Abstract:
Background: The objectives of this analysis were to document trends in and risk factors associated with the cesarean
birth rate in low- and middle-income country sites participating in the Global Network for Women’s and Children’s
Health Research (Global Network).
Methods: This is a secondary analysis of a prospective, population-based study of home and facility births con‑
ducted in the Global Network sites.
Results: Cesarean birth rates increased uniformly across all sites between 2010 and 2018. Across all sites in multivari‑
able analyses, women younger than age twenty had a reduced risk of cesarean birth (RR 0.9 [0.9, 0.9]) and women
over 35 had an increased risk of cesarean birth (RR 1.1 [1.1, 1.1]) compared to women aged 20 to 35. Compared to
women with a parity of three or more, less parous women had an increased risk of cesarean (RR 1.2 or greater [1.2,
1.4]). Four or more antenatal visits (RR 1.2 [1.2, 1.3]), multiple pregnancy (RR 1.3 [1.3, 1.4]), abnormal progress in labor
(RR 1.1 [1.0, 1.1]), antepartum hemorrhage (RR 2.3 [2.0, 2.7]), and hypertensive disease (RR 1.6 [1.5, 1.7]) were all associ‑
ated with an increased risk of cesarean birth, p<0.001. For multiparous women with a history of prior cesarean birth,
rates of vaginal birth after cesarean were about 20% in the Latin American and Southeast Asian sites and about 84%
at the sub-Saharan African sites. In the African sites, proportions of cesarean birth in the study were highest among
women without a prior cesarean and a single, cephalic, term pregnancy. In the non-African sites, groups with the
greatest proportion of cesarean births were nulliparous women with a single, cephalic, term pregnancy and all mul‑
tiparous women with at least one previous uterine scar with a term, cephalic pregnancy.
Conclusion: Cesarean birth rates continue to rise within the Global Network. The proportions of cesarean birth are
higher among women with no history of cesarean birth in the African sites and among women with primary elective
cesarean, primary cesarean after induction, and repeat cesarean in the non-African sites.
Keywords: Cesarean birth, Low- and middle-income countries, Trends, Risk factors, Vaginal birth after cesarean,
Robson classifcation
