Rural-urban disparities in caesarean deliveries in sub-Saharan Africa: a multivariate non-linear decomposition modelling of Demographic and Health Survey data.

Introduction: Globally, the rate of caesarean deliveries increased from approximately 16.0 million in 2000 to 29.7 million in 2015. In this study, we decomposed the rural-urban disparities in caesarean deliveries in sub-Saharan Africa.

Methods: Data for the study were extracted from the most recent Demographic and Health Surveys of twenty-eight countries in sub-Saharan Africa. We included 160,502 women who had delivered in health facilities within the five years preceding the survey. A multivariate non-linear decomposition model was employed to decompose the rural-urban disparities in caesarean deliveries. The results were presented using coefficients and percentages.

Results: The pooled prevalence of caesarean deliveries in the 28 countries considered in the study was 6.04% (95% CI = 5.21-6.88). Caesarean deliveries' prevalence was highest in Namibia (16.05%; 95% CI = 14.06-18.04) and lowest in Chad (1.32%; 95% CI = 0.91-1.73). For rural-urban disparities in caesarean delivery, the pooled prevalence of caesarean delivery was higher in urban areas (10.37%; 95% CI = 8.99-11.75) than rural areas (3.78%; 95% CI = 3.17-4.39) across the 28 countries. Approximately 81% of the rural-urban disparities in caesarean deliveries were attributable to the differences in child and maternal characteristics. Hence, if the child and maternal characteristics were levelled, more than half of the rural-urban inequality in caesarean deliveries would be reduced. Wealth index (39.2%), antenatal care attendance (13.4%), parity (12.8%), mother's educational level (3.5%), and health insurance subscription (3.1%) explained approximately 72% of the rural-urban disparities in caesarean deliveries.

Conclusion: This study shows significant rural-urban disparities in caesarean deliveries, with the disparities being attributable to the differences in child and maternal characteristics: wealth index, parity, antenatal care attendance, mother's educational level, and health insurance subscription. Policymakers in the included countries could focus and work on improving the socioeconomic status of rural-dwelling women as well as encouraging antenatal care attendance, women's education, health insurance subscription, and family planning, particularly in rural areas.