Socioeconomic differences in caesarean section – are they explained by medical need? An analysis of patient record data of a large Kenyan hospital (original) (raw)
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Scientific Reports, 2022
Caesarean delivery (C-section) has been increasing worldwide; however, many women from developing countries in Sub-Saharan Africa are deprived of these lifesaving services. This study aimed to explore the impact of certain socioeconomic factors, including respondent's education, husband's education, place of residence, and wealth index, on C-section delivery for women in Sub-Saharan Africa. We used pooled data from 36 demographic and health surveys (DHS) in Sub-Saharan Africa. Married women aged 15-49 years who have at least one child in the last five years were considered in this survey. After inclusion and excluding criteria, 234,660 participants were eligible for final analysis. Binary logistic regression was executed to determine the effects of selected socioeconomic factors. The countries were assembled into four sub-regions (Southern Africa, West Africa, East Africa, and Central Africa), and a meta-analysis was conducted. We performed random-effects model estimation for meta-analysis to assess the overall effects and consistency between covariates and utilization of C-section delivery as substantial heterogeneity was identified (I 2 > 50%). Furthermore, the metaregression was carried out to explain the additional amount of heterogeneity by country levels. We performed a sensitivity analysis to examine the effects of outliers in this study. Findings suggest that less than 15% of women in many Sub-Saharan African countries had C-section delivery. Maternal education (OR 4.12; CI 3.75, 4.51), wealth index (OR 2.05; CI 1.94, 2.17), paternal education (OR 1.71; CI 1.57, 1.86), and place of residence (OR 1.51; CI 1.44, 1.58) were significantly associated with the utilization of C-section delivery. These results were also consistent in sub-regional meta-analyses. The meta-regression suggests that the total percentage of births attended by skilled health staff (TPBASHS) has a significant inverse association with C-section utilization regarding educational attainment (respondent & husband), place of residence, and wealth index. The data structure was restricted to define the distinction between elective and emergency c-sections. It is essential to provide an appropriate lifesaving mechanism, such as C-section delivery opportunities, through proper facilities for rural, uneducated, impoverished Sub-Saharan African women to minimize both maternal and infant mortality.
International Journal for Equity in Health, 2019
Background Inappropriate use of Caesarean Section (CS) delivery is partly to blame for Ghana’s high maternal mortality rate. However, previous research offered mixed findings about factors associated with CS use. The goal of this study is to examine use of CS in Ghana and the socioeconomic factors associated with it. Methods Data from the nationally representative 2014 Ghana Demographic and Health Survey (GDHS) was used after permission from the Monitoring and Evaluation to Assess and Use Results (MEASURE) Demographic and Health Survey (DHS) program. Univariable and multivariable logistic regression models were fitted to examine the socioeconomic inequalities in CS use. The independent variables included maternal age, marital status, religion, ethnicity, education, place of residence, wealth quintile, and working status. Concentration index (CI) and rate-ratios were computed to ascertain the level of CS inequalities. Results Out of the 4294 women, 11.4% had CS delivery. However, the...
BMJ, 2018
OBJECTIVE To provide an update on economic related inequalities in caesarean section rates within countries. DESIGN Secondary analysis of demographic and health surveys and multiple indicator cluster surveys. SETTING 72 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. PARTICIPANTS Women aged 15-49 years with a live birth during the two or three years preceding the survey. MAIN OUTCOME MEASURES Data 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. RESULTS National 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. CONCLUSIONS Substantial 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.
BMC Public Health, 2020
BackgroundIn Ethiopia, there is a paucity of studies on inequality in caesarean section using methodologically rigorous and well-established approaches. In this study, we showed extent and the overtime dynamics of inequality in caesarean section in Ethiopia following rigorous methodologies.MethodsThe data for analysis came from Ethiopia Demographic and Health Surveys (EDHS) conducted between 2000 and 2016. We used the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) to analyze the data. Caesarean delivery was disaggregated by four equity stratifiers, namely education, wealth, residence and regions. Relative and absolute summary measures were calculated for each equity stratifier to capture inequality from different perspectives. 95% Uncertainty Interval was calculated around a point estimate to measure statistical significance.ResultsWe found large socioeconomic and area-based inequalities in use of caesarean section in all study surveys. The inequalities ha...
Caesarean section rate in Nigeria between 2013 and 2018 by obstetric risk and socioeconomic status
Tropical Medicine & International Health, 2021
objectives Caesarean section (CS) can be life-saving for both mother and child, but in Nigeria the CS rate remains low, at 2.7% of births. We aimed to estimate the rate of CS and early neonatal mortality in Nigeria according to obstetric risk and socioeconomic background and to identify factors associated with CS. methods We used the 2018 Nigeria Demographic and Health Survey, encompassing 33 924 live births within the last 5 years, to estimate the CS rate and early neonatal mortality rate (ENMR) by obstetric risk group, informed by the Robson classification. The CS rate and ENMR were assessed within each Robson group and stratified by socioeconomic background. Logistic regression analyses were used to explore determinants of CS. results Almost three-quarters (72.4%) of all births were to multiparous women, with a singleton baby of normal birthweight, thus a low-risk group similar to Robson 3, and with a CS rate of 1.0%. CS rates in the two high-risk groups (multiple pregnancy and preterm/low birthweight) were low, 7.1% (95% CI: 5.2-9.7) and 1.8 % (95% CI: 1.4-2.4), respectively. The ENMR was particularly high for multiple pregnancy (175 per 1000 live births; 95% CI: 131-230). Greater number of antenatal visits, unwanted pregnancy, multiple pregnancy, household wealth, maternal education, Christians/Others versus Muslims and referral during childbirth were positively associated with CS. conclusion Inequitable access to CS is not limited to socioeconomic determinants, but also related to obstetric risk factors, calling for increased efforts to improve access to CS for high-risk pregnancies.
International Journal for Equity in Health, 2014
Background: Caesarean section (CS) can prevent maternal or fetal complications. Sub-Saharan Africa has the lowest CS levels in the world but large variations are seen between and within countries. The tertiary hospital, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania has had a high level of CS over years. The aim of this study was to examine trends in the socio-demographic background of babies born at KCMC from year 2000 to 2013, and trends in the CS percentage, and to identify socio-demographic factors associated with CS at KCMC during this period. Methods: This is a registry-based study. The analyses were limited to singletons born by women from Moshi urban and rural districts. The Chi square test for linear trend was used to examine trends in the CS percentage and trends in the socio-demographic background of the baby. The association between different socio-demographic factors and CS was assessed using logistic regression. The analyses were stratified by the mother's residence. Results: The educational level of mothers and fathers and the age of the mothers of singletons born at KCMC increased significantly from year 2000 to 2013 both among urban and rural residents. Among 29,752 singletons, the overall CS percentage was 28.9%, and there was no clear trend in the overall CS percentage between 2000 and 2013. In the multivariable model, factors associated with higher odds of CS were: having been referred for delivery, maternal age above 25 and no-or primary education level of the baby's father. Among rural mothers, no-or primary education, being from the Pare tribe and para 2-3 were also associated with higher odds of CS. Being from the Chagga tribe and high parity were associated with lower odds of CS compared to other tribes and parity 1. Conclusions: The CS percentage remained high but stable over time. Large variations in CS levels between different socio-demographic groups were observed. The educational level of the parents of babies born at KCMC increased over time, possibly reflecting persistent inequitable access to the services offered at the hospital.
Examining inequalities in access to delivery by caesarean section in Nigeria
PLOS ONE
Background Maternal deaths are far too common in Nigeria, and this is in part due to lack of access to lifesaving emergency obstetric care, especially among women in the poorest strata in Nigeria. Data on the extent of inequality in access to such lifesaving intervention could convince policymakers in developing an appropriate intervention. This study examines inequality in access to births by caesarean section in Nigeria. Methods Data for 20,468 women who gave birth in the five years preceding 2013 Nigerian Demographic and Health Survey (DHS) were used for this study. Inequality in caesarean delivery was assessed using the concentration curve and multiple logistic regression models.
Assessing five-year trend and socio-demographic determinants of caesarean section delivery in Ghana
Research Square (Research Square), 2024
Introduction:The rate of caesarean section (C-section) deliveries has been increasing globally, including in low-and middle-income countries like Ghana. Understanding the trends, patterns, and socio-demographic determinants of C-section deliveries is crucial for improving maternal healthcare services and reducing unnecessary surgical interventions. This study aims to assess the trend and factors associated with CS deliveries in Ghana using secondary data from the District Health Information Management System 2 (DHIMS-2) database. Methods:A cross-sectional study design was employed, utilizing secondary data extracted from the District Health Information Management System 2 (DHIMS-2) database covering a period of ve years (2017-2021). The data included information on C-section deliveries from both public and private health facilities in Ghana. Descriptive and inferential analysis was conducted to explore the associations between socio-demographic factors and C-section delivery. Results:The study ndings revealed that a signi cant proportion of women who underwent C-section deliveries had formal education up to the JHS/Middle school level. Most of the deliveries occurred in hospitals and government-owned facilities. The study also observed that more than half of the women had a C-section delivery, with the highest percentage occurring in 2019 and 2020. Additionally, the majority of women had health insurance coverage. Conclusion:The high C-section rate in Ghana may be attributed to various factors such as increasing availability and accessibility of C-section deliveries, socio-demographic factors, and regional disparities in healthcare access and resources. Advanced maternal age, higher levels of education, and formal employment were found to be associated with a higher likelihood of C-section deliveries. These ndings highlight the need for a comprehensive and patient-centered approach to maternal healthcare in Ghana, which includes efforts to strengthen antenatal care services, promote natural childbirth, improve access to quality healthcare facilities, enhance healthcare provider training, address regional disparities, and strengthen health insurance coverage. By addressing these recommendations, Ghana can strive towards reducing unnecessary caesarean section deliveries and improving maternal health outcomes for women across the country.
Factors that contribute to current caesarean section rates in selected hospitals in Nairobi, Kenya
2021
Background: Over the past three decades, there has been a sustained increase in caesarean section rates around the world despite the fact that the World Health Organization has indicated that there is no justification for any region to have a caesarean section rate higher than 15% and amidst concerns of unfavorable perinatal and postnatal outcomes associated with caesarean section deliveries. Objective: To assess the factors that contribute to the caesarean section rates in hospitals in Nairobi. Methods: This was a cross-sectional survey in which all the women who delivered during the data collection period in three selected maternity units (Nairobi Women's Hospital, St. Mary's Mission Hospital and Pumwani Maternity Hospital) were requested to participate. A total of 513 pregnant women consented and were interviewed. The facilities were selected based on the National Hospital Insurance Fund (NHIF) categorization of hospitals in Kenya as: Category A (Government hospitals), Category B (Private and Mission) and Category C (Private). A questionnaire was used to interview the women while medical charts were used to establish hospital days. Data was analyzed using the SPSS computer software. Descriptive statistics was done on all variables. Bivariate and multivariate analysis were performed to determine the factors that contribute to caesarean-section rates. Study Findings. The mean age of the women was 26.5 years (SD±4.9).Significant associations were shown between age of the women and caesarean section rates (χ2=15.534,p=0.0001),facility type(as defined by the NHIF categorization) and caesarean section rate(χ2=10.20,p=0.006),previous caesarean section and caesarean section rate (χ2=274.3,p<0.001),birth order and caesarean section rate (χ2=15.386,p=0.000),age and type of section(χ2=8.29,p=0.04) and employment status and type of section(χ2=10.4,p=0.006).The recorded caesarean rates were: Private hospital 44%, Mission/Private hospital 25% and Public hospital 29%, Emergency caesarean section 20% and elective caesarean sections 10%.The most common indication for emergency caesarean section was fetal distress and that for elective caesarean section was a previous scar. Conclusion & Recommendations: Factors that contribute to caesarean section rates are age, facility type, previous caesarean section and birth order. The rates observed are higher than the World Health Organization recommendations of 5% to 15%. This study also concludes that it may be had to define an umbrella optimal CS rate for health institutions and thus recommends that such rates should be contextualized.