Measuring the unmet need for caesarean sections in sub-Saharan Africa and South Asia

Background. Caesarean sections are critical interventions in obstetric care. The unmet need for caesareans is an important indicator for monitoring emergency obstetric care coverage: several methods have been proposed, however there is no consensus on how to measure the unmet need for caesareans in sub-Saharan Africa and South Asia. Methods. First, trends in the caesarean rate by wealth were analysed in 26 countries in sub-Saharan Africa and South Asia using Demographic and Health Surveys, in order to identify groups with rates below 1% and 2%. Second, a global online survey was conducted on obstetricians’ opinions of the optimal caesarean rate. Third, linked hospital and population-based data were used to validate the Unmet Obstetric Need (UON) indicator in central Ghana, which measures the unmet need for surgery for absolute maternal indications (AMIs), and to investigate novel approaches using hospital data. Results. The caesarean rate was extremely low among poor women in most sub-Saharan African and South Asian countries. The median optimal caesarean rate reported by obstetricians worldwide was 20%, and there was a large variation in responses (IQR: 15-30%). The 1.4% threshold for the UON indicator was found not to be valid in Ghana. For most complications – including AMIs, among which caesarean rates were close to 100% – women were equally likely to have their need for caesareans met regardless of their educational level. Conclusion. The optimal caesarean rate remains unknown, and thus cannot be used as a benchmark for measuring the unmet need. The UON indicator does not produce valid estimates of AMI-related mortality avertable with caesareans, however caesarean rates below 1% probably indicate a critical unmet need for life-saving surgery. Comparing caesarean rates in hospitals by education is useful for determining whether population-based differences in the caesarean rate are partly explained by differential access to care within facilities.