Substantial inequalities in cesarean births persist in many countries

A study published by The BMJ today shows that caesarean section rates have increased in most countries during the past decade, particularly among the richest fifth, indicating an increase in wealth related inequality over time.

The researchers suggest this inequality might be due to a combination of inadequate access to emergency obstetric care among the poorest groups and high levels of caesarean use without medical indication in the richest groups. And they call for country specific strategies to address these inequalities and improve maternal and newborn health.

Access to caesarean section is an essential component of obstetric care, but with adverse consequences at both low and high levels of caesarean use, monitoring rates is important to understand trends in potential underuse and overuse and also to identify inequities in caesarean use.

So an international team of researchers led by WHO set out to provide an update on economic related inequalities in caesarean section rates within a large number of countries from all world regions and measure the change in inequality over time.

They analysed data from demographic and health surveys and multiple indicator cluster surveys conducted between 2010 and 2014 in 72 low and middle income countries. To look at the change in inequality over time, they included data from surveys done 10 years earlier, between 2000 and 2004, which were available for 28 out of the 72 countries.

Participants included women aged 15-49 years with a live birth during the two or three years preceding the survey and data were presented separately for five subgroups, ranging from the poorest to the richest fifth of household wealth.

They found that there were large inequalities between countries, with national rates ranging from 0.6% in South Sudan to 58.9% in the Dominican Republic.

They also found substantial inequalities within countries: rates tended to be lower (less than 10%) in poorer fifths, likely representing underuse, and higher (more than 15%) in richer fifths, often representing overuse. The extent of inequality varied greatly across countries, with several distinct regional patterns.

For example, most countries from the Latin American region had high caesarean section rates and large levels of absolute inequality, whereas countries from the African region tended to have low caesarean section rates across all wealth fifths and small absolute inequalities.

Caesarean section rates also showed a persistence, and in many countries a widening, of wealth related inequalities in caesarean section rates. Almost all (26 out of 28) countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth compared with the poorest fifth, indicating an increase in inequality over time in most of these countries.

The researchers acknowledge several limitations. For example, comparable data were not available for some countries with the highest caesarean section rates in the world, and current caesarean section rates may already be higher in some study countries. Also, they did not adjust for other relevant factors, such as education or place of residence.

Nevertheless, they say their analysis shows that considerable inequalities remain both between and within countries, and they call on policy makers to "invest in targeted policies and strategies to ensure equitable access to caesarean section and improve maternal and newborn health for all."