Prevalence, urban-rural disparity and determinants of caesarean section delivery among women delivering at health facilities in 48 low- and middle-income countries: a multilevel and decomposition analysis.

INTRODUCTION

Caesarean section rates have increased globally, exceeding the WHO's recommended threshold of 15%. Understanding the prevalence, sociogeographic disparities and determinants of caesarean section delivery is essential for optimising its use and improving maternal and child health outcomes.

METHODS

The study used demographic and health survey data, which was conducted between 2015 and 2024 in 48 low- and middle-income countries with a total of 387 397 weighted samples. STATA V.17 was used to extract, recode and perform statistical analyses. Mixed-effects multilevel logistic regression was used to identify the significant predictors of caesarean section delivery. Statistical significance was set at a p value<0.05. A logit-based multivariate decomposition analysis was applied to examine rural-urban disparities in caesarean delivery use.

RESULTS

The prevalence of caesarean section delivery among women delivering at health facilities was 19.9% (95% CI 19.7% to 20.1%). History of terminated pregnancy, four or more antenatal care visits, higher wealth quintile, higher education status, age at first birth, insurance coverage, media exposure and residing in urban areas were significant predictors of caesarean section delivery. The decomposition analysis showed that 61.8% of the rural-urban caesarean section gap was due to differences in characteristics (endowments), while 38.2% stemmed from differences in their effects (coefficients).

CONCLUSION

Caesarean delivery rates in low- and middle-income countries surpass the WHO's recommended thresholds, with marked socioeconomic and geographic disparities. Key determinants of caesarean delivery use and urban-rural gaps highlight structural inequalities in healthcare access and delivery. Targeted interventions are needed to enhance equitable access to quality maternal care, refine financing and promote maternal education.