Abstract:
Background: Caesarean 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.
Methods: We 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.
Results: Indication 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.
Conclusions: Socioeconomic 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.