Rural–urban disparities in caesarean deliveries in sub-Saharan Africa: a multivariate non-linear decomposition modelling of Demographic and Health Survey data

Abstract

Introduction Globally, the rate of caesarean deliveries increased from approximately 16.0 million in 2000 to 29.7 million in 2015. In this study, we decomposed the rural–urban disparities in caesarean deliveries in sub-Saharan Africa. Methods Data for the study were extracted from the most recent Demographic and Health Surveys of twenty-eight countries in sub-Saharan Africa. We included 160,502 women who had delivered in health facilities within the five years preceding the survey. A multivariate non-linear decomposition model was employed to decompose the rural–urban disparities in caesarean deliveries. The results were presented using coefficients and percentages. Results The pooled prevalence of caesarean deliveries in the 28 countries considered in the study was 6.04% (95% CI = 5.21–6.88). Caesarean deliveries' prevalence was highest in Namibia (16.05%; 95% CI = 14.06–18.04) and lowest in Chad (1.32%; 95% CI = 0.91–1.73). For rural-urban disparities in caesarean delivery, the pooled prevalence of caesarean delivery was higher in urban areas (10.37%; 95% CI = 8.99–11.75) than rural areas (3.78%; 95% CI = 3.17-4.39) across the 28 countries. Approximately 81% of the rural–urban disparities in caesarean deliveries were attributable to the differences in child and maternal characteristics. Hence, if the child and maternal characteristics were levelled, more than half of the rural–urban inequality in caesarean deliveries would be reduced. Wealth index (39.2%), antenatal care attendance (13.4%), parity (12.8%), mother’s educational level (3.5%), and health insurance subscription (3.1%) explained approximately 72% of the rural–urban disparities in caesarean deliveries. Conclusion This study shows significant rural–urban disparities in caesarean deliveries, with the disparities being attributable to the differences in child and maternal characteristics: wealth index, parity, antenatal care attendance, mother’s educational level, and health insurance subscription. Policymakers in the included countries could focus and work on improving the socioeconomic status of rural-dwelling women as well as encouraging antenatal care attendance, women's education, health insurance subscription, and family planning, particularly in rural areas.

Inequalities in the prevalence of Caesarean section and associated factors in rural and urban Nigeria: insights from the 2018 Nigeria Demographic and Health Survey

“…Compared to the 2.0% reported in 2008 36 and the 2.1% estimated in 2013 9 , the present nding indicates a marginal increase; nonetheless, our study supports an underutilisation, indicating unmet needs, and emphasising the necessity for improved access to life-saving CS in Nigeria. Consistent with this position, the CS prevalence in our study is considerably lower than the pooled estimate for sub-Saharan Africa (6.04%) 32 and those of similar African countries, including Rwanda 15.6% (in 2019-2020) 37 , Ghana (12.80% in 2014) 38 , Liberia (5.48 in 2019-2020) 32 , and Togo (7.0 in 2013-2014) 32 .…”

“…In all residences, higher maternal education was strongly associated with increased CS odds, echoing previous evidence of maternal education's centrality to healthcare services utilisation 9,26,28 . Urban residency also demonstrated a signi cant association with higher odds of CS (overall population), similar to ndings in Nigeria and elsewhere 9,27,32,38 , potentially re ecting the 'urban advantage' in access to services 28,30,32 . Furthermore, mothers from rich households had elevated CS odds across overall, rural, and urban settings in Nigeria, re ecting socioeconomic disparities in CS access in Nigeria 46 .…”

“…Inequality, on the other hand, serves as a measurable metric for assessing these inequities, re ecting the observed differences across subpopulation groups 31 -a phenomenon well pronounced in maternal healthcare services utilisation 12,28,30 . Inequality can, for instance, manifest across various domains, including geographic divides (e.g., rural versus urban dwellings) 28,32 , socioeconomic status (wealth index or educational attainment levels) 29,30,32 , age differentials 33,34 , ethnicity 12,28 , etc. Understanding these disparities is vital for designing effective and target-oriented public health interventions, policies, and healthcare services.…”

Trends and determinants of early initiation of breastfeeding in Indonesia: A multivariate decomposition analysis

“…Further, as the number of women having caesarean deliveries keeps increasing globally and in Indonesia, our findings become more concerning [ 38 ]. Although the percentage is generally lower in LMICs, we should note that caesarean delivery went up rapidly in LMICs, particularly among higher-income groups and those living in urban areas [ 40 , 41 ]. There is typically a higher financial compensation for medical professionals and healthcare facilities in the case of a caesarean section compared to a vaginal delivery [ 42 ].…”

“…This disparity in payment may potentially contribute to the prevalence of non-indicated caesarean sections. Additionally, access to biased information can affect women’s preference for caesarean sections, and those from higher socioeconomic backgrounds and urban areas are more likely to undergo the procedure [ 41 ]. Therefore, interventions reducing medically unnecessary caesarean deliveries should be improved.…”