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      Rising trends and inequalities in cesarean section rates in Pakistan: Evidence from Pakistan Demographic and Health Surveys, 1990-2013

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          Abstract

          Despite global efforts to improve maternal health, many developing countries including Pakistan have failed to achieve the target of a 75% reduction in maternal deaths by 2015. Addressing socioeconomic inequalities in access to emergency obstetric care is crucial for reducing the maternal mortality rate. This study was done to examine the time trends and socioeconomic inequalities in the utilization of cesarean section (C-section) in Pakistan during 1990–2013. We used data from the Pakistan Demographic and Health Surveys (PDHS) conducted during 1990 to 2013. All these surveys are nationally representative surveys of ever-married women aged 15–49 years with a sample size of 6611, 10,023, and 13,558 women in 1990–1991, 2006–2007, and 2012–2013, respectively, with an overall response rate of over 90%. The unit of analysis for this study was women with their most recent live birth in the five years preceding the surveys. Bivariate analyses and multivariable logistic regression models were employed to investigate the prevalence of cesarean sections according to selected sociodemographic characteristics of women. C-section rates were found to have increased during this period, with an especially significant rise from 2.7% in 1990–1991 to 15.8% in 2012–2013 with lower utilization among the non-educated women (7.5%), compared with the women with higher education (40.3%). C-section rates ranged from 5.5% in the poorest women to 35.3% in the richest women. Only 11.5% of the rural women had a C-section compared to 25.6% of the urban women. A greater likelihood of having a cesarean section was observed in the richest, highly educated, and urban-living women while there was no significant difference observed in cesarean section rates between the private and public sectors in all three surveys. To improve maternal health, routine monitoring and evaluation of the provision of emergency obstetric services are needed to address the underuse of C-section in poor and rural areas and overuse in rich and urban areas.

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          Most cited references 35

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          Maternal mortality: who, when, where, and why.

          The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world compared with about one in 30 000 in Northern Europe. Such a discrepancy poses a huge challenge to meeting the fifth Millennium Development Goal to reduce maternal mortality by 75% between 1990 and 2015. Some developed and transitional countries have managed to reduce their maternal mortality during the past 25 years. Few of these, however, began with the very high rates that are now estimated for the poorest countries-in which further progress is jeopardised by weak health systems, continuing high fertility, and poor availability of data. Maternal deaths are clustered around labour, delivery, and the immediate postpartum period, with obstetric haemorrhage being the main medical cause of death. Local variation can be important, with unsafe abortion carrying huge risk in some populations, and HIV/AIDS becoming a leading cause of death where HIV-related mortaliy rates are high. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable--rural populations and poor people--is essential if substantial progress is to be achieved by 2015.
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            Rates of caesarean section: analysis of global, regional and national estimates.

            Rates of caesarean section are of concern in both developed and developing countries. We set out to estimate the proportion of births by caesarean section (CS) at national, regional and global levels, describe regional and subregional patterns and correlate rates with other reproductive health indicators. We analysed nationally representative data available from surveys or vital registration systems on the proportion of births by CS. We used local non-parametric regression techniques to correlate CS with maternal mortality ratio, infant and neonatal mortality rates, and the proportion of births attended by skilled health personnel. Although very unevenly distributed, 15% of births worldwide occur by CS. Latin America and the Caribbean show the highest rate (29.2%), and Africa shows the lowest (3.5%). In developed countries, the proportion of caesarean births is 21.1% whereas in least developed countries only 2% of deliveries are by CS. The analysis suggests a strong inverse association between CS rates and maternal, infant and neonatal mortality in countries with high mortality levels. There is some suggestion of a direct positive association at lower levels of mortality. CS levels may respond primarily to economic determinants.
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              The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014

              Background Caesarean section (CS) rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate CS rate and the associated additional short- and long-term risks and costs. We present the latest CS rates and trends over the last 24 years. Methods We collected nationally-representative data on CS rates between 1990 to 2014 and calculated regional and subregional weighted averages. We conducted a longitudinal analysis calculating differences in CS rates as absolute change and as the average annual rate of increase (AARI). Results According to the latest data from 150 countries, currently 18.6% of all births occur by CS, ranging from 6% to 27.2% in the least and most developed regions, respectively. Latin America and the Caribbean region has the highest CS rates (40.5%), followed by Northern America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%). Based on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%) with an average annual rate of increase of 4.4%. The largest absolute increases occurred in Latin America and the Caribbean (19.4%, from 22.8% to 42.2%), followed by Asia (15.1%, from 4.4% to 19.5%), Oceania (14.1%, from 18.5% to 32.6%), Europe (13.8%, from 11.2% to 25%), Northern America (10%, from 22.3% to 32.3%) and Africa (4.5%, from 2.9% to 7.4%). Asia and Northern America were the regions with the highest and lowest average annual rate of increase (6.4% and 1.6%, respectively). Conclusion The use of CS worldwide has increased to unprecedented levels although the gap between higher- and lower-resource settings remains. The information presented is essential to inform policy and global and regional strategies aimed at optimizing the use of CS.
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                Author and article information

                Affiliations
                [1 ] Department of Health Policy and Management, College of Medicine, Seoul National University, Seoul, South Korea
                [2 ] Department of Public Health, Keimyung University, Daegu, South Korea
                [3 ] Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, South Korea
                National Academy of Medical Sciences, NEPAL
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Contributors
                Role: Conceptualization, Role: Data curation, Role: Formal analysis, Role: Investigation, Role: Methodology, Role: Writing – original draft
                Role: Formal analysis, Role: Writing – review & editing
                ORCID: http://orcid.org/0000-0002-9585-8266, Role: Supervision, Role: Validation, Role: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                17 October 2017
                2017
                : 12
                : 10
                29040316 5645133 10.1371/journal.pone.0186563 PONE-D-17-23110
                © 2017 Mumtaz et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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                Figures: 0, Tables: 4, Pages: 14
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                Funding
                Funded by: National Research Foundation of Korea (KR)
                Award ID: No. NRF-2014R1A2A1A11051392
                Award Recipient : ORCID: http://orcid.org/0000-0002-9585-8266
                This study was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) (No. NRF- 2014R1A2A1A11051392).The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Obstetric Procedures
                Cesarean Section
                People and Places
                Geographical Locations
                Asia
                Pakistan
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Medicine and Health Sciences
                Health Care
                Socioeconomic Aspects of Health
                Medicine and Health Sciences
                Public and Occupational Health
                Socioeconomic Aspects of Health
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Birth
                Labor and Delivery
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Birth
                Labor and Delivery
                Earth Sciences
                Geography
                Geographic Areas
                Rural Areas
                Research and Analysis Methods
                Research Design
                Survey Research
                Surveys
                Health Surveys
                Custom metadata
                This study used globally authorized, publically available and nationally representative DHS data sets from Pakistan, conducted during 1990-2013. These data sets were downloaded from the official website of the DHS program ( https://dhsprogram.com), after obtaining permission from the DHS team. The DHS is a global program supported by the United States Agency for International Development and ICF International, and conducts surveys worldwide to collect high-quality data on maternal and child healthcare, women’s empowerment, domestic violence, and knowledge of HIV/AIDS to provide guidelines in the policy-making and health evaluation programs of various nations.

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