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Review: Cesarean Delivery in Low- and Middle-Income Countries

Key findings

  • This review examines the quality of care metrics for Cesarean delivery in low- and middle-income countries (LMICs), addressing the six domains of equity, effectiveness, efficiency, safety, timeliness and patient-centeredness
  • Equity, effectiveness and efficiency of Cesarean delivery need to be better monitored and analyzed at the facility, regional and national levels. In some settings both underuse and overuse of Cesarean delivery are occurring
  • Uptake of the World Health Organization (WHO) Surgical Safety Checklist has been low in LMICs; even greater hurdles are deficits in the workforce, infrastructure and supply chain
  • The WHO recommends that most women deliver in primary care facilities, but women with complications often cannot be transferred appropriately; timeliness of referral to Cesarean delivery within a facility may also be inadequate
  • Rising global rates of Cesarean delivery do not reflect patient-centered care; large majorities of women express a preference for vaginal delivery

In many low- and middle-income countries (LMICs), the reduction of maternal and neonatal mortality has plateaued in recent years, and the rate of stillbirths has actually increased. Poor quality of health care, rather than a lack of skilled birth attendance or facility-based delivery, seems to be driving a significant proportion of the mortality.

Metrics on Cesarean delivery (CD), the most common surgical procedure performed in many facilities in LMICs and amongst women, provide insights into the overall quality of obstetrics care a health care system provides around childbirth. In Seminars in Fetal and Neonatal Medicine, Adeline A. Boatin, MD, MPH, co-director of Global Health in the Department of Obstetrics and Gynecology at Massachusetts General Hospital, and colleagues examine CD in LMICs using the six domains proposed by the 2001 Institute of Medicine report on the quality of care.


In 2015, average regional rates of CD varied from 44% in Latin American and Caribbean countries to 4%–6% in much of sub-Saharan Africa. However, a national rate can mask overuse of CD in some subpopulations and dire lack of access in others. In Ghana, for example, the national CD rate was 16% in 2017, but it was 12% in the poorest quintile of the population compared with 46% in the richest quintile. Differences in CD rate according to maternal wealth also occur at the facility level.

Unlike health care interventions such as immunization, where achieving universal coverage is the goal, optimizing CD access is complex. Inequities may be due to the provision of unnecessary procedures, not just lack of access. At global, national, regional and institutional levels, monitoring is needed to find out which women are undergoing CD and which are not.


A considerable proportion of CDs are performed without medical indication, or for questionable indications. Both the World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics recommend using the Robson classification system to evaluate CD trends within and between health care facilities.

The Robson system categorizes deliveries into 10 groups based on maternal parity, onset of labor, prior CD, fetal presentation, number of neonates and gestational age at delivery. Broad implementation would permit analysis of interfacility, interregional and international differences in practice and inform the implementation of evidence-based strategies to optimize CD in certain groups, such as women who previously underwent CD.


Efficiency is closely tied to effectiveness and equity. Ineffective use of CD leads to the waste of valuable resources; inequitable use wastes limited resources if unnecessary procedures are performed in some populations.

It is often difficult to determine an appropriate rate of CD for individual health care facilities. The WHO has developed an online calculator, the C-Model, that estimates the expected CD rate according to the characteristics of the population a facility serves. It can be combined with the Robson system to assess both efficiency and effectiveness.


Rates of maternal mortality, perinatal mortality and stillbirth after cesarean delivery are 40–100 times higher in LMICs than in high-income countries. Along with reports of higher complication rates, these findings raise questions about safety standards and practices. Reductions in postoperative morbidity and mortality by up to 50% have been demonstrated with the use of the WHO Surgical Safety Checklist. However, uptake of this tool has been only about 30% in LMICs compared with close to 90% in high-income countries. Besides lack of awareness of the checklist, the main drivers of poor uptake are the length of the checklist and lack of staff to perform it. Far greater hurdles are the need to overcome deficits in the workforce, infrastructure and supply chain resources needed to provide safe surgery.


The vast majority of cesarean deliveries in sub-Saharan Africa are done as emergencies, even for women with antenatally determined indications, which dramatically increases the risk of complications and mortality. Furthermore, the WHO recommends that most women deliver in primary care facilities where basic emergency obstetric and newborn care is available. This policy promotes access to facilities near women's homes, but it presumes women with complications can be transferred appropriately. To the contrary, referrals are often made too late, and transport to facilities capable of performing CD is often inadequate or unavailable. Timeliness of referral within a facility capable of performing CD may also be inadequate. In some LMICs, median intervals between decision and delivery range from 2–5 hours. Frequently reported barriers include shortages of staff, supplies and water; power outages; and having to share operating room facilities with non-obstetric services.

Patient-centered Care

Rising global CD rates seem to be in direct opposition to women's desires. In Latin America, where national CD rates are the highest in the world, less than 25% of women express a preference for CD. In Asia and sub-Saharan Africa, 80%–90% of women prefer vaginal delivery.

Reasons for that preference vary regionally but common explanations include fear of death, pain, social consequences (e.g., "failure of womanhood") or impoverishment. These fears are legitimate but may also stem from a dearth of education, counseling and respectful attention when health care providers are overburdened.

An Action Agenda

A table in the article presents suggested metrics for assessing the quality of care for CD in low-resource settings, adapted from evidence-based indicators published by Citron et al. in Surgery. Establishing regional or global consensus on a set of metrics would allow benchmarking across time and between facilities and countries. However, the suggestions are preliminary; their feasibility and efficiency remain to be determined.

Global CD rates vary from 0.6% in South Sudan to 58% in the Dominican Republic

The cost associated with the global "excess" of CD compared to the global "need" of CD of US$432 million

to 90% of women prefer vaginal delivery with some regional differences

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