Socioeconomic inequalities in C-section deliveries in low- and middle-income countries: measurement and determinants

While C-section (CS) deliveries exhibit significant socioeconomic inequalities in low- and middle-income countries (LMICs), the extent and underlying drivers of these inequalities remain poorly understood. This study assesses these inequalities and identifies key contributing factors.

The most recent nationally representative samples of live births (n=652 539) from the Demographic and Health Surveys, conducted between 2014 and 2024 in 44 LMICs, were used to calculate the CS delivery rates. The Wagstaff (WI) and Erreygers (EI) indices were used to measure the relative and absolute socioeconomic inequalities in CS delivery. Meta-regression analyses were performed to identify the proximate determinants of the observed socioeconomic inequalities in CS delivery across the selected LMICs.

CS delivery rates varied across LMICs, with a median of 6.25% (IQR=16.18). The WI and EI indicated that CS deliveries were concentrated among high socioeconomic backgrounds, with only one country exhibiting no inequality. The pooled estimates (WI: 0.32, 95% CI 0.28 to 0.36 and EI: 0.11, 95% CI 0.09 to 0.14) further demonstrate the concentration of CS among the rich in LMICs. Meta-regression analyses indicated that inequalities in education and antenatal care were significantly and positively associated with the concentration of CS deliveries among wealthier women.

CS delivery concentration among wealthier women remains a health concern in LMICs. Given the positive link between higher education and antenatal care with CS deliveries, country-specific policies promoting health education and targeted messaging during antenatal care visits on the adverse health effects of unnecessary CS deliveries may help reduce socioeconomic inequalities in CS delivery.