Academic journal article Bulletin of the World Health Organization

Reliability of Data on Caesarean Sections in Developing Countries

Academic journal article Bulletin of the World Health Organization

Reliability of Data on Caesarean Sections in Developing Countries

Article excerpt


Population-based rates for caesarean section are considered an important indicator of access to essential obstetric care in developing countries. Various United Nations agencies promote this indicator for use in the evaluation of sale motherhood programmes (1). The interpretation of the indicator is difficult in the absence of information on the indication for the procedure. Studies have shown that as prevalence of caesarean sections increases, the decision on whether to perform such an operation is increasingly based on fetal rather than maternal indications (2). Moreover, high rates for caesarean sections may hide unnecessary interventions (3-6), even in settings where there is an unmet need for caesarean sections. Nevertheless, in settings where rates for caesarean section are low and mainly done for maternal indications, crude population-based rates for caesarean section remain very useful as they are likely to reflect life-saving care.

Data on population-based rates for caesarean section come from two sources: household surveys in which women of reproductive age are interviewed regarding recent births, and hospital-based studies which rely on record review for the numerator and estimates of the number of live births from censuses of surveys for the denominator. There has been no validation of data obtained by either method.

The objective of this study was to assess the reliability of rates for caesarean section obtained from these two data sources. The specific sources we examined were: women's self-report of a caesarean section in Demographic and Health Surveys (DHS) and hospital-based data on caesarean sections collected in Unmet Obstetric Need (UON) studies (7, 8). Recommendations for improvement of data quality are discussed for both methods.


Data sources

The data examined here came from regional estimates of the caesarean section rate between 1989 and 1999 in six countries: Benin, Burkina Faso, Haiti, Mali, Morocco and Niger. The data collection procedures for the two methods are described below. The reference points of the estimates are shown in Table 1.

DHS surveys are based on nationally-representative samples of women of reproductive age. The sample sizes for the countries in this study ranged flora 6000-13 000, and for the individual regions from 350 to 3500. The questionnaire includes a complete live-birth history for every woman. Questions regarding maternal health care are asked of women who have had a live birth during the three or five years prior to the survey. No maternal health-care questions are asked of women who have had a stillbirth. Data for the numerator of the DHS caesarean section rate come from all positive responses to the question: Was (NAME) delivered by caesarean section? The denominator of the DHS caesarean section rate is the number of live births in the last three of five years.

The DHS interviewer manual states the following: "A caesarean section is a delivery of a baby through an incision in the woman's abdomen and womb, rather than through the birth canal. Such a delivery is necessary for some women due to pregnancy complications. Find out whether the baby was delivered by an operation and not through the birth canal" (9). Discussions with DHS staff suggested that in some countries this definition is specifically discussed during interviewer training to ensure that interviewers do not confuse caesareans with episiotomies. However, most agreed that such discussions are probably rare, because trainers believe the definition to be easily understood.

UON studies document all major surgical obstetric interventions performed within a specific administrative region. This involves an in-depth review of the records flora all public and private health facilities with surgical capacity, including, for example, a referral hospital in the capital city, to include women seeking care outside their local region. …

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