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. 2021 Nov 16;16(11):e0259791.
doi: 10.1371/journal.pone.0259791. eCollection 2021.

Trends, wealth inequalities and the role of the private sector in caesarean section in the Middle East and North Africa: A repeat cross-sectional analysis of population-based surveys

Stephen J McCall  1 , Aline Semaan  2 , Noon Altijani  3 , Charles Opondo  3 , Mohamed Abdel-Fattah  4 , Tamar Kabakian-Khasholian  5
Affiliations

Trends, wealth inequalities and the role of the private sector in caesarean section in the Middle East and North Africa: A repeat cross-sectional analysis of population-based surveys

Stephen J McCall et al. PLoS One. .

Abstract

Objective: To examine trends and variations of caesarean section by economic status and type of healthcare facility in Arab countries in the Middle East and North Africa (MENA).

Methods: Secondary data analysis of nationally representative household surveys conducted between 2008-2020 across nine Arab countries in the MENA region. The study population was women aged 15-49 years with a live birth in the two years preceding the survey. Temporal changes in the proportion of deliveries by caesarean section in each country were calculated using generalised linear models and presented as risk differences (RD) with 95% confidence intervals (95%CI). Caesarean section was disaggregated by household wealth index and type of healthcare facility.

Results: Use of caesarean section ranged from 57.3% (95%CI:55.6-59.1%) in Egypt to 5.7% of births (95%CI:4.9-6.6%) in Yemen. Overall, the use of caesarean section has increased across the MENA region, except in Jordan, where there was no evidence of change (RD -2.3 (95%CI: -6.0 ‒1.4)). Across most countries, caesarean section use was highest in the richest quintile compared to the poorest quintile, for example, 42.8% (95%CI:38.0-47.6%) vs. 22.6% (95%CI:19.6-25.9%) in Iraq, respectively. Proportion of caesarean section was higher in private sector facilities compared to public sector: 21.8% (95%CI:18.2-25.9%) vs. 15.7% (95%CI:13.3-18.4%) in Yemen, respectively.

Conclusion: Variations in caesarean section exist within and between Arab countries, and it was more commonly used amongst the richest quintiles and in private healthcare facilities. The private sector has a prominent role in observed trends. Urgent policies and interventions are required to address non-medically indicated intervention.

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Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: Professor Abdel-Fattah’s full declaration is on his webpage [URL: https://www.abdn.ac.uk/iahs/research/obsgynae/profiles/m.abdelfattah]. All other authors have no conflicts of interest to report.

Figures

Fig 1
Fig 1. Proportion of caesarean sections at last birth that occurred in the previous two years before the survey in nine countries in the Middle East and North Africa.
Red line indicate internationally agreed-upon limits for underuse and overuse of caesarean section.
Fig 2
Fig 2. Proportion of caesarean sections by country, survey period and wealth quintile.
Fig 3
Fig 3. The use of caesarean section in private and public sector facilities by country and survey period.
Fig 4
Fig 4. Proportion of all births according to the place of delivery.
Fig 5
Fig 5. Caesarean section use in public and private sector facilities, by wealth quintile and country, for the most recent survey.
Last DHS/MICS survey was used. Qatar did not collect wealth quintile.
See this image and copyright information in PMC

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