Magnitude and trends in socio-economic and geographic inequality in access to birth by cesarean section in Tanzania: evidence from five rounds of Tanzania demographic and health surveys (1996-2015)

Gebretsadik Shibre; Betregiorgis Zegeye; Bright Opoku Ahinkorah; Mpho Keetile; Sanni Yaya

doi:10.1186/s13690-020-00466-3

Magnitude and trends in socio-economic and geographic inequality in access to birth by cesarean section in Tanzania: evidence from five rounds of Tanzania demographic and health surveys (1996-2015)

Arch Public Health. 2020 Sep 15:78:80. doi: 10.1186/s13690-020-00466-3. eCollection 2020.

Authors

Gebretsadik Shibre¹, Betregiorgis Zegeye², Bright Opoku Ahinkorah³, Mpho Keetile⁴, Sanni Yaya^{5

6}

Affiliations

¹ Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.
² Shewarobit Field Office, HaSET Maternal and Child Health Research Program, Addis Ababa, Ethiopia.
³ School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW Australia.
⁴ Population Studies and Demography, University of Botswana, Gaborone, Botswana.
⁵ School of International Development and Global Studies, University of Ottawa, 120 University Private, Ottawa, Ontario K1N 6N5 Canada.
⁶ The George Institute for Global Health, Imperial College London, London, United Kingdom.

Abstract

Background: Majority of maternal deaths are avoidable through quality obstetric care such as Cesarean Section (CS). However, in low-and middle-income countries, many women are still dying due to lack of obstetric services. Tanzania is one of the African countries where maternal mortality is high. However, there is paucity of evidence related to the magnitude and trends of disparities in CS utilization in the country. This study examined both the magnitude and trends in socio-economic and geographic inequalities in access to birth by CS.

Methods: Data were extracted from the Tanzania Demographic and Health Surveys (TDHSs) (1996-2015) and analyzed using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software. First, access to birth by CS was disaggregated by four equity stratifiers: wealth index, education, residence and region. Second, we measured the inequality through summary measures, namely Difference (D), Ratio (R), Slope Index of Inequality (SII) and Relative Index of Inequality (RII). A 95% confidence interval was constructed for point estimates to measure statistical significance.

Results: The results showed variations in access to birth by CS across socioeconomic, urban-rural and regional subgroups in Tanzania from 1996 to 2015. Among the poorest subgroups, there was a 1.38 percentage points increase in CS coverage between 1996 and 2015 whereas approximately 11 percentage points increase was found among the richest subgroups within same period of time. The coverage of CS increased by nearly 1 percentage point, 3 percentage points and 9 percentage points among non-educated, those who had primary education and secondary or higher education, respectively over the last 19 years. The increase in coverage among rural residents was 2 percentage points and nearly 8 percentage points among urban residents over the last 19 years. Substantial disparity in CS coverage was recorded in all the studied surveys. For instance, in the most recent survey, pro-rich (RII = 15.55, 95% UI; 10.44, 20.66, SII = 15.8, 95% UI; 13.70, 17.91), pro-educated (RII = 13.71, 95% UI; 9.04, 18.38, SII = 16.04, 95% UI; 13.58, 18.49), pro-urban (R = 3.18, 95% UI; 2.36, 3.99), and subnational (D = 16.25, 95% UI; 10.02, 22.48) absolute and relative inequalities were observed.

Conclusion: The findings showed that over the last 19 years, women who were uneducated, poorest/poor, living in rural settings and from regions such as Zanzibar South, appeared to utilize CS services less in Tanzania. Therefore, such subpopulations need to be the central focus of policies and programmes implemmentation to improve CS services coverage and enhance equity-based CS services utilization.

Keywords: Caesarean section; DHS; Global health; Inequality; Tanzania.