ArticlesSocioeconomic differentials in caesarean rates in developing countries: a retrospective analysis
Introduction
Socioeconomic inequalities in use of maternal health services have gained increased attention in recent years.1, 2 Disparities between poor and rich in access to a skilled attendant at delivery are substantial in the developing world.1, 3 Differences in uptake of maternal-health care are often greater within than between countries and are generally greater than those shown for uptake of child-health services.4 In many countries, nearly 100% of the very rich have access to a skilled attendant compared with almost none of the very poor.3
Little is known about socioeconomic differentials in access to life-saving obstetric care in hospitals, yet women's timely access to competent hospital care is essential to achieve low levels of maternal mortality.5, 6 The main reason for this gap is that defining timely and competent life-saving care is not easy. De Brouwere and Van Lerberghe7 developed a powerful indicator of access to life-saving obstetric surgery, but the reliance on health-facility records makes the ascertainment of socioeconomic status difficult. Population-based caesarean rates have been promoted as indicators of access to life-saving obstetric care,8 although the optimum rate is still a matter of debate.7, 9, 10, 11 All-cause caesareans might comprise women who need a surgical intervention to save their or their baby's life as well as women for whom there is no clinical need; hence interpreting crude caesarean rates is difficult.12 Population-based caesarean rates of no less than 5% and no more than 15% have been suggested as optimum,8 although both these minimum and maximum values have been called into question.7, 10, 11 However, although not all caesareans are necessarily life-saving, there can be little doubt that caesarean rates of less than 1% indicate an unmet need for potentially life-saving care.13
The Demographic and Health Surveys (DHS) provide the most representative and widely available source of data for birth by caesarean in developing countries. The DHS are based on nationally representative samples of women of reproductive age and are highly standardised. The questionnaire asks women about antenatal and delivery care for livebirths they have reported in the past 3 or 5 years, thus providing a nationally representative sample of livebirths. The questionnaire also asks whether the baby was born by caesarean; the self-reported data for caesareans are thought to be reliable.14
A DHS comparative study15 and individual country-based analyses, such as the final country reports from the DHS, have long shown differences in caesarean rates by, for example, urban or rural residence, women's education, and region, but these stark differentials are rarely, if ever, discussed in the published literature. With the exception of urban and rural differentials,16, 17 little comparative work has been undertaken to describe the extent of the discrepancies across countries. We aimed to examine the extent of inequalities in caesarean rates across socioeconomic groups in several developing countries for which data are available.
Section snippets
Methods
We used data from the most recent DHS survey from countries in sub-Saharan Africa, south and southeast Asia, and Latin America and the Caribbean for which data on both caesarean and the wealth index were available. The DHS computes a wealth index by a principal components analysis of household assets18 and then categorises households into wealth quintiles. Our unit of analysis is a delivery ending in a livebirth occurring within 3 years before the interview. We restricted our sample to
Results
The sample consisted of data for 199 916 deliveries ending in a livebirth in 42 countries. The reference point for caesarean rates (ie, the midpoint of the 3 year reference period) ranged from 1988 to 2002, although the estimate for 38 of the 42 countries fell between 1994 and 2002. The sample included 26 countries in sub-Saharan Africa, seven in south and southeast Asia, and nine in Latin America and the Caribbean. These countries represent around 59% of all livebirths in the developing world
Discussion
The extent of access to caesareans varies substantially between and within countries. At one extreme are the poorest countries—mostly in sub-Saharan Africa—where large parts of the population have little access, even among the wealthy. Only a few have reasonable access, creating what has been called a pattern of massive deprivation.6 At the other extreme are seven countries, mostly Latin American, where caesareans are far in excess of the suggested maximum threshold of 15% for at least 40% of
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