The role of health insurance in shaping cesarean section rates among Indonesian women

Background Understanding how health insurance ownership is associated with cesarean section delivery is essential for assessing maternal health service utilization in Indonesia. This study examines the relationship between insurance type and cesarean delivery among Indonesian women, while accounting for the national survey design. Methods This study used secondary data from the 2023 Indonesian Health Survey, including 70,916 women who delivered within five years preceding the survey. Complex survey adjusted logistic regression was applied to account for the multistage and stratified sampling design. Health insurance ownership was categorized as uninsured, government-run, private-run, or hybrid. Adjusted odds ratios and predicted probabilities were estimated. Firth's penalized likelihood regression was conducted as a sensitivity analysis for the hybrid insurance group. Results Overall, 25.9% of women reported cesarean delivery. After survey adjustment, cesarean delivery was more prevalent among insured women than uninsured women. Predicted probabilities indicated a higher absolute probability of cesarean delivery among women with government-run, private-run, and hybrid insurance. Estimates for the hybrid insurance group were consistent in direction but should be interpreted cautiously due to the small sample size. Conclusion Health insurance ownership is associated with higher cesarean delivery rates in Indonesia. These findings reflect associations rather than causal effects and may be influenced by differences in clinical risk profiles and health system factors.