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

Abstract

ObjectiveTo provide an update on economic related inequalities in caesarean section rates within countries.DesignSecondary analysis of demographic and health surveys and multiple indicator cluster surveys.Setting72 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.ParticipantsWomen aged 15-49 years with a live birth during the two or three years preceding the survey.Main outcome measuresData 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.ResultsNational 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.ConclusionsSubstantial 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.

WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing

“…Recent studies suggest that the benchmark for assessing normal labour progression, which was derived from studies conducted over 60 years ago, may not be appropriate for clinical decision making for individual women 7, 8. Although unnecessary labour interventions are generally more common in middle‐ and high‐income settings,9 the routine use of ineffective and potentially harmful labour practices are also widespread in resource‐limited settings, with the consequent misallocation of scarce resources and a further widening of the equity gap 10, 11, 12. On the other hand, failure to employ effective labour interventions when needed is also a recognised contributor to health inequities and poor quality of care during childbirth 9…”

“…7,8 Although unnecessary labour interventions are generally more common in middle-and high-income settings, 9 the routine use of ineffective and potentially harmful labour practices are also widespread in resource-limited settings, with the consequent misallocation of scarce resources and a further widening of the equity gap. [10][11][12] On the other hand, failure to employ effective labour interventions when needed is also a recognised contributor to health inequities and poor quality of care during childbirth. This is an open access article distributed under the terms of the Creative Commons Attribution IGO License which permits unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited.…”

The role of the respectful maternity care model in São Paulo, Brazil: A cross‐sectional study

“…35 The incidence of blood transfusion in the study (2.4%) was 10 times higher than the results of a study from the United States (0.26%), which studied 8.5 million deliveries. 38,39 A recent systematic review about the immersion in water during labor and birth did not report on any studies assessing perineal tear outcomes. It is possible that since those women were focused on natural birth assistance, many of the women may not have used oxytocin or other uterotonics after birth to avoid medical interventions.…”

“…Contrary to the current literature, our findings showed no higher risk of subsequent cesarean in women who had a previous cesarean. 38,39 A recent systematic review about the immersion in water during labor and birth did not report on any studies assessing perineal tear outcomes. 40 Our findings indicating that water birth may prevent perineal tears are in line with results from a recently published Swedish study.…”

Contextual risk factors impacting the colonization and development of the intestinal microbiota: Implications for children in low‐ and middle‐income countries

“…Another report on 72 LMIC revealed that the most impoverished fifth of the population reported a median of 3.7% of cesarean sections compared to 18.4% within the richest fifth of the population (Boatin et al, 2018). This difference highlighted the underuse of this procedure in the poorest regions (e.g., less than 2% in Chad, Ethiopia, Niger; Boatin et al, 2018). Those obtaining cesarean sections within impoverished regions can experience exacerbated risks due to limited resources and underqualified healthcare professionals (Shah et al, 2009;Souza et al, 2010;Yaya, Uthman, Amouzou, & Bishwajit, 2018).…”