Within country inequalities in caesarean section rates: observational study of 72 low and middle income countriesBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k55 (Published 24 January 2018) Cite this as: BMJ 2018;360:k55
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Re: Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries
Caesarean section rates in low and middle income countries: don’t forget China
With adverse consequences at both low and high levels of caesarean use, monitoring rates is important to understand trends in potential underuse and overuse and also to identify inequities in caesarean use. We commend Adeline Adwoa Boatin and colleagues on their meticulous epidemiological investigation, which provided an update on economic related inequalities in caesarean section rates within 72 low and middle income countries from all world regions and the change in inequality over time. 1
In their study, researchers found that considerable wealth related inequalities in caesarean deliveries remain both between and within countries. These inequalities might be due to lack of skilled health staff and health infrastructure, the existence of user fees, or cultural beliefs around the value and safety of caesarean section among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries.
Caesarean section is a life-saving surgical procedure when certain complications arise during pregnancy and labour. However, since the 1990s, China has seen a dramatic increase in the rates of caesarean delivery, which has even reached more than 50%. 2 3 Data from the World Health Organization Global Survey on Maternal and Perinatal Health Research Group showed that nearly half (46.2%) of all births in China were delivered by caesarean section in 2007-08. 4 Using county-level aggregated information on the number of live births, another research recent found that the overall annual rate of caesarean deliveries increased in China between 2008 and 2014, and also discovered that there was major geographic variation in rates and trends over time, with declining in some of the largest urban areas. 5 Many socioeconomic factors, including individual income, education, place of residence, expanded access to hospital care, and financial incentives for physicians to perform caesareans, influenced caesarean section rates in China. 5 6
As the authors stated in the first limitation, this study does not include some of the countries with one of the highest caesarean section rates in the world, such as China, which provides basic clinical care and public health services to a fifth of the world’s population. 7 China plays a very important role in terms of both population and caesarean section rates in developing countries. If it can include China in the next update, it will be made the results more stable and reliable in exploring the economic related inequalities in caesarean section rates within low and middle income countries.
1. Boatin AA, Schlotheuber A, Betran AP, et al. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. Bmj 2018;360:k55. doi: 10.1136/bmj.k55
2. Hellerstein S, Feldman S, Duan T. China's 50% caesarean delivery rate: is it too high? BJOG : an international journal of obstetrics and gynaecology 2015;122(2):160-4. doi: 10.1111/1471-0528.12971
3. Mi J, Liu F. Rate of caesarean section is alarming in China. The Lancet 2014;383(9927):1463-64. doi: 10.1016/s0140-6736(14)60716-9
4. Lumbiganon P, Laopaiboon M, Gulmezoglu AM, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet 2010;375(9713):490-9. doi: 10.1016/S0140-6736(09)61870-5
5. Li HT, Luo S, Trasande L, et al. Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014. Jama 2017;317(1):69-76. doi: 10.1001/jama.2016.18663
6. Feng XL, Xu L, Guo Y, et al. Factors influencing rising caesarean section rates in China between 1988 and 2008. Bulletin of the World Health Organization 2012;90(1):30-9, 39A. doi: 10.2471/BLT.11.090399
7. Li X, Lu J, Hu S, et al. The primary health-care system in China. The Lancet 2017;390(10112):2584-94. doi: 10.1016/s0140-6736(17)33109-4
Competing interests: No competing interests