Rates of Cesarean Delivery In Developing Countries Suggest Unequal Access
The best current estimate of the overall rate of cesarean delivery in developing countries is 12%, according to a study using nationally representative data from 82 nations with a median reference year of 1996. Regional rates vary from 3% in Sub-Saharan Africa to 26% in East Asia and in Latin America and the Caribbean.1 Among individual countries, Chad has the lowest rate (0.4%) and Chile the highest (40%). On average, rates among urban women are three times as high as those among rural women.
In 1994, the World Health Organization recommended that a nation's cesarean birth rate should be in the range 5–15%, and cautioned that a rate lower than 5% may indicate inadequate access to the procedure. However, there is currently no consensus on the optimal range. This study documents population-based national rates of cesarean births in the developing world, calculates regional rates, assesses trends in national rates and examines the disparity in use of cesarean delivery between urban and rural women.
Rates were calculated using a variety of data sources; however, nationally representative surveys of reproductive-age women conducted between 1990 and 2003 (mostly Demographic and Health Surveys) were the source for information on 73 of the 82 countries included. The median reference year was 1996, with a range of 1992–2003 for the nine different regions. Regional rates were weighted using the estimated number of births occurring in each country in 2000.
Overall, an estimated 12% of all live births in developing countries are cesarean deliveries; this represents nearly 14 million cesarean births in 2000. The reference year is 1993 or earlier for 16 of the 82 nations; the estimate rises only marginally when these earlier data are excluded. However, the overall rate drops to 9% when data for China are excluded; China's cesarean rate is 26%, and 16% of births in the developing world occur there.
East Asia and Latin America and the Caribbean have the highest regional cesarean rates (26%), followed by West Asia (11%), North Africa (8%), South Asia (7%), Eurasia and Southeast Asia (5%) and Sub-Saharan Africa (3%). Twenty-five of the 29 countries in Sub-Saharan Africa have rates of 5% or lower. The nations with the highest rates are Chile, Brazil, Dominican Republic, South Korea, China and Iran (30–40%).
The average annual rate of change between 1991 and 1998 (the average reference years for surveys taken in 1986–1994 and 1996–2003, respectively) was calculated for 36 countries, representing 45% of all births in the developing world in 2000. In 26 of these countries, rates were higher in 1998 than in 1991: Thirteen nations showed annual increases of 0–5%, eight had increases of 6–10% and five had increases of 11% or more. Of the 10 countries that had either no change or a decline in rates, nine were in Sub-Saharan Africa.
Cesarean rates among urban women were, on average, three times as high as those among rural women. With the exception of Peru and Paraguay, the largest disparities (urban-rural ratios of 5–9) were in countries that have low cesarean rates, and thus the disparity represents relatively small absolute differences between the two populations. Thirteen of the 17 nations in Sub-Saharan Africa showed an increase in this disparity from 1991 to 1998 (using the same data as for the average annual rates); no pattern of increasing or decreasing disparity by residence was seen for nations in other regions.
The researchers believe that because many of these developing countries have both high rates of maternal mortality and a marked disparity in cesarean rates between urban and rural women, the generally low cesarean rates suggest that those who are at greatest risk for obstetric complications do not have adequate access to the procedure. In countries where access is poor, the researchers say, it is critical to determine the proportion of women who likely need such live-saving care but fail to get it.
This study has a number of limitations. Many of the estimates are based on data that are more than 10 years old, and because cesarean rates appear to have increased over the study period, these estimates are likely to be lower than current cesarean rates. Another limitation is that the data for eight countries were collected from health facilities rather than representative surveys, and these lower-quality data are believed to yield lower cesarean estimates. Finally, the assessment of trends based on secondary analysis of survey data is inherently difficult, and even large changes in rates may not be statistically significant, especially where national rates are low.
To address the relative scarcity of data on cesarean delivery in developing countries, the researchers call for improved monitoring of the procedure, especially in nations with poor medical access. Such monitoring could also help determine the level of unmet obstetric need, particularly among rural women; this would aid in identifying women who require but fail to receive cesareans. The researchers suggest that the UN Millennium Development Goal of increasing the use of skilled attendants at birth represents "an excellent opportunity to direct attention to rapidly changing practices regarding cesarean birth," particularly in countries and areas "where women die from lack of availability of and access to this procedure and where women and health systems experience the consequences of unnecessary surgical intervention."—J. Thomas
1. Stanton CK and Holtz SA, Levels and trends in cesarean birth in the developing world, Studies in Family Planning, 2006, 37(1):41–48.