Towards optimizing Caesarean section: The challenges of concurrent underuse, unsafe use and overuse in developing countries.

Makinde OI1*, Oriji PC1, Osegi N1
1Department of Obstetrics and Gynaecology, Federal Medical Centre, Yenagoa, Bayelsa State, Nigeria.
*Correspondence: Dr. Olakunle I. Makinde; +234 803 213 6315;

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Caesarean section is a lifesaving procedure but not without risks. While the developed countries are currently bothered by the rising Caesarean section rates and the feared consequences of repeat Caesarean section on the woman, developing countries are all faced with challenges of ensuring adequate access to safe Caesarean section. Inequalities also exist in the access to Caesarean section within developing countries where adequate access and overuse, especially among the population above low social class and in the urban settings coexists with lack of access and underuse among the poorest of the population usually in rural areas. Too little, too late access to Caesarean section is associated with unsafe Caesarean section procedures. Where access to Caesarean section is below the recommended threshold, maternal and perinatal morbidity and mortality is high. Authors reviewed relevant literatures on the current state of knowledge on underuse, unsafe use and overuse of Caesarean section with a focus on developing countries.

Keywords: Caesarean section rate, Indications for Caesarean section, Underuse, Unsafe use, Overuse, Developing countries

Cite this article: Makinde OI, Oriji PC, Osegi N. Towards optimizing Caesarean section: The challenges of concurrent underuse, unsafe use and overuse in developing countries.Yen Med J. 2020; 2(1):157-170.


  1. Gupta M, Saini V. Caesarean section: mortality and morbidity. JCDR. 2018;12(9):1-6.
  2. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet. 2018;392(10155):1349-1357. doi: 10.1016/S0140-6736(18)31930-5.
  3. Boerma T, Ronsmans C, Melesse D, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018;392:1341-1348. doi: 10.1016/S0140-6736(18)31928-7.
  4. Sobhy S, Arroyo-Manzano D, Murugesu N, Karthikeyan G, Kumar V, Kaur I, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. Lancet. 2019;393:1973-1982. doi: 10.1016/S0140-6736(18)32386-9.
  5. Maswime S. Improving access to caesarean section and perioperative care in LMICs. Lancet. 2019;393(10184):1919-1920. doi: 10.1016/S0140-6736(18)32589-3.
  6. Betran AP, Ye J, Moller A-B, Zhang J, Gulmezoglu AM, Torloni MR (2016) The increasing trend in caesarean section rates: Global, regional and national estimates: 1990-2014. PLoS One. 2016;11(2):e0148343. doi:10.1371/journal.pone.0148343.
  7. Betran AP, Torloni MR, Zhang JJ, Gulmezoglu AM for the WHO working group on caesarean section. WHO Statement on caesarean section rates. BJOG. 2016;123:667-670.
  8. World Health Organization. WHO Statement on caesarean section rates. Available from: Accessed November 15, 2019.
  9. Fistula Care Plus and Maternal Health Task Force. Cesarean section safety and quality in low-resource settings: report of a technical consultation, July 27–28, 2017. New York, NY: EngenderHealth/Fistula Care Plus; 2017.
  10. Ologunde R, Vogel JP, Cherian MN, Sbaiti M, Merialdi M, Yeats J. Assessment of cesarean delivery availability in 26 low and middle-income countries: a cross-sectional study. Am J Obstet Gynecol. 2014;211(5):504.e1-504.e12. doi: 10.1016/j.ajog.2014.05.022.
  11. World Health Organization. Deaths from caesarean sections 100 times higher in developing countries: global study, 2019. Available from: Accessed December 10, 2019.
  12. Mylonas I, Friese K. Indications for and risks of elective cesarean section. Dtsch Arztebl Int. 2015;112:489–495. doi: 10.3238/arztebl.2015.0489.
  13. Souza JP, Gulmezoglu AM, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Medicine. 2010;8:71.
  14. Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first caesarean delivery. Obstet Gynecol. 2012;120:1181-1193.
  15. Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GML. Caesarean section for non-medical reasons at term. Cochrane Database Syst Rev. 2012;3:CD004660. doi: 10.1002/14651858.CD004660.pub3.
  16. American College of Obstetricians and Gynecologists. Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2014;123:693-711.
  17. Osegi N, Makinde OI. Towards optimizing caesarean section: a five-year review of caesarean sections at a southern Nigeria hospital. Int J Reprod Contracept Obstet Gynecol. Forthcoming 2020 Jan;9(1).
  18. Patil P, Bhardwaj M, Sharma P, Chandrakar G. Changing trends in indication of cesarean section in a tertiary care centre of Central India. Int J Reprod Contracept Obstet Gynecol. 2017;6:2829-2835.
  19. Betran AP, Temmerman M, Kingdon C, Mohiddin A, Opiyo N, Torloni MR, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. Lancet. 2018;392:1358-1368.
  20. O’Donnell O. Access to health care in developing countries: breaking down demand side barriers. Cad Saude Publica. 2007;23(12):2820-2834.
  21. Dare AJ. Making caesarean section safer for African mothers. Lancet. 2019;7(4):PE402-E403. doi: 10.1016/S2214-109X(19)30054-3.
  22. Ushie BA, Udoh EE, Ajayi AI. Examining inequalities in access to delivery by caesarean section in Nigeria. PLoS One. 2019;14(8):e0221778. doi: 10.1371/journal.pone.0221778.
  23. Yaya S, Uthman OA, Amouzou A, Bishwajit G. Disparities in caesarean section prevalence and determinants across Sub-Saharan Africa countries. Glob Health Res Policy. 2018;3(19). doi: 10.1186/s41256-018-0074-y.
  24. Vora KS, Cottagiri SA, Saiyed S, Tailor P. Public health aspects of caesarean section including overuse and underuse of the procedure. Int Res J Public Health. 2019;3:30. doi: 10.28933/irjph-2019-05-0306.
  25. World Health Organization. Monitoring emergency obstetric care: a handbook. Available at Accessed November 15, 2019.
  26. Bright T, Felix L, Kuper H, Polack S. A systematic review of strategies to increase access to health services among children in low and middle income countries. BMC Health Serv. Res. 2017;17:252. doi: 10.1186/s12913-017-2180-9.
  27. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008;1136:161-171. doi: 10.1196/annals.1425.011.
  28. United Nations Department of Economic and Social Affairs. The Millennium Development Goals Report, 2015. New York, NY: United Nations; 2015.
  29. World Health Organization. Investing in Health for Africa: The Case for Strengthening Systems for Better Health Outcomes. Geneva, Switzerland: World Health Organization; 2010.
  30. World Health Assembly. 68th World Health Assembly resolution: strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Geneva, Switzerland: World Health Organization, 2015.
  31. Nyamtema A, Mwakatundu N, Dominico S, Mohamed H, Shayo A, Rumanyika R, et al. Increasing the availability and quality of caesarean section in Tanzania. BJOG. 2016;123:1676-1682. doi: 10.1111/1471-0528.14223.
  32. Ravit M, Audibert M, Ridde V, de Loenzien M, Schantz C, Dumont A. Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa. BMJ Glob Health. 2018;3:e000558. doi: 10.1136/bmjgh-2017-000558.
  33. Edu CB, Agan TU, Monjok E, Makowiecka K. Effect of free medical health care program on health-seeking behaviour of women during pregnancy, intrapartum and postpartum periods in Cross River State of Nigeria: a mixed method study. Open Access Maced J Med Sci. 2017;5(3):370-382. doi: 10.3889/oamjms.2017.075.
  34. Ogundipe OL. Experiences of women participating in a safe motherhood (Abiye) project in Ondo state of Nigeria. Int J Curr Micobiol App Sci. 2013;2(12):148-161.
  35. Walker IA, Reshamwalla S, Wilson IH. Surgical safety checklists: do they improve outcomes? Br J Anaesth. 2012;109:47-54.
  36. World Health Organization. WHO recommendation on routine antibiotic prophylaxis for women undergoing elective or emergency caesarean section. The WHO Reproductive Health Library. Geneva, Switzerland: World Health Organization; 2015.
  37. Royal College of Obstetricians and Gynaecologists. Birth After Previous Caesarean Birth (Green-top Guideline No. 45). Available from: Published October 1, 2015. Accessed December 11, 2019.
  38. Seffah JD, Adu-Bonsaffoh K. Vaginal birth after caesarean section: current trends and outlook in Ghana. J West Afr Coll Surg. 2014;4(2):1-25.
  39. Ness A. Vaginal birth after cesarean. In: Berghella V,ed. Obstetric Evidence Based Guidelines. Colchester, England: Informa UK Ltd; 2007:99–106.
  40. Ball E, Hinshaw K. The current management of vaginal birth after previous caesarean delivery. Obstet Gynaecol. 2007;9:77-82. doi: 10.1576/toag.
  41. Rossi AC, D’Addario V. Maternal morbidity following a trial of labour after caesarean section vs elective repeat caesarean delivery: a systematic review with metaanalysis. Am J Obstet Gynecol. 2008;199(3):224-231. doi: 10.1016/j.ajog.2008.04.025.
  42. Macones GA, Peipert J, Nelson DB, Odibo A, Stevens EJ, Stamilio DM et al. Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol. 2005;193:1656-1662. doi:10.1016/j.ajog.2005.04.002.
  43. Bujold E, Hammoud AO, Hendler I, Berman S, Blackwell SC, Duperron L, et al. Trial of labour in patients with a previous cesarean section: does maternal age influence the outcome? Am J Obstet Gynecol. 2004;190:1113-1118. doi:10.1016/j.ajog.2003.09.055.
  44. Shipp TD, Zelop C, Repke JT, Cohen A, Caughey AB, Leiberman E. The association of maternal age and symptomatic uterine rupture during a trial of labor after prior cesarean delivery. Obstet Gynecol. 2002;99:585-588. doi:10.1016/S0029‐7844(01)01792‐6.
  45. Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of spontaneous labour with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281-1287. doi: 10.1097/AOG.0b013e3181fdef6e.
  46. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva, Switzerland: World Health Organization; 2018.
  47. Okafor II. Neglected obstructed labour and the need to revive the “dying obstetric art of fetal destructive vaginal operations” in the developing countries. Ann Clin Case Rep. 2016;1:1049.
  48. Coleman VH, Lawrence H, Schulkin J. Rising caesarean delivery rates: The impact of caesarean delivery on maternal request. Obstet Gynecol Surv. 2009;64(2):115-119.
  49. Kingdon C, Downe S, Betran AP. Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis. BMJ Open. 2018;8:e025073. doi:10.1136/bmjopen-2018-025073.
  50. Kingdom C, Downe S, Betran AP. Women’s and communities’ views of targeted educational interventions to reduce unnecessary caesarean section: qualitative evidence synthesis. Reprod Health. 2018;15:130. doi: 10.1186/s12978-018-0570-z.
  51. Kingdom C, Downe S, Betran AP. Non-clinical interventions to reduce unnecessary caesarean section targeted at organizations, facilities and systems: systematic review of qualitative studies. PLoS One. 2018;13(9):e0203274. doi: 10.1371/journal.pone.0203274.
  52. Chen I, Opiyo N, Tavender E, Mortazhejri S, Rader T, Petkovic J, et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev. 2018;9:CD005528. doi: 10.1002/14651858.CD005528.pub3
  53. World Health Organization. WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections. Geneva, Switzerland: World Health Organization; 2018.
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