The maternal mortality is a major issue of public health in developing countries. Essential obstetric cares, especially caesarean section, play a crucial role in the decrease of maternal mortality. WHO, FNUAP and UNICEF estimate that the minimum acceptable rate of caesarean section in developing countries must reach 5% to guarantee safety for both the new-born and the mother. In Madagascar; the average national rate of caesarean section was 0.6% in 1997. In the area of Toamasina, this rate was 0.7%. To increase the number of women who can access to those essential obstetric cares, several solutions may be followed. One of them is to develop health insurance for pregnant women. This kind of solution seems to be well accepted and equitable. To reach this goal, this study was carried out to define sociodemographic characteristics of women who got caesarean section in Toamasina, to assess the cost of a caesarean section at the CHR (regional hospital) of Toamasina, and to measure the evolution of the caesarean section rate in the area. A retrospective survey was carried out for the years 1999, 2000 and 2001 including all women who got a caesarean section in the area of Toamasina: in the hospital of Toamasina and in the one of Fenerive-Est. Data were collected in both hospitals. 748 women were included in the survey The cost-analysis consisted in a partial medico-economic cost analysis which was measured from the patient's point of view. Sociodemographic characteristics are comparable with the results found in the literature. The mean age of the women involved was 28+/-7 years. The main indications for caesarean section were foeto-pelvic disproportion (37%) and placenta praevia (12%). The maternal mortality rate was 3%. The rate of infantile mortality was 18%. The cover rate of caesarean section in the area of the CHR is estimated respectively at 0.58%, 0.67% and 0.71% for the years 1999, 2000 and 2001. Data collection step was very difficult to carry out. The rates of death among the mother (0.3%) and among the new-born (18%) were definitely too important. But, these rates were comparable with those found in the bibliography. The cover rate of the caesarean section is too low, however it was increasing during these 3 years. About 2000 women per year needed a caesarean without having it. The cost for the society of the morbidity and the mortality caused by the lack of availability of caesarean section is drastic. The price of a caesarean section is about 250 000 Fmg (approximately 36 euros). The average income is about 170 000 Fmg (25 euros) per month per inhabitant. Thus, the price asked was dramatically too high for a majority of people. The availability of caesarean section had to be improved in the area of Toamasina. More than ten years after the first International Conference about the Maternity without Risk in Nairobi, it appeared that something had to be done quickly in Madagascar. The solution to develop a public health insurance, or others actions, seemed to be relevant and urgent.