Résumé

Objectif

Examiner les tendances temporelle des taux d'accouchement par césarienne en Asie du Sud et en Afrique sub-saharienne, par pays et quintile de richesse.

Méthodes

Les données transversales ont été extraites des résultats de 80 Enquêtes Démographiques et Sanitaires menées dans 26 pays en Asie du Sud ou en Afrique sub-saharienne. Les taux d'accouchement par césarienne ont été évalués – sous forme de pourcentages des accouchements qui ont abouti à une naissance vivante – pour chaque quintile de richesse dans chaque enquête. Les taux annuels enregistrés pour chaque pays ont alors été comparés pour voir s'ils avaient augmenté au fil du temps.

Résultats

Les taux d'accouchement par césarienne ont augmenté au fil du temps dans l'ensemble des pays étudiés, sauf six, mais ils sont systématiquement inférieurs à 5% dans 18 des pays et inférieurs ou égaux à 10% dans 8 autres pays. Parmi la couche des 20% les plus pauvres de la population, les césariennes représentaient moins de 1% et moins de 2% des accouchements dans, respectivement, 12 et 21 pays étudiés. Dans chacun des 11 pays, le taux d'accouchement par césarienne dans la couche des 40% les plus pauvres de la population est resté sous 1%. Au Tchad, en Éthiopie, en Guinée, à Madagascar, au Mali, au Mozambique, au Niger et au Nigéria, le taux est resté sous 1% dans la couche des 80% les plus pauvres. Si l'on compare avec les 22 pays africains étudiés, les 4 pays étudiés en Asie du Sud ont connu une plus grande augmentation de leur taux d'accouchement par césarienne au fil du temps. Cependant, les taux enregistrés au sein du quintile le plus pauvre dans chacun de ces pays chute systématiquement sous 2%.

Conclusion

Les taux d'accouchement par césarienne au sein de larges couches de la population en Afrique sub-saharienne sont très faibles, probablement à cause du manque d'accès à un tel acte chirurgical.

Resumen

Objetivo

Analizar las tendencias temporales de las tasas de parto por cesárea en Asia meridional y África subsahariana, por país y por quintil de riqueza.

Métodos

Se obtuvieron datos transversales de los resultados de 80 encuestas de demografía y salud realizadas en 26 países de Asia meridional y África subsahariana. Se evaluaron las tasas de parto por cesárea, como porcentaje de los partos que terminaron en nacimientos vivos, en cada quintil de ingresos en cada encuesta. Se compararon las tasas anuales registradas de cada país para comprobar si habían aumentado con el tiempo.

Resultados

Las tasas de parto por cesárea han aumentado con el tiempo en todos los países de estudio, excepto seis. Sin embargo, se halló que las tasas son sistemáticamente inferiores al 5% en 18 de los países y al 10% o menos en los otros ocho países. Entre el 20% de la población más pobre, las cesáreas representaron menos del 1% y menos del 2% de los partos en 12 y 21 de los países de estudio, respectivamente. En cada uno de los 11 países, la tasa de parto por cesárea del 40% de la población pobre se mantuvo por debajo del 1%. En el Chad, Etiopía, Guinea, Madagascar, Malí, Mozambique, Níger y Nigeria, la tasa se mantuvo por debajo del 1% en el 80% de la población pobre. En comparación con los 22 países africanos de estudio, los cuatro países de estudio de Asia meridional experimentaron un mayor aumento en sus tasas de parto por cesárea a lo largo del tiempo. Sin embargo, las tasas registradas en el quintil más pobre de cada uno de estos países se redujeron de forma constante por debajo del 2%.

Conclusión

Las tasas de parto por cesárea en amplios sectores de la población del África subsahariana son muy bajas, probablemente debido a la falta de acceso a este tipo de cirugía.

ملخص

الغرض

بحث الاتجاهات المؤقتة في معدلات الولادة القيصرية في جنوب آسيا وأفريقيا جنوب الصحراء الكبرى، حسب البلد والشريحة الخمسية الأغنى.

الطريقة

تم استخلاص البيانات المقطعية من نتائج 80 مسحاً ديمغرافياً وصحياً تم إجراؤها في 26 بلداً في جنوب آسيا وأفريقيا جنوب الصحراء الكبرى. وتم تقييم معدلات الولادة القيصرية – كنسب مئوية للولادات التي انتهت بمواليد أحياء – لكل شريحة خمسية أغنى في كل مسح. وبعد ذلك، تم مقارنة المعدلات السنوية المسجلة لكل بلد لمعرفة ما إذا كانت قد زادت بمرور الزمن.

النتائج

ازدادت معدلات الولادة القيصرية بمرور الوقت في كل بلدان الدراسة عدا ست بلدان ولكنها كانت بشكل متسق أقل من 5 % في 18 بلداً من البلدان و10 % أو أقل في البلدان الثماني الأخرى. ومن بين 20 % الأفقر من السكان، مثلت العمليات القيصرية أقل من 1 % وأقل من 2 % من الولادات في 12 و21 بلداً من بلدان الدراسة على التوالي. وفي كل بلد من البلدان الإحدى عشر، ظل معدل الولادة القيصرية في نسبة 40 % الأفقر من السكان أقل من 1 %. وفي تشاد وأثيوبيا وغينيا ومدغشقر ومالي وموزمبيق والنيجر ونيجيريا، ظل المعدل أقل من 1 % في نسبة 80 % الأفقر. وبالمقارنة مع الاثني عشر بلداً أفريقياً من بلدان الدراسة، شهدت أربع بلدان من بلدان الدراسة في جنوب آسيا زيادة أكبر بكثير في معدلات الولادة القيصرية فيها بمرور الوقت. وعلى الرغم من ذلك، فإن المعدلات المسجلة بين الخمس الأفقر في كل بلد من هذه البلدان قد انخفضت بشكل ثابت دون 2 %.

الاستنتاج

معدلات الولادة القيصرية بين قطاعات كبيرة من السكان في أفريقيا جنوب الصحراء الكبرى منخفضة للغاية، ويعود ذلك على الأرجح إلى ضعف إمكانية الوصول لهذه الجراحة.

摘要

目的

通过国家和财富五分位考查南亚和撒哈拉以南非洲剖腹产率的时间趋势。

方法

从在南亚和撒哈拉以南非洲26 个国家执行的80 个人口统计和健康调查的结果中提取横断面数据。评估每项调查中每个财富五分位的剖腹产率（占活产出生的百分比）。然后与每个国家记录的年剖腹产率进行比较，观察是否随时间增长。

结果

除了六个国家外，所有研究国家的剖宫产率都随时间上升，但在18 个国家中始终低于 5%，在其他8 个国家中不超过10%。在最贫困的20%人口中剖腹产术占分娩数1%和 2%以下的研究国家分别有12 个和21 个。在11 个国家中，每个国家最穷的 40%人口的剖腹产率保持在1%以下。在乍得、埃塞俄比亚、几内亚、马达加斯加、马里、莫桑比克、尼日尔和尼日利亚，最穷的80%人口中这个比例保持在不到1%。较之22 个非洲研究国家，在南亚的四个研究国家剖腹产率随时间增长明显得多。但是，这些国家中每个国家最贫穷的五分位人口记载的比例始终低于 2%。

结论

撒哈拉以南非洲人口众多区域剖腹产率非常低，可能是因为做不起这样的手术。

Резюме

Цель

Изучить временные тенденции частоты принятия родов посредством кесарева сечения в Южной Азии и странах Африки южнее Сахары в зависимости от страны и уровня благосостояния.

Методы

Данные для перекрестного исследования были получены из результатов 80 демографических и медицинских обследований, проведенных в 26 странах Южной Азии и странах Африки южнее Сахары. В каждом исследовании производилась оценка частоты принятия родов посредством кесарева сечения как процентного показателя родов, которые завершились рождением живого ребенка, по отношению к уровню благосостояния. Затем производилось сравнение годовых показателей, полученных для каждой страны, с целью выявления повышения количества таких операций.

Результаты

Во всех исследуемых странах, кроме шести, был отмечен рост количества приема родов методом кесарева сечения, но выявленные показатели были стабильно ниже  5% в восемнадцати странах и 10% или менее в остальных восьми странах. Среди самых бедных 20% населения принятие родов методом проведения кесарева сечения составило менее  2% родов в 21 исследуемой стране и менее 1% родов в остальных 12 исследуемых странах. В 11 странах частота принятия родов методом кесарева сечения в 40% беднейшей части населения составляла менее 1%. В Республике Чад, Эфиопии, Гвинее, Мадагаскаре, Мали, Мозамбике, Нигере и Нигерии количество кесаревых сечений составляло менее  1% для 80% беднейшей части населения. В сравнении с 22 исследуемыми африканскими странами в четырех исследуемых странах Южной Азии с течением времени было отмечено значительное увеличение количества родов, принимаемых с помощью кесарева сечения. Тем не менее, частота проведения этой операции в самых бедных слоях населения этих стран стабильно составляла менее  2%.

Вывод

Частота приема родов методом кесарева сечения для больших групп населения стран Африки южнее Сахары является очень низкой, вероятно, из-за низкой доступности таких операций.

Introduction

Caesarean sections, when adequately indicated, can prevent poor obstetric outcomes and be life-saving procedures for both the mother and the fetus.¹1 Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B et al.; WHO Global Survey on Maternal and Perinatal Health Research Group. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 2010;8:71. doi: http://dx.doi.org/10.1186/1741-7015-8-71 PMID:21067593
https://doi.org/10.1186/1741-7015-8-71... However, at a time when the caesarean delivery rate – as a percentage of live births – has been rising globally,¹1 Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B et al.; WHO Global Survey on Maternal and Perinatal Health Research Group. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 2010;8:71. doi: http://dx.doi.org/10.1186/1741-7015-8-71 PMID:21067593
https://doi.org/10.1186/1741-7015-8-71... there is growing concern about unnecessary caesarean sections.²2 Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A et al.; World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007;335:1025. doi: http://dx.doi.org/10.1136/bmj.39363.706956.55 PMID:17977819
https://doi.org/10.1136/bmj.39363.706956... Unnecessary caesarean sections can increase the risk of maternal morbidity, neonatal death and neonatal admission to an intensive care unit.²2 Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A et al.; World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 2007;335:1025. doi: http://dx.doi.org/10.1136/bmj.39363.706956.55 PMID:17977819
https://doi.org/10.1136/bmj.39363.706956... At the same time, there is also concern that – in low-income countries in general and among the poorer sections of the populations in such countries in particular – caesarean sections are not always accessible, even when they are clearly indicated.³3 Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 2006;368:1516–23. doi: http://dx.doi.org/10.1016/S0140-6736(06)69639-6 PMID:17071285
https://doi.org/10.1016/S0140-6736(06)69...

There is no consensus on the “optimal” rate of caesarean delivery at the population level. Although values between 5% and 15% of live births have been suggested, the basis on which these thresholds have been proposed is not clear.⁴4 Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization; 2009. Available from: http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/obstetric_monitoring.pdf [accessed 30 July 2013].
http://www.unfpa.org/webdav/site/global/... Some historical studies indicate that low maternal mortalities can be achieved when the caesarean delivery rate is far below 15% of live births. In the Netherlands, for example, maternal mortality had fallen below 20 deaths per 100 000 live births by 1950, when caesarean sections were associated with less than 2% of live births.⁵5 Thiery M, Derom R. Review of evaluation studies on caesarean section: trends in caesarean section and perinatal mortality. In: Kaminski M, Breart G, Buekens P, editors. Perinatal care delivery systems: description and evaluation in European Community countries. London: Oxford University Press; 1986. pp. 93-113.^,66 Loudon I. Death in childbirth: an international study of maternal care and maternal mortality 1800–1950. Oxford: Clarendon Press; 1992. The results of some ecological studies indicate not only that no further reductions in mortality occur when caesarean delivery rates increase above 10%, but also that rates above 15% may be associated with additional mortality.⁷7 Althabe F, Sosa C, Belizán JM, Gibbons L, Jacquerioz F, Bergel E. Cesarean section rates and maternal and neonatal mortality in low-, medium-, and high-income countries: an ecological study. Birth 2006;33:270–7. doi: http://dx.doi.org/10.1111/j.1523-536X.2006.00118.x PMID:17150064
https://doi.org/10.1111/j.1523-536X.2006... ^,88 Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol 2007;21:98–113. doi: http://dx.doi.org/10.1111/j.1365-3016.2007.00786.x PMID:17302638
https://doi.org/10.1111/j.1365-3016.2007... The World Health Organization (WHO) has suggested that a caesarean delivery rate of 15% should be taken as a threshold that should not be exceeded – rather than a target to be achieved.⁴4 Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization; 2009. Available from: http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/obstetric_monitoring.pdf [accessed 30 July 2013].
http://www.unfpa.org/webdav/site/global/...

The lower threshold for an “acceptable” rate of caesarean delivery has received much less attention than the upper threshold. Extremely low rates are indications that access to surgical care is poor and that, in consequence, women, fetuses and neonates are dying unnecessarily. As 1 to 2% of all births are associated with conditions that absolutely require caesarean sections to save the mothers' lives – such as obstructed labour and complete placenta praevia – caesarean delivery rates of less than 1% or less than 2% are thought to reflect a real deficit in access to life-saving obstetric care and to be associated with excess maternal mortality.⁹9 De Brouwere V, Dubourg D, Richard F, Van Lerberghe W. Need for caesarean sections in West Africa. Lancet 2002;359:974–5. doi: http://dx.doi.org/10.1016/S0140-6736(02)07993-X PMID:11918936
https://doi.org/10.1016/S0140-6736(02)07... ^–1212 De Brouwere V, van Lerberghe W. Les besoins obstétricaux non couverts. Paris: L’Harmattan; 1998. French. Rates of at least 5% are thought to be necessary to save the greatest numbers of both mothers and neonates, although there is little evidence to support such a cut-off.⁴4 Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization; 2009. Available from: http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/obstetric_monitoring.pdf [accessed 30 July 2013].
http://www.unfpa.org/webdav/site/global/...

National rates of caesarean delivery can mask substantial within-country variation in the rates of such surgery. For example, urban rates are consistently found to be higher than rural rates¹³13 Stanton CK, Holtz SA. Levels and trends in cesarean birth in the developing world. Stud Fam Plann 2006;37:41–8. doi: http://dx.doi.org/10.1111/j.1728-4465.2006.00082.x PMID:16570729
https://doi.org/10.1111/j.1728-4465.2006... and the rates for the poorest sections of the population often fall well below the national mean. In a retrospective analysis of data from Demographic and Health Surveys (DHSs) conducted in 42 developing countries, caesarean delivery rates were often found to fall below 1% either in the poorest quintile of the population (20 countries) or in all but the richest quintile (six countries).³3 Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 2006;368:1516–23. doi: http://dx.doi.org/10.1016/S0140-6736(06)69639-6 PMID:17071285
https://doi.org/10.1016/S0140-6736(06)69... Only in five countries included in this analysis did the rate of caesarean delivery in the poorest quintile exceed 5% of live births.³3 Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 2006;368:1516–23. doi: http://dx.doi.org/10.1016/S0140-6736(06)69639-6 PMID:17071285
https://doi.org/10.1016/S0140-6736(06)69...

With Millennium Development Goals (MDGs) 4 and 5 nearing their target date of 2015, it is timely and necessary to assess recent progress in improving access to caesarean sections. In this paper we analyse trends in caesarean delivery rates in southern Asia and sub-Saharan Africa over the past 15 years. We focused on countries in southern Asia and sub-Saharan Africa because such countries account for 85% of all maternal deaths¹⁴14 Trends in maternal mortality: 1990 to 2010. Geneva: World Health Organization; 2012. Available from: http://www.who.int/reproductivehealth/publications/monitoring/9789241503631/en/ [accessed 8 August 2013].
http://www.who.int/reproductivehealth/pu... and 73% of all intrapartum neonatal deaths globally.¹⁵15 Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK et al. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet 2009;107(Suppl 1):S5–18, S19. doi: http://dx.doi.org/10.1016/j.ijgo.2009.07.016 PMID:19815202
https://doi.org/10.1016/j.ijgo.2009.07.0... We examined caesarean delivery rates over time and by wealth quintile and estimated, for each country, how many and which of the five wealth quintiles were experiencing caesarean delivery rates below 1%, 2% and 5%.

Methods

All of the data that we analysed – retrospectively – came from DHSs, which are nationally representative cross-sectional household surveys in which detailed birth histories for women of reproductive age are collected. All of the datasets that we used were downloaded from the MEASURE DHS website.¹⁶16 MEASURE DHS – Demographic and Health Surveys. Calverton: MEASURE DHS; 2013. Available from: http://measuredhs.com/ [accessed 30 July 2013].
http://measuredhs.com/... In such surveys, socioeconomic status is evaluated – using principal components analysis – as a relative wealth index that is based on household assets. These indices then allow each surveyed household to be assigned to one of five wealth quintiles. The data that we used came from the countries in southern Asia or sub-Saharan Africa that were included in the “Countdown to 2015” initiative,¹⁷17 Requejo JH, Bryce J, Victora C. Countdown to 2015: building a future for women and children: the 2012 report. Washington: World Health Organization; 2012. Available from: http://www.countdown2015mnch.org/reports-and-articles/2012-report [accessed 8 August 2013].
http://www.countdown2015mnch.org/reports... although only data from the 26 countries where there had been at least two DHSs were analysed. The countries that we investigated were categorized into three regions – eastern and southern Africa, southern Asia, and western and central Africa – according to the classification of the United Nations Children's Fund.¹⁸18 The state of the world’s children 2012: children in an urban world. New York: United Nations Children’s Fund; 2012. Available from: http://www.unicef.org/sowc2012/ [accessed 8 August 2013].
http://www.unicef.org/sowc2012/...

We merged all available surveys for each country and pooled the data for all deliveries associated with a live birth in the 5 years preceding each survey whenever possible. In a few surveys, data on deliveries were only collected for the 3 or 4 years preceding the survey. We investigated the mode of delivery for each singleton birth and for the neonate who was born last in each multiple birth.

Deliveries that had been recorded as caesareans even though they had occurred in locations where caesarean sections were implausible – such as homes, dispensaries and health posts – were recoded as vaginal deliveries.¹⁹19 Stanton CK, Dubourg D, De Brouwere V, Pujades M, Ronsmans C. Reliability of data on caesarean sections in developing countries. Bull World Health Organ 2005;83:449–55. PMID:15976896 The data on deliveries in higher-level facilities were excluded if information on mode of delivery was missing. However, the proportion of deliveries included in a survey that had missing information on mode of delivery never exceeded 3.3% – recorded in a survey in the United Republic of Tanzania in 1996 – and generally fell below 1%. The response rate in each of the surveys that we investigated was at least 90%.

We used three types of analysis. All analyses took account of sampling weights, in addition to clustering and stratification where appropriate. First, we calculated caesarean delivery rates by country and survey year. These rates were calculated as percentages of the deliveries that ended in live births – excluding, in multiple births, the deliveries of all but the last born neonates. We tested for time trends in these rates by using a binomial log–linear regression model²⁰20 Cummings P. Methods for estimating adjusted risk ratios. Stata J 2009;9:175–96. to calculate annual rates of increase – as crude risk ratios (RRs) per year. Since caesarean sections are no longer a rare outcome in several of the countries that we investigated, odds ratios obtained with logistic regression would have overestimated the RRs. For each study country, annual rates of increase in caesarean deliveries were calculated for all the women and for the women who fell in the two lowest wealth quintiles combined – that is, for the poorest 40% of the women in the country. We also calculated caesarean delivery rates by wealth quintile and survey year within each country.

Finally, we categorized each delivery according to whether the mother lived in a rural or urban area and whether her household's wealth index fell above the national median value – indicating that the mother was “richer” – or below it – indicating that the woman was “poorer”. This allowed us to evaluate caesarean delivery rates separately for relatively poor and wealthy urban women and relatively poor and wealthy rural women. All of the data analyses were performed using Stata SE version 12 (StataCorp LP, College Station, United States of America).

Results

Data were available for 80 surveys, which had been conducted in four countries in southern Asia, 11 countries in western and central Africa and 11 countries in eastern and southern Africa. The median number of surveys per country was three, with a range of two to four. In the surveys, data on births in the previous 5 years (n = 68), 4 years (n = 1) or 3 years (n = 11) had been collected. The total sample consisted of 686 789 deliveries – each of which had ended in a live birth – that had occurred between 1985 and 2011.

Table 1 presents the caesarean delivery rates recorded in the 3 to 5 years preceding each survey, by country and survey year, and the corresponding annual rates of increase. Statistically significant increases in caesarean delivery rates – varying from 2 to 19% per year – were observed in seven of the 11 study countries in western and central Africa, nine of the 11 study countries in eastern and southern Africa and all four of the study countries in southern Asia. However, only 12 of the study countries – three in western and central Africa, five in eastern and southern Africa and the four in southern Asia – showed evidence of an increase in caesarean delivery rates among the two lowest wealth quintiles. The crude RRs for the annual rates of increase in these 12 countries varied from 1.03 in Madagascar to 1.30 in Bangladesh. We were not able to calculate an annual rate of increase for the poorest 40% in Chad because caesarean deliveries had only been reported in one year in the surveys from Chad that we investigated.

Caesarean delivery rates were found to be very low in the sub-Saharan African study countries. In the most recent survey for each country, for example, 10 of the study countries in sub-Saharan Africa had national rates of less than 2% and only five countries – Ghana, Kenya, Lesotho, Rwanda and Uganda – had national rates of more than 5%. The corresponding rates recorded in the most recent survey in each of three of the study countries in southern Asia were much higher. Nepal was the only southern Asian study country in which the most recently recorded, national, caesarean delivery rate was less than 5%.

Table 2 (available at: http://www.who.int/bulletin/volumes/91/12/13-117598) and Fig. 1 present the caesarean delivery rates stratified by wealth quintile and survey. The rates were extremely low among the poorest quintile in every survey. In the most recent survey for each country, for example, the caesarean delivery rates among the poorest quintile were less than 1% in 12 of the study countries – all in sub-Saharan Africa – and they were less than 2% in all of the study countries except Lesotho, Malawi, Rwanda, Uganda and Zimbabwe. Caesarean delivery rates among the richest quintile were much higher in all of the study countries but exceeded 15% only in Bangladesh, India and Pakistan.

In the most recent survey for each of 17 of the study countries, caesarean delivery rates increased monotonically from the lowest quintile for wealth to the highest (Table 2). In the other nine study countries, the between-quintile variation in the rates was very small. In 10 of the study countries in sub-Saharan Africa – seven in western and central Africa and three in eastern and southern Africa – caesarean delivery rates of less than 1% had been recorded among the poorer 40% or 60% of women. In eight of these countries – Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria – the poorer 80% of women had caesarean delivery rates of less than 1%. The poorest quintile in three of the study countries in southern Asia had caesarean delivery rates of more than 1%. In Nepal, however, the corresponding rate for the two lowest quintiles for wealth combined was less than 1%. In seven of the eight study countries that had national rates above 5%, the overall rate for the three lowest wealth quintiles combined was less than 5%.

In the most recent surveys, caesarean delivery rates were highest among the “urban richer” in all 26 study countries and lowest among the “rural poorer” in 18 of the study countries (Table 3). In all four study countries in southern Asia, the caesarean delivery rate was higher among the “rural richer” than among the “urban poorer”; the absolute difference ranged from 2.6% in Nepal (95% confidence interval, CI: −2.0 to 7.2) to 10.2% in Bangladesh (95% CI: 7.7 to 12.7). Of the study countries in sub-Saharan Africa, however, only Ghana and Kenya had markedly higher caesarean delivery rates in the “rural richer” than in the “urban poorer” – with absolute differences of 5.0% (95% CI: −0.3 to 10.3) and 6.7% (95% CI: 3.0 to 10.4), respectively. In six western African and two eastern African countries, the rural women – whether “richer” or “poorer” – had caesarean delivery rates of less than 2%.

Discussion

Although caesarean delivery rates have been rising in almost all of the countries that we investigated in southern Asia and sub-Saharan Africa, they remain astonishingly low. In our analysis, 18 countries still had national rates of less than 5% recorded in their most recent surveys, and none of the study countries had a national rate above 10%. Caesarean sections were extremely rare among the poor: they were below 1% for the poorest 20% of the population in each of 12 countries, the poorest 40% in 11 countries and the poorest 80% in eight countries. They fell below 2% for the poorest 20% in each of 21 countries. Over the study period, the study countries in southern Asia experienced a much greater rise in caesarean delivery rates than the countries that we investigated in sub-Saharan Africa. Nevertheless, in the most recent surveys that we included in our analysis, the rates among the poorest 20% of the populations remained below 2% in all four of the southern Asian study countries.

The low rates of caesarean delivery in sub-Saharan Africa are presumably a reflection of very low levels of access to caesarean sections, which are themselves associated with extremely poor access to emergency surgical care in general.²¹21 Pearson L, Shoo R. Availability and use of emergency obstetric services: Kenya, Rwanda, Southern Sudan, and Uganda. Int J Gynaecol Obstet 2005;88:208–15. doi: http://dx.doi.org/10.1016/j.ijgo.2004.09.027 PMID:15694109
https://doi.org/10.1016/j.ijgo.2004.09.0... ^,2222 Luboga S, Macfarlane SB, von Schreeb J, Kruk ME, Cherian MN, Bergström S et al.; Bellagio Essential Surgery Group (BESG). Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Med 2009;6:e1000200. doi: http://dx.doi.org/10.1371/journal.pmed.1000200 PMID:20027218
https://doi.org/10.1371/journal.pmed.100... A recent study in Ghana, Kenya, Rwanda, Uganda and the United Republic of Tanzania – five countries included in our study – revealed massive gaps in the infrastructure for emergency surgical care.²³23 Hsia RY, Mbembati NA, Macfarlane S, Kruk ME. Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap. Health Policy Plan 2012;27:234–44. doi: http://dx.doi.org/10.1093/heapol/czr023 PMID:21441566
https://doi.org/10.1093/heapol/czr023... Fewer than 50% of the hospitals surveyed had dependable running water and electricity, and only 19–50% of the hospitals provided 24-hour emergency care.²³23 Hsia RY, Mbembati NA, Macfarlane S, Kruk ME. Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap. Health Policy Plan 2012;27:234–44. doi: http://dx.doi.org/10.1093/heapol/czr023 PMID:21441566
https://doi.org/10.1093/heapol/czr023... Countries in sub-Saharan Africa generally have few skilled workers able to perform surgery – including caesarean sections – and most of their qualified doctors live in urban areas.²²22 Luboga S, Macfarlane SB, von Schreeb J, Kruk ME, Cherian MN, Bergström S et al.; Bellagio Essential Surgery Group (BESG). Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Med 2009;6:e1000200. doi: http://dx.doi.org/10.1371/journal.pmed.1000200 PMID:20027218
https://doi.org/10.1371/journal.pmed.100... ^,2424 Pollock JD, Love TP, Steffes BC, Thompson DC, Mellinger J, Haisch C. Is it possible to train surgeons for rural Africa? A report of a successful international program. World J Surg 2011;35:493–9. doi: http://dx.doi.org/10.1007/s00268-010-0936-z PMID:21191583
https://doi.org/10.1007/s00268-010-0936-... In the present study, caesarean delivery rates were extremely low among both the richer and poorer women who lived in rural areas, where structural and workforce constraints may be the most important barriers to access.

A household's ability to pay for the surgery is thought to be an important determinant of caesarean deliveries.²⁵25 Gartoulla P, Liabsuetrakul T, Chongsuvivatwong V, McNeil E. Ability to pay and impoverishment among women who give birth at a University Hospital in Kathmandu, Nepal. Glob Public Health 2012;7:1145–56. doi: http://dx.doi.org/10.1080/17441692.2012.733719 PMID:23083138
https://doi.org/10.1080/17441692.2012.73... ^,2626 Arsenault C, Fournier P, Philibert A, Sissoko K, Coulibaly A, Tourigny C et al. Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households. Bull World Health Organ 2013;91:207–16. doi: http://dx.doi.org/10.2471/BLT.12.108969 PMID:23476093
https://doi.org/10.2471/BLT.12.108969... The cost of emergency caesarean sections can be catastrophic for households.²⁵25 Gartoulla P, Liabsuetrakul T, Chongsuvivatwong V, McNeil E. Ability to pay and impoverishment among women who give birth at a University Hospital in Kathmandu, Nepal. Glob Public Health 2012;7:1145–56. doi: http://dx.doi.org/10.1080/17441692.2012.733719 PMID:23083138
https://doi.org/10.1080/17441692.2012.73... ^,2626 Arsenault C, Fournier P, Philibert A, Sissoko K, Coulibaly A, Tourigny C et al. Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households. Bull World Health Organ 2013;91:207–16. doi: http://dx.doi.org/10.2471/BLT.12.108969 PMID:23476093
https://doi.org/10.2471/BLT.12.108969... Although user fee exemptions have been one of the key strategies to increase access to delivery care in sub-Saharan Africa,²⁷27 Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Tashobya CK et al. Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy Plan 2011;26(Suppl 2):ii16–29. doi: http://dx.doi.org/10.1093/heapol/czr062 PMID:22027916
https://doi.org/10.1093/heapol/czr062... their impact on caesarean delivery rates has yet to be rigorously evaluated. While such fee exemptions may have contributed to the rises seen in caesarean delivery rates in countries such as Ghana and Senegal,²⁸28 Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V. The national free delivery and caesarean policy in Senegal: evaluating process and outcomes. Health Policy Plan 2010;25:384–92. doi: http://dx.doi.org/10.1093/heapol/czq013 PMID:20360258
https://doi.org/10.1093/heapol/czq013... ^,2929 Asante F, Chikwama C, Daniels A, Armar-Klemesu M. Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana. Ghana Med J 2007;41:110–7. PMID:18470328 such rises cannot be categorically attributed to the exemptions. Furthermore, a household's ability to pay for surgery may not be the main barrier to caesarean sections in settings where the necessary health facilities are sparsely distributed.³⁰30 Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One 2011;6:e17155. doi: http://dx.doi.org/10.1371/journal.pone.0017155 PMID:21386886
https://doi.org/10.1371/journal.pone.001...

The rapid rises seen in caesarean delivery rates in southern Asia over our study period are somewhat surprising, given that most births in this region still take place at home. In the latest DHSs for Bangladesh, India, Nepal and Pakistan, for example, only 15%, 39%, 37% and 35% of the recorded deliveries occurred in a health facility, respectively (data not shown). However, many of these deliveries probably took place in private hospitals,³⁰30 Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One 2011;6:e17155. doi: http://dx.doi.org/10.1371/journal.pone.0017155 PMID:21386886
https://doi.org/10.1371/journal.pone.001... where obstetricians and general practitioners are available to lead delivery care and the incentives to perform caesarean sections may be relatively greater.³¹31 Parkhurst JO, Rahman SA. Life saving or money wasting? Perceptions of caesarean sections among users of services in rural Bangladesh. Health Policy 2007;80:392–401. doi: http://dx.doi.org/10.1016/j.healthpol.2006.03.015 PMID:16698113
https://doi.org/10.1016/j.healthpol.2006... This may explain why such large proportions of the women who delivered in health facilities in Bangladesh, India, Nepal and Pakistan – 51%, 22%, 12% and 20%, respectively – had caesarean sections (data not shown). In the present analysis, caesarean delivery rates in the richest quintile were found to be more than 15% in Bangladesh, India and Pakistan, and the rates among the “rural richer” in all four study countries in southern Asia were found to be substantially higher than those among the “urban poorer”.

In every country that we investigated, caesarean delivery rates among the women in the richest quintile were much higher than the rates seen in the poorest quintile. This difference was particularly noticeable in Bangladesh, India and Pakistan, where the poorest quintile probably receives fewer caesarean sections than are indicated, while the richest quintile receives too many – increasing maternal and neonatal morbidity.³²32 Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A et al.; WHO 2005 global survey on maternal and perinatal health research group. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367:1819–29. doi: http://dx.doi.org/10.1016/S0140-6736(06)68704-7 PMID:16753484
https://doi.org/10.1016/S0140-6736(06)68... In general – as postulated by the “inverse equity hypothesis” – the wealthy are more likely to adopt new medical interventions than the poor, often leading to increased health inequalities – at least in the short term.³³33 Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 2000;356:1093–8. doi: http://dx.doi.org/10.1016/S0140-6736(00)02741-0 PMID:11009159
https://doi.org/10.1016/S0140-6736(00)02... In southern Asia, however, the richest mothers appear to be receiving more caesarean sections than are warranted, with potentially adverse effects.

Our analysis has several limitations. First, we only had data for 26 of the 48 countries in sub-Saharan Africa and southern Asia that were included in the “Countdown to 2015” initiative.¹⁷17 Requejo JH, Bryce J, Victora C. Countdown to 2015: building a future for women and children: the 2012 report. Washington: World Health Organization; 2012. Available from: http://www.countdown2015mnch.org/reports-and-articles/2012-report [accessed 8 August 2013].
http://www.countdown2015mnch.org/reports... . Second, the dates of the most recently published survey varied substantially between countries, and some countries may have made more progress since their most recent survey. The last available survey data for seven of the 11 study countries in western and central Africa were collected before 2007. Third, the caesarean delivery rates estimated in household surveys – generally from the statements of women of reproductive age – tend to be higher than the rates estimated from the records of the corresponding health facilities where caesarean deliveries may be performed.¹⁹19 Stanton CK, Dubourg D, De Brouwere V, Pujades M, Ronsmans C. Reliability of data on caesarean sections in developing countries. Bull World Health Organ 2005;83:449–55. PMID:15976896 However, the facility-derived estimates tend to fall within the 95% CIs of the corresponding household survey estimates.¹⁹19 Stanton CK, Dubourg D, De Brouwere V, Pujades M, Ronsmans C. Reliability of data on caesarean sections in developing countries. Bull World Health Organ 2005;83:449–55. PMID:15976896 Fourth, the wealth index used in the DHSs has several inherent biases that require careful scrutiny. The type of household assets investigated varies between the surveys, and the wealth index – which represents a household's wealth relative to other households in one particular country at the time of the survey – should not be used to compare absolute levels of wealth between surveys. The association between household wealth and residence in an urban or rural area may be complex.³⁴34 Rutstein S. The DHS wealth index: approaches for rural and urban areas. Washington: Macro International Inc.; 2008. Available from: http://www.measuredhs.com/publications/publication-WP60-Working-Papers.cfm [accessed 8 August 2013].
http://www.measuredhs.com/publications/p... Although those who live in urban areas are typically richer than their rural counterparts, the intrinsic meaning of the underlying wealth associated with many assets differs according to the area. We used national wealth indices – rather than urban- and rural-specific wealth indices – to enable direct comparisons between the richer and poorer halves of the populations in rural and urban areas. We were unable to analyse caesarean delivery rates according to wealth quintiles separately for urban and rural residents because the sample was too small, particularly in terms of the number of women from “urban poorer” households. Fifth, some women may have contributed more than one birth to the sample. However, restricting the analysis to only one birth per woman did not alter our findings (data not shown). Lastly, when computing annual rates of increase, we assumed that caesarean delivery rates increased in log–linear fashion. Our conclusions were, however, unaltered when RRs for the increases were calculated by comparing one survey to the next (data not shown).

Programmes to reduce maternal and neonatal mortality should have clear indicators to identify need, monitor implementation and change the course of action, as required.⁴4 Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization; 2009. Available from: http://www.unfpa.org/webdav/site/global/shared/documents/publications/2009/obstetric_monitoring.pdf [accessed 30 July 2013].
http://www.unfpa.org/webdav/site/global/... There has been a reluctance to include caesarean delivery rates as a core indicator for the monitoring of safe motherhood programmes, partly because the thresholds for “acceptable” or target rates are so uncertain, and partly because such an indicator may be perceived as promoting the unnecessary medicalization of obstetric care. However, this reluctance is unjustified, particularly when very low thresholds are set for the minimum rate. While caesarean delivery rates cannot be a substitute for the measurement of levels of maternal mortality, caesarean rates among the poor should be a key indicator for measuring progress towards achieving MDG 5.³⁵35 Countdown equity analyses by country – 2012. Geneva: Countdown to 2015 Secretariat; 2013. Available from: http://www.countdown2015mnch.org/documents/2012Report/2012Equity/full_equity_profiles_2012.pdf [accessed 28 May 2013].
http://www.countdown2015mnch.org/documen... In the post-2015 health agenda – where the focus is shifting towards measuring the coverage for essential interventions – rates of caesarean delivery among the poor will be critical indicators of access to emergency obstetric care. In addition, as general childhood mortality is reduced, neonatal deaths become relatively more important and access to caesarean sections – when indicated to save the fetus – increases in relative importance as well. Although estimates of the caesarean delivery rate required for indications related to the fetus are imprecise,⁷7 Althabe F, Sosa C, Belizán JM, Gibbons L, Jacquerioz F, Bergel E. Cesarean section rates and maternal and neonatal mortality in low-, medium-, and high-income countries: an ecological study. Birth 2006;33:270–7. doi: http://dx.doi.org/10.1111/j.1523-536X.2006.00118.x PMID:17150064
https://doi.org/10.1111/j.1523-536X.2006... this rate is unlikely to be less than 5% of all births.

Despite the encouraging progress made in increasing national rates of caesarean delivery, large sections of the population in sub-Saharan Africa still lack access to life-saving caesarean sections, and women and children – particularly poor women and their children – are dying as a consequence. Improvements in access to caesarean sections will require massive investments in health system strengthening, particularly in terms of addressing shortages in the health workforce and the infrastructure gaps in rural hospitals.³⁶36 Bergström S. Commentary: who will do the caesareans when there is no doctor? Finding creative solutions to the human resource crisis. BJOG: An International Journal of Obstetrics & Gynaecology. 2005;112:1168–9. doi: http://dx.doi.org/10.1111/j.1471-0528.2005.00719.x
https://doi.org/10.1111/j.1471-0528.2005... The human resource challenge could be partly addressed by allowing clinical officers to perform caesarean deliveries,³⁷37 Wilson A, Lissauer D, Thangaratinam S, Khan KS, MacArthur C, Coomarasamy A. A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies. BMJ 2011;342:d2600. doi: http://dx.doi.org/10.1136/bmj.d2600 PMID:21571914
https://doi.org/10.1136/bmj.d2600... although the sustainability of this strategy when implemented on a large scale remains uncertain. However, as long as hospitals lack the core infrastructure to perform surgery safely – including access to water and electricity – one cannot begin to address the emergency obstetric needs of pregnant women in sub-Saharan Africa.

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References

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