Temporal trends in between and within-country inequalities in caesarean delivery in low- and middle-income countries: a Bayesian analysis

Objective: To provide updated information about between-country variations, temporal trends and changes in inequalities within countries in caesarean delivery (CD) rates. Design: Cross-sectional study of Demographic and Health Survey (DHS) during 1990–2018. Setting: 74 low- and middle-income countries (LMICs). Population: Women 15–49 years of age who had live births in the last 3 years. Methods: Bayesian linear regression analysis was performed and absolute differences were calculated. Main outcome measure: Population-level CD by countries and sociodemographic characteristics of mothers over time. Results: CD rates, based on the latest DHS rounds, varied substantially between the study countries, from 1.5% (95% CI 1.1–1.9%) in Madagascar to 58.9% (95% CI 56.0–61.6%) in the Dominican Republic. Of 62 LMICs with at least two surveys, 57 countries showed a rise in CD during 1990–2018, with the greatest increase in Sierra Leone (19.3%). Large variations in CD rates were observed across mother's wealth, residence, education and age, with a higher rate of CD by the richest and urban mothers. These inequalities have widened in many countries. Stratified analyses suggest greater provisioning of CD by the richest mothers in private facilities and poorest mothers in public facilities. Conclusions: CD rates varied substantially across geographical locations and over time, irrespective of public or private health facilities. Changes in CD rates continue across wealth, place of residence, education, and age of mother, and are widening in most study countries. Tweetable abstract: Increasing caesarean delivery rates were greater among the richest and urban mothers than their counterparts, with widened gaps in LMICs.