Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

Abstract

Objective: To provide an update on economic related inequalities in caesarean section rates within countries.

Design: Secondary analysis of demographic and health surveys and multiple indicator cluster surveys.

Setting: 72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time.

Participants: Women aged 15-49 years with a live birth during the two or three years preceding the survey.

Main outcome measures: Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change.

Results: National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries.

Conclusions: Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.

Fig 1

Caesarean section rates by economic status in 72 low and middle income countries (demographic and health surveys or multiple indicator cluster surveys 2010-14). Circles indicate countries, with each country represented by five circles (one for each wealth subgroup). Horizontal blue lines indicate the median (middle point of estimates) of all countries within each subgroup, and blue bands indicate the interquartile range (middle 50% of estimates)

Fig 2

Caesarean section rates by economic status in selected countries (demographic and health surveys or multiple indicator cluster surveys 2010-14). Circles indicate countries, with each country represented by five circles (one for each wealth subgroup). Vertical blue lines indicate the difference between the minimum and maximum rate in each country. The blue horizontal band indicates the range 10-15%

Fig 3

National caesarean section rates compared with wealth related inequality in caesarean section (difference between richest and poorest fifths) in 72 low and middle income countries, by World Health Organization region (demographic and health surveys or multiple indicator cluster surveys 2010-14). Shapes indicate countries, with each country represented by one shape. Dashed black lines indicate the median (middle point) of all countries

Fig 4

Income inequality (GINI index) compared with wealth related inequality in caesarean section rates (difference between richest and poorest fifths) in 57 low and middle income countries, by World Health Organization region. Shapes indicate countries, with each country represented by one shape. The blue line (regression line) indicates the association between income inequality and wealth related inequality in caesarean section rates

Fig 5

Change over time in national caesarean section rates compared with change over time in poorest fifth compared with richest fifth in 28 low and middle income countries, by World Health Organization region (demographic and health surveys or multiple indicator cluster surveys 2000-04 and 2010-14). Shapes indicate countries, with each country represented by one shape. Dashed black lines indicate the median (middle point) of all countries