Use and Quality of Cesarean Delivery in a Low and Middle Income Setting: National Results from Two Emergency Obstetric and Newborn Care Assessments
Abstract Background: Cesarean delivery (CD) rates have reached epidemic levels in many high and middle income countries while increasingly, low income countries are challenged both by high urban CD rates and high unmet need in rural areas. The managing authority of health care institutions often plays a role in these disparities. This paper shows changes between 2008 and 2016 in CD rates and the capacity of the Ethiopian health system to deliver quality CD services, highlighting the role of the management sector.Methods: We compare results from two national cross-sectional emergency obstetric and newborn care assessments using descriptive statistics. The sample includes 111 hospitals in 2008 and 316 hospitals in 2016, and 275 CD case reviews in 2008 and 568 in 2016. Our primary outcome measures include population- and institutional-based CD rates; hospital readiness to perform CD; quality of clinical management; and the relative size of Robson classification groupsResults: The national population-based rate increased (< 1% to 2.7%) as did all regional rates. Rates ranged from 24% in urban settings to less than 1% in several rural regions. The institutional rate was 54% in the private for-profit sector in 2016, up from 46% in 2008. Hospital readiness to perform CDs increased in public and for-profit hospitals. Only half of the women whose cases were reviewed received uterotonics after delivery of the baby, but use of prophylactic antibiotics was high. Partograph use increased from 9% to 42% in public hospitals, but was negligible or declined elsewhere. In 2016, a third of case reviews from the public sector were among low-risk nulliparous women (Robson group 1).Conclusions: Between 2008 and 2016, government increased the availability of CD services, improved public hospital readiness and some aspects of clinical quality. Strategies tailored to further reduce the high unmet need for CD and what appears to be an increasing number of unnecessary cesareans are discussed. Adherence to best practices and universal coverage of water and electricity will improve the quality of hospital services while the use of the Robson classification system may serve as a useful quality improvement tool.