Cesarean delivery and associated socioeconomic factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data

Abstract

Background: The increasing trends in cesarean delivery are globally acknowledged. However, in many low-resource countries, socioeconomic disparities have created a pattern of underuse and overuse among lower and higher socioeconomic groups. The impact of rising cesarean delivery rates on neonatal survival is also unclear.Objective: To examine cesarean delivery and its associated socioeconomic patterns and neonatal survival outcome in Kenya and Tanzania.Methods: We employed binary logistic regression to analyze cross-sectional demographic and health survey data on neonates born in health facilities in Kenya (2014) and Tanzania (2016).Results: Cesarean delivery rates ranged from 5% among uneducated, rural Tanzanian women to 26% among educated urban women in Kenya to 37.5% among managers in urban Tanzania. Overall findings indicated higher odds of cesarean delivery among mothers from richest households, adjusted odds ratio (aOR) 1.4 (95% CI 1.2-1.8), those insured, aOR 1.6 (95% CI 1.3-1.9), highly educated, aOR 1.6 (95% CI 1.2-2.0) and managers aOR 1.7 (95% CI 1.3-2.2), compared to middle class, no insurance, primary education and unemployed, respectively. Overall, compared to normal births and while adjusting for maternal risk factors, cesarean delivery was significantly associated with neonatal mortality in Kenya and Tanzania, overall aOR 1.7 (95% CI 1.2-2.7). However, statistical significance ceased when fetal risk factors and number of antenatal care visits were further controlled for, aOR 1.6 (95% CI 0.9-2.6).Conclusion: Disproportionate access to cesarean delivery has widened in Kenya and Tanzania. Higher risks of cesarean-related neonatal deaths exist. Medically indicated or not, the safety and/or choice of cesarean delivery is best addressed on individual basis at the health-facility level. However, policy initiatives to eliminate incentives, improve equitable access and accountability to reduce unnecessary cesarean deliveries through well-informed decisions are needed. Efforts to prevent unintended pregnancies among adolescents as well as training of health workers and continuous research to improve neonatal outcomes are vital.

Keywords: Socioeconomic factors; cesarean delivery; logistic regression; low-resource countries; neonatal mortality.

Figure 1.

Neonatal mortality rates (NMR) and cesarean delivery (CD) rates among highest and lowest socioeconomic groups in Kenya between 2003 and 2014 [11,39]

Figure 2.

Neonatal mortality rates (NMR) and cesarean delivery (CD) rates among highest and lowest socioeconomic groups in Tanzania between 2004 and 2016 [12,40]

Figure 3.

Graphical representations A, B, C, and D showing cesarean delivery rates by socioeconomic characteristics and place of residence in 2014-2016, in Kenya and Tanzania

Figure 4.

Forest plot presentation of adjusted odds ratios, 95% confidence interval (Table 4), showing aggregate associations between socioeconomic characteristics and cesarean delivery in Kenya and Tanzania, 2014–2016