Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries

BMJ 2018; 360 doi: (Published 24 January 2018) Cite this as: BMJ 2018;360:k55
  1. Adeline Adwoa Boatin, instructor in obstetrics, gynecology and reproductive biology1,
  2. Anne Schlotheuber, technical officer2,
  3. Ana Pilar Betran, medical officer3,
  4. Ann-Beth Moller, technical officer3,
  5. Aluisio J D Barros, professor4,
  6. Ties Boerma, professor5,
  7. Maria Regina Torloni, professor6,
  8. Cesar G Victora, emeritus professor4,
  9. Ahmad Reza Hosseinpoor, health equity monitoring lead2
  1. 1Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
  2. 2Department of Information, Evidence and Research, World Health Organization, Geneva, 1211, Switzerland
  3. 3HRP–UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
  4. 4International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
  5. 5Countdown to 2030 for Women’s, Children’s and Adolescents’ Health; and Center for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
  6. 6Evidence Based Healthcare Post Graduate Program, São Paulo Federal University, São Paulo, Brazil
  1. Correspondence to: A R Hosseinpoor hosseinpoora{at}
  • Accepted 13 December 2017


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.


  • Contributors: AAB and AS contributed equally to this study and are the guarantors. ARH conceived and designed the study with inputs from AAB, APB, and ABM. AS, AJDB, and ARH analysed and interpreted the data. AAB and AS drafted the manuscript with inputs from APB, ABM, and ARH. AJDB, TB, MRT, and CV critically commented and provided revisions to the manuscript. All authors read and approved the final manuscript. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

  • Funding: This study received no specific funding.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: Data from the demographic and health surveys and multiple indicator cluster surveys are freely available at and The disaggregated data presented in this study, derived from reanalysis of publicly available demographic and health surveys and multiple indicator cluster surveys microdata, are available through the WHO health equity monitor database at

  • Transparency: The lead authors (AAB and AS) affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (, which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.

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