Socioeconomic differences in caesarean section \u2013 are they explained by medical need? An analysis of patient record data of a large Kenyan hospital

Lisa Van Der Spek,Tanja A J Houweling,Thomas Van Den Akker,Sterre Sanglier,Hillary M Mabeya,Paul L J M Mertens

doi:10.1186/s12939-020-01215-2

Abstract

BackgroundCaesarean section (C-section) rates are often low among the poor and very high among the better-off in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context.MethodsWe analyzed electronic records of 12,209 women who gave birth in a teaching hospital in Kenya in 2014. C-section rates were calculated by socioeconomic position (SEP), using maternal occupation (professional, small business, housewife, student) as indicator. We assessed if women had documented clinical indications according to hospital guidelines and if socioeconomic differences in C-section rates were explained by indication.ResultsIndication for C-section according to hospital guidelines was more prevalent among professionals than housewives (16% vs. 9% of all births). The C-section rate was also higher among professionals than housewives (21.1% vs. 15.8% [OR 1.43; 95%CI 1.23–1.65]). This C-section rate difference was largely explained by indication (4.7 of the 5.3 percentage point difference between professionals and housewives concerned indicated C-sections, often with previous C-section as indication). Repeat C-sections were near-universal (99%). 43% of primary C-sections had no documented indication. Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate.ConclusionsSocioeconomic differences in C-section rates can be largely explained by unnecessary primary C-sections and higher supposed need due to previous C-section. Prevention of unnecessary primary C-sections and promoting safe trial of labor should be priorities in addressing C-section over-use and reducing inequalities.Tweetable abstractUnnecessary primary C-sections and ubiquitous repeat C-sections drive overall C-section rates and C-section inequalities.

Highlights

Caesarean section (C-section) rates are often low among the poor and very high among the betteroff in low- and middle-income countries
Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate
Socioeconomic differences in C-section rates can be largely explained by unnecessary primary Csections and higher supposed need due to previous C-section

Summary

Introduction

Caesarean section (C-section) rates are often low among the poor and very high among the betteroff in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context. Caesarean section (C-section) rates are rapidly rising in low and middle income countries [1] and can reach very high levels among women of higher socioeconomic position (SEP) [2]. Unmet need for Csection among poor women in these countries is usually high. While C-section rates remain low in most SubSaharan African countries, they are gradually increasing, and socioeconomic differences in C-section rates are substantial [3]. While the surgery can be life-saving when medically indicated, C-section rates above 10% at the population level are not associated with improved maternal and newborn outcomes [5, 6].

Objectives

Methods

Results

Discussion

Conclusion