Trend and associated factors of cesarean section rate in Ethiopia: Evidence from 2000 2019 Ethiopia demographic and health survey data

  • PLoS ONE, Volume 18, No. 3 March, Year 2023

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Study Justification:
– The study aimed to determine the trend of cesarean section (CS) rates in Ethiopia and identify factors that influence it.
– The World Health Organization (WHO) recommends a CS prevalence of less than 5% to indicate an unmet need and a prevalence of more than 15% may pose risks to mother and child.
– Access to CS in resource-limited countries like Ethiopia was much lower than the recommended levels.
– This study aimed to provide evidence on the CS trend and associated factors in Ethiopia to inform interventions and improve maternal and child health outcomes.
Study Highlights:
– The CS rate in Ethiopia increased from 5.1% in 1995 to 16% in 2019 in urban areas and from 0.001% in 1995 to 3% in rural areas.
– The overall increment of CS rate from 1995 to 2019 was 0.7% per year.
– Factors associated with higher odds of CS included age (25-34 years and 34-49 years), education level (primary, secondary, and higher education), multiple pregnancies, obesity, living in an urban area, and increased number of antenatal care visits.
– Factors associated with lower odds of CS included parity of 2-4 children and birth order greater than four.
Recommendations for Lay Reader and Policy Maker:
– Intervention efforts need to be prioritized for women living in rural areas to improve access to CS services.
– Empowering women’s education can help address the current problem by increasing awareness and decision-making power.
– Encouraging co-services such as antenatal care (ANC) usage can contribute to better maternal and child health outcomes.
– Policy makers should consider allocating resources and implementing strategies to improve CS rates in both urban and rural areas.
Key Role Players Needed to Address Recommendations:
– Ministry of Health: Responsible for developing and implementing policies and programs to improve maternal and child health, including access to CS services.
– Health Facilities: Need to ensure availability of trained healthcare providers and necessary infrastructure for safe CS procedures.
– Community Health Workers: Can play a crucial role in raising awareness about the importance of CS and promoting ANC services.
– Non-Governmental Organizations: Can provide support in terms of funding, capacity building, and advocacy for improving CS rates.
Cost Items to Include in Planning Recommendations:
– Training and Capacity Building: Budget for training healthcare providers on safe CS procedures and management of complications.
– Infrastructure and Equipment: Allocate funds for upgrading health facilities to meet the requirements for performing CS surgeries.
– Awareness and Education Campaigns: Budget for community-level awareness programs and educational materials to promote the importance of CS and ANC services.
– Monitoring and Evaluation: Set aside resources for monitoring and evaluating the implementation of interventions and measuring the impact on CS rates.
Please note that the cost items provided are general suggestions and may vary based on the specific context and needs of Ethiopia.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on multiple Ethiopia Demographic and Health Surveys (EDHS) conducted over a period of time. The study used a large weighted sample size and employed statistical analysis techniques. The results show a clear trend in the cesarean section rate and identify several factors associated with cesarean section delivery. However, to improve the evidence, the abstract could provide more details on the methodology, such as the sampling technique used in the surveys and the specific statistical tests conducted. Additionally, it would be helpful to include information on the limitations of the study and any potential biases.

The world health organization considers cesarean section (CS) prevalence of less than 5% suggests an unmet need. On the other hand, a prevalence of more than 15% may pose to risk to mother and child, however, access to CS in a resource-limited country like Ethiopia was much lower than the aforementioned level, Therefore, this was the first study to determine the trend of CS, and factors that influence it. Methods This was done based on the five Ethiopia Demographic and Health Surveys. Trend analysis was done separately for rural and urban. The significance of the trend was assessed using the Extended Mantel-Haenszel chi-square test. The factors on CS delivery were identified based on DHS 2016 data. A multi-level logistic regression analysis technique was used to identify the factors associated with cesarean section delivery. The analysis was adjusted for the different individual-and community-level factors affecting cesarean section delivery. Data analysis was conducted using STATA 14.1 software. Result The rate of cesarean section increased from 5.1% in 1995 to 16% in 2019 in an urban area and 0.001 in 1995 to 3% in a rural area, the overall increment of CS rate was 0.7% in 1995 to 2019 at 6%. The odds of cesarean section were higher among 25 34 years (AOR = 2.79; 95% CI: 1.92, 4.07) and 34 49 years (AOR = 5.23;95% CI: 2.85,9.59), among those educated at primary school level (AOR = 1.94; 95% CI: 1.23,3.11), secondary education (AOR = 2.01; 95% CI: 1.17, 3.56) and higher education (AOR = 4.12; 95% CI: 2.33 7.29) with multiple pregnancies (AOR = 11.12; 95% CI: 5.37, 23.), with obesity (AOR = 1.73; 95% CI: 1.22, 2.45), living in an urban area (AOR = 2.28; /95% CI: 1.35 3.88), and increased with the number of ANC visit of 1 3 and 4th(AOR = 2.26; 95% CI: 1.12, 4.58), (AOR = 3.34; 95% CI: 1.12, 4.58), respectively. The odds of cesarean section are lower among parity of 2 4 children (AOR = 0.54; 95% CI: 0 .37, 0.80) and greater than four birth order (AOR = 0.42;95% CI: 0.21,0.84). Conclusion In Ethiopia, the CS rate is below the WHO recommended level in both urban and rural areas, thus, intervention efforts need to be prioritized for women living in a rural area, empowering women s education, encouraging co-services such as ANC usage could all help to address the current problem.

The study was done in Ethiopia. Ethiopia is a multi-ethnic country in east Africa with a diverse population. It is bordered on the west by Sudan, on the east by Somalia and Djibouti, on the north by Eritrea, and the south by Kenya. The country has a total area of 1,112,000 square kilometers Ethiopia is divided into eleven regions and two municipal governments. Tigray, Afar, Amhara, Oromiya, Somali, Benishangul-Gumuz, Southern Nations Nationalities and People (SNNP), Gambela, Sidama, South Western, and Harari are among the regions involved. Addis Ababa and Dire Dawa are administrative cities [21]. According to the EDHS 2016 and 2011, the prevalence of CS in Ethiopia was 1.9% [13] and 0.7% [22], respectively [13, 22]. The research was based on secondary data from the EDHS. Factors associated with CS were identified using EDHS 2016 data, whereas trend analysis was done using EDHS 2000, 2005, 2011, 2016, and 2019 (mini EDHS) data. Since EDHS collected data about births in the previous 5 years, the data indicated CS from 1995 to 2019 [13]. All EDHS surveys used a sample that was aimed to represent all of the country’s regions and administrative cities. The survey participants were chosen using a two-stage stratified sampling technique. The first stage was a selection of the enumeration areas. The enumeration areas were stratified into urban and rural. In the second stage, households in the selected enumeration area were selected. The sample size was then allocated using a probability-proportional allocation method. 645 enumeration areas (EAs) were chosen for the 2016 DHS. There were 202 EAs from urban regions and 443 from rural areas. Six hundred twenty-four EAs were included in the 2011 DHHS (187 from urban regions and 437 from rural areas) [13]. The 2005 EDHS had 540 EAs (145 from urban areas and 395 from rural areas), while the 2000 DHS included 539 EAs (138 from urban and 401 from rural) [14, 22]. Then, on average 27 to 32 households per EA were selected from all surveys. The source population was all live births from reproductive-age women within 5 years before the survey in Ethiopia. A total weighted sample of 46,317 live births (12,260 in EDHS 2000, 11,163 in EDHS 2005, 11,872 in EDHS 2011, and 11,022 in EDHS 2016) was used for analysis. Detailed sampling procedure can be found from the EDHS [13, 14, 22, 23]. Five interviewer-administered questions were used by the EDHS: the household questionnaire, thewomen questionnaire, the men questionnaire, the biomarker questionnaire, and the health facility questionnaire [4, 14, 22, 23]. Data was collected for this study from children under the age of five surveys, born to interviewed mothers who gave birth within five years of the survey year 1995–2016, which was included in the kid records. The data collection tool was created in English initially, then translated into the country’s three main languages: Amharic, Oromiffa, and Tigrigna. The Somaligna and Afarigna languages were also used in the 2000 DHS [4, 22]. The outcome variable in this study is the CS which was taken dichotomous and coded by the value “1” (one) if the respondents underwent cesarean delivery and “0” (zero) if not. There were three categories of independent variables; institution-related, socio-demographic and economic factors, and pregnancy-related factors. Institutional factors include the place of delivery (public vs private), the number of antenatal care visits (no visit, 1–3 and >4), pregnancy-related factors including parity (Primi-parous, multi-parous, and Grand-multi-parous), birth order (first, second, third or higher), maternal, body–mass index (normal, underweight and overweight), Size of the baby was determined from the maternal recall of baby’s weight at birth (very large, average, smaller than the average), socio-demographic and economic factors consist of maternal education, maternal age at birth, marital status, mothers’ employment status (yes/no), wealth index (poor, middle, rich), residences, and region. Completed EDHS questionnaires were meticulously tagged, entered, and modified after data collection The distribution of study participants in the sample was weighted to create nationally representative data [22]. STATA software version 14 was used to analyze the data. Frequency and percentage were utilized as descriptive statistics. Using chi-square analysis, the CS rate was compared across several socio-economic, maternal, and child characteristics. The DHS surveys gathered information on the mode of delivery of birth within the previous five years. The rate was calculated for each year between 1995 and 2019 based on the specific year of delivery, 2019 mini DHS data was included for the trend analysis, however, for determinate factors, the data was not completed. The Extended Mantel-Haenszel chi-square test for linear trend was used to examine the significance of the trend of the CS rate using the OpenEpi software (Version 3.01) dose-response program [24]. A 95% significant probability of the existence of a trend was declared when the p-value was less than 0.05. Further, the change in trend CS rate is presented in two ways, Absolute increase of CS rate and relative increase as the average annual rate of increase (AARI), to find the absolute change increase, subtract the latest CS rate from the earliest CS rate and to find an average annual rate of increase, AARI = [(an / am) [1 / (n-m)]]-1; where am; is the first observation of CS rate, and; is the latest observation of CS rate, m is the first observed year and n is the latest observed year. The AARI is a geometric progression ratio that provides a constant rate of change during the study period [3]. To identify factors associated with CS delivery, a Multi-level logistic regression analysis technique was applied, since the data had hierarchical and clustering nature. A total of four models were carried out. The first model was an empty model that was used to calculate the random variability in the intercept. The second model estimated the influence of individual-level factors on CS delivery. The third model looked at how community-level factors are associated with CS delivery. Finally, the fourth model computed the influence of individual and community-level factors on cesarean delivery. The Intra-Cluster Correlation (ICC) was determined to illustrate the correlation between clusters within a model, and the intra-cluster correlation (ICC) is expected to be ≥ 10% when using this model. The power of variables included in each model in predicting CS delivery was also determined using the Proportional Change in Variance (PCV). To determine the factors that associated with cesarean section, the model with the highest PCV value was used. Significant factors were considered as variables with a p-value less than 0.05. All Ethiopian Demographic and Health Surveys obtained ethical approval from the Ethiopian Health and Nutrition Research Institute Review Board, the Ministry of Science and Technology, ICF International’s Institutional Review Board, and the CDC. Data was collected after informed consent was obtained, and all information was kept private. After reviewing the brief descriptions of the study provided to the DHS program, the Demographic, and Health Surveys Program granted authorization to access EDHS data for this specific research. The data sets were handled with the utmost confidentiality [13].

Based on the provided information, here are some potential innovations that could be recommended to improve access to maternal health in Ethiopia:

1. Strengthening healthcare infrastructure: Investing in the improvement and expansion of healthcare facilities, particularly in rural areas, can help increase access to maternal health services, including cesarean sections.

2. Increasing skilled healthcare providers: Training and deploying more skilled healthcare providers, such as doctors, nurses, and midwives, can ensure that there are enough qualified professionals to perform cesarean sections and provide other essential maternal health services.

3. Improving transportation and logistics: Enhancing transportation networks and logistics systems can help overcome geographical barriers and ensure that pregnant women can reach healthcare facilities in a timely manner, especially in remote areas.

4. Promoting community-based care: Implementing community-based care programs, such as mobile clinics or community health workers, can bring essential maternal health services closer to women in rural areas, making it easier for them to access cesarean sections when needed.

5. Increasing awareness and education: Conducting awareness campaigns and educational programs can help women and their families understand the importance of maternal health services, including cesarean sections, and encourage them to seek appropriate care during pregnancy and childbirth.

6. Strengthening referral systems: Establishing effective referral systems between primary healthcare centers and higher-level facilities can ensure that women who require cesarean sections are promptly referred to the appropriate healthcare facility with the necessary resources and expertise.

7. Addressing financial barriers: Implementing financial support mechanisms, such as health insurance or subsidies, can help alleviate the financial burden associated with cesarean sections and make them more accessible to women, particularly those from low-income backgrounds.

8. Enhancing data collection and analysis: Continuously collecting and analyzing data on cesarean section rates and associated factors can provide valuable insights for policymakers and healthcare providers to identify gaps and develop targeted interventions to improve access to maternal health services.

It is important to note that these recommendations are based on the information provided and may need to be further tailored and contextualized to the specific needs and challenges of the Ethiopian healthcare system.
AI Innovations Description
Based on the study conducted in Ethiopia, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Increase access to cesarean section (CS) services: Since the CS rate in Ethiopia is below the World Health Organization’s recommended level, efforts should be made to increase access to CS services, especially in rural areas where access is limited. This can be done by improving infrastructure and resources in healthcare facilities, training healthcare providers in CS procedures, and ensuring the availability of necessary equipment and supplies.

2. Empower women’s education: The study found that women with higher levels of education were more likely to undergo CS. Therefore, empowering women through education can help improve their understanding of maternal health and the importance of timely interventions such as CS when necessary. This can be achieved through educational campaigns, community outreach programs, and providing access to quality education for women.

3. Encourage antenatal care (ANC) usage: The odds of CS were found to increase with the number of ANC visits. Promoting and encouraging regular ANC visits among pregnant women can help identify high-risk pregnancies and ensure appropriate interventions are provided in a timely manner. This can be done through community health workers, mobile clinics, and awareness campaigns highlighting the benefits of ANC.

4. Address socio-economic factors: The study identified socio-economic factors such as maternal age, education, employment status, and wealth index as influencing CS rates. Addressing these factors, such as providing economic opportunities for women, improving access to education and employment, and reducing income disparities, can contribute to better maternal health outcomes.

5. Target interventions in rural areas: The study found that access to CS services was particularly low in rural areas. Therefore, targeted interventions should be implemented to improve access to maternal health services in these areas. This can include establishing mobile clinics, providing transportation services for pregnant women, and training healthcare providers in rural areas to perform CS procedures.

Overall, a comprehensive approach that addresses infrastructure, education, access to care, and socio-economic factors is needed to improve access to maternal health services, specifically CS, in Ethiopia. By implementing these recommendations, the country can work towards reducing maternal and neonatal mortality rates and improving overall maternal health outcomes.
AI Innovations Methodology
Based on the provided study, here are some potential recommendations to improve access to maternal health in Ethiopia:

1. Increase access to cesarean section (CS) services: Since the CS rate in Ethiopia is below the World Health Organization’s recommended level, efforts should be made to increase access to CS services, especially in rural areas where access is limited. This can be achieved by improving infrastructure and resources in healthcare facilities, training healthcare providers in CS procedures, and ensuring that CS services are available and affordable to all women who need them.

2. Improve education and awareness: Empowering women through education and increasing awareness about the importance of maternal health can help address the current problem. This can be done through community-based education programs, campaigns, and outreach activities that provide information on the benefits of antenatal care, safe delivery practices, and the availability of CS services.

3. Strengthen antenatal care (ANC) services: ANC visits play a crucial role in identifying high-risk pregnancies and ensuring appropriate care. Increasing the number of ANC visits and improving the quality of care provided during these visits can help reduce complications during childbirth and the need for emergency CS. This can be achieved by training healthcare providers in ANC protocols, improving the availability of ANC services in rural areas, and promoting early and regular ANC attendance among pregnant women.

4. Address socio-economic factors: Socio-economic factors such as maternal education, wealth status, and employment can influence access to maternal health services. Efforts should be made to address these factors by promoting girls’ education, providing financial support for maternal health services, and creating employment opportunities for women. This can help improve access to CS and other maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Collect data on the current status of maternal health access, including CS rates, ANC attendance, and socio-economic factors. This can be done through surveys, interviews, and analysis of existing data sources such as the Ethiopia Demographic and Health Surveys.

2. Model development: Develop a simulation model that incorporates the identified recommendations and their potential impact on improving access to maternal health. This model should consider factors such as population demographics, healthcare infrastructure, resource allocation, and the effectiveness of interventions.

3. Parameter estimation: Estimate the parameters of the simulation model based on available data and expert knowledge. This may involve statistical analysis, literature review, and consultation with relevant stakeholders.

4. Scenario analysis: Conduct scenario analysis to simulate the impact of different combinations of recommendations on improving access to maternal health. This can involve varying parameters such as the coverage of CS services, the number of ANC visits, and the level of education and awareness.

5. Impact assessment: Assess the impact of the simulated scenarios on key indicators of maternal health access, such as CS rates, ANC attendance, and maternal and neonatal outcomes. This can be done by comparing the results of the different scenarios and analyzing the changes in these indicators.

6. Policy recommendations: Based on the simulation results, provide policy recommendations on the most effective combination of interventions to improve access to maternal health. Consider factors such as feasibility, cost-effectiveness, and sustainability in making these recommendations.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and data availability in Ethiopia.


Identifiers:
DOI: 10.1371/journal.pone.0282951
Research Areas:
Community Interventions, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations
Study Countries:
Djibouti, Eritrea, Ethiopia, Kenya, Multi-Countries, Somalia, Sudan
Study Design:
Cross Sectional Study, Grounded Theory, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Male & Female
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