Quantifying Urban–Rural Disparities in Caesarean Section Deliveries in India: A Multilevel and Fairlie Decomposition Approach

Introduction: Caesarean section (C-section) delivery is a critical maternal health intervention when medically indicated; however, its rapid increase beyond recommended levels (range of 10–15%) raises concerns about unnecessary surgical births. India has witnessed a substantial rise in C-section deliveries, with pronounced urban–rural differentials, reflecting inequalities in healthcare access, service provision, and socioeconomic status. Understanding how place of residence interacts with demographic and socioeconomic factors is essential for addressing inequities in delivery care. Data and Methods: This study used data from the National Family Health Survey (NFHS-5, 2019–21), covering 155,624 most recent institutional births among currently married women aged 15–49 years in India. Descriptive and bivariate analyses were followed by stratified (urban, rural and total) multilevel logistic regression models (individuals nested within PSUs, districts, and states) to assess contextual variation and determinants. Model fit was evaluated using AIC, BIC, and intra-class correlation coefficients (ICCs). Furthermore, to understand the factors associated with differential pattern in Caesarean delivery in rural and urban Fairlie decomposition technique has been applied. Results Overall, 26.6% of deliveries occurred by C-section, with a substantially higher prevalence in urban areas (36.6%) compared to rural areas (22.3%). Multilevel analysis showed significant clustering at PSU, district, and state levels. Deliveries in private hospitals had markedly higher odds of C-section (AOR = 5.02; 95% CI: 4.84–5.20). Higher maternal age, education, wealth status, ≥ 4 ANC visits, and pregnancy complications increased the likelihood of C-section, while higher birth order and longer birth intervals reduced it. Even after adjustment, rural residence remained associated with lower odds of C-section. Fairlie decomposition analysis revealed that 93.8% of the urban–rural gap in caesarean section deliveries is explained by observed characteristics, with maternal factors contributing the largest share. Place of delivery alone accounted for nearly half of the explained disparity (49.9%), followed by household wealth (15.7%) and region (8.3%). Conclusion C-section delivery in India is strongly patterned by place of residence, healthcare sector, and socioeconomic advantage. The findings highlight growing urban–private sector dominance in C-section use and persistent contextual inequalities. Policy efforts should focus on regulating private facilities, improving quality of obstetric care in rural areas, and promoting evidence-based delivery practices to ensure medically appropriate and equitable maternal healthcare.