropolitan Region, India, drawing insights from both women and obstetric practitioners (public and private). Through this, the study aimed to identify potential suggestions to improve obstetric care in vulnerable settings. Methods The study employed an explanatory sequential mixed methods design. Quantitative data were collected through cross-sectional surveys in 2019, 2021, 2022 and 2024, including a pooled sample of 5,162 mothers of children aged 0–2 years. Logistic regression analysis was conducted to identify factors associated with C-sections. Qualitative data collection from October 2024 to February 2025 involved in-depth interviews ( N = 44) with women who underwent C-sections and public and private practitioners. Thematic analysis was performed using substantive coding to inductively develop themes. Results C-section rates increased from 25% in 2019 to 37% in 2024, with a 15% increase in private facilities and 10% increase in public facilities. Maternal age, gravida, timing of antenatal care registration and number of antenatal visits were significantly associated with C-sections. Qualitative findings identified several interconnected reasons, such as institutional limitations, evolving obstetric practices, risk perceptions, awareness and lifestyle changes, to be contributing to C-sections. Likelihood of reported reasons was greater among primigravida women, contributing to a rise in repeat C-sections. Reported reasons were similar between public and private facilities, whereas practitioners and women had divergent perspectives towards rising C-section rates. Conclusions C-sections are rising in urban informal settlements among women primarily accessing public facilities. Non-medical reasons influence medical indications and decisions for C-sections. A multi-pronged approach involving both community-based and systemic interventions is needed to reduce avoidable C-sections. This study provides critical evidence to inform interventions for improving patient-practitioner relations and delivery experiences while bettering obstetric outcomes in vulnerable settings.