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.