Patterns of Facility Utilization and Birth Outcomes in Low-Risk Pregnancies: A Comparison of Primary and Higher-Level Health Facilities in Urban Indonesia

Background Global cesarean section (CS) rates have nearly doubled in the past two decades, with many countries exceeding the 10–15% threshold recommended by the WHO as medically necessary. While CS can be life-saving in certain obstetric emergencies, its unnecessary use increases maternal and neonatal risks and burdens health systems. In Indonesia, the influence of delivery facility type on CS rates among low-risk pregnancies remains underexplored. Methods We conducted a cross-sectional analytical study using routinely collected maternal health data from a primary health care facility (Puskesmas) and a secondary-level referral hospital in Surabaya, Indonesia, from January 2023 to December 2024. All singleton pregnancies with a recorded Kartu Skor Poedji Rochjati (KSPR) score and documented delivery outcomes were eligible. Descriptive analyses were performed on the full cohort, while comparisons of CS and low birth weight (LBW) outcomes were restricted to women classified as low risk. Pearson’s Chi-square test and multivariable logistic regression were used to compare outcomes and estimate adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results Despite being classified as low risk, most women delivered in secondary or tertiary facilities rather than in primary care. Maternal and neonatal outcomes did not significantly differ between facility types; however, delivery in tertiary facilities was independently associated with higher odds of CS (aOR 2.22; 95% CI 1.06–4.63) compared to primary facilities. No significant association was found between facility type and LBW. Conclusion Facility level—not only clinical risk profile—appears to influence intervention rates in low-risk pregnancies. Strengthening the capacity, quality, and public trust in primary-level maternity care could help align service utilization with the intended referral system, reduce unnecessary interventions, and preserve higher-level resources for women with genuine obstetric risks.