According to the WHO, the CS rate in any population should lie within the range of 5-15% and there is no justification in any specific geographic region to have more than 10-15% CS births [6, 20]. However, the current study has demonstrated that in Addis Ababa the rate had increased significantly between 1995 and 2010 and it persisted above 15% since 2003.
Ethiopia, alike most of the developing countries, is characterized by inadequate access to CS service. The recent DHS 2011 indicated that only 1.5% of all births in the country were Caesarean deliveries . Another large-scale institution based study estimated a national rate of 0.6% that ranged from 0.2 to 9% across the sub-national regions . The earlier two DHS surveys also came up with extremely low figures [17, 19]. Compared to the aforementioned studies, the relatively high CS rate found in Addis Ababa clearly indicate that national level figures can mask within-country variation and can at times mislead public health interventions. Consequently, collection of sub-national data or disaggregation of national figures is of enormous significance.
Based on the linear regression analysis, between 1995 and 2010, the prevalence of CS had been increasing with an annual rate of 1.6%. Elsewhere, few studies have also documented such rapid rate of increment. A hospital based study in Nairobi, Kenya reported a rise from 20.4% in 1996 to 38.1% in 2004 with an equivalent rate of 2% per year . In Ribeirao Preto, Brazil the CS prevalence increased from 30.3% in 1978 to 50.8% in 1994 with the approximate annual rate of 1.2% . Likewise, in Hong Kong from 1987 to 1999 the prevalence rose steadily from 16.6 to 27.4 with the rate of 0.8% per year .
Although the CS rates were elevated in all socioeconomic groups, the procedure was more frequent among socio-economically privileged women. According to a study in China, educated women were 3–4 times more likely to have CS as compared to illiterates; further, women from the upper income quartile had 3 fold increased probability of CS than those from the lowest quartile . Studies in Brazil and Italy also concluded the same [26, 27]. At times women may consider CS as less painful, convenient and safer option than vaginal delivery ; hence, the socio-economically empowered women who have limited financial barriers may over-utilize the service.
The results show that the CS rate among women who delivered in the private for-profit health institutions was considerably high (41.7%) and it was also two times higher than the rate in the public institutions. Likewise, a national study conducted in 2008 in Ethiopia found 3 times higher CS rate in the private sector . The finding can be due to various reasons. Firstly, private institutions may conduct CS without clear-cut medical indications or on maternal request in order to satisfy their clients’ demand. Secondly, as the service provided by the private sector is commonly perceived to be of better quality, mothers with complications that genuinely need CS may often prefer them.
Based on the estimated crude birth rate and population size of Addis Ababa , in 2010 approximately 44,300 births had taken place in the city. Considering the 24.4% CS rate computed for the specific year, approximately 10,721 Caesarean births had happened in 2010. Consequently, taking 15% as the maximum optimum CS rate, in 2010 alone roughly 4,076 unnecessary CS were performed in the city.
A study conducted by the WHO in 2010 , estimated the global cost of unnecessary and extra needed CS for the year 2008. The unit marginal cost of the procedure was predicted by considering costs associated with the medical supplies, post-operative hospital stay, human resources time and management of potential medical complications. Ultimately country specific unit values were determined and used to estimate the global cost. In the study, the unit cost calculated for Ethiopia was 132.7 US dollars per procedure. Considering this cost as a valid estimate, the 4,076 unnecessary procedures conducted in Addis Ababa in 2010 might have incurred around 540,885 US Dollars (10,276,815 Ethiopian Birr).
In general unlike many previous undertakings, this study assessed the differentials of CS rate based on community based data and assessed the trend over a reasonable period of time. Conversely, some limitations need to be considered while interpreting the findings of the study. Differentials of CS rate were identified based on bivariate analysis hence confounding cannot be excluded. The available sample size for each data point was adequate to estimate the CS rate with 3-5% margin of error; however, smaller margin of error would have been more optimal for the study. Further, at times when mothers had more than two births in the reference period, only the recent one was considered for the analysis and this could have introduced selection bias in the study.