Date Published: July 26, 2019
Publisher: Public Library of Science
Author(s): Myriam de Loenzien, Clémence Schantz, Bich Ngoc Luu, Alexandre Dumont, Calistus Wilunda.
Caesarean section (CS) can prevent maternal and neonatal mortality and morbidity. However, it involves risks and high costs that can be a burden, especially in low and middle income countries. The aim of this study is to assess its magnitude and correlates among women of reproductive age in the urban and rural areas of Vietnam. We analyzed microdata from the national Multiple Indicator Cluster Survey (MICS) conducted in 2014 by using a representative sample of households at the national level in both urban and rural areas. A total of 1,350 women who delivered in institutional settings in the two years preceding the survey were included. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analyses were undertaken to identify the factors associated with CS. Odds ratios with a 95% confidence interval were used to ascertain the direction and strength of the associations. The overall CS rate among the women who delivered in healthcare facilities in Vietnam has rapidly increased and reached a high level (29.2%). After controlling for significant characteristics, living in urban areas doubles the likelihood of undergoing a CS (OR = 1.98; 95% CI 1.48 to 2.67). Maternal age at delivery over 35 years is a major positive correlate of CS. Beyond this common phenomenon, different distinct lines of socioeconomic and demographic cleavage operate in urban compared with rural areas. The differences regarding the correlates of CS according to the place of residence suggest that specific measures should be taken in each setting to allow women to access childbirth services that are appropriate to their needs.
Caesarean section (CS) can prevent maternal and neonatal mortality and morbidity when medically justified. However, it involves risks and high costs that can be a burden, especially in low and middle income countries  . There is no consensus on an optimal population-level frequency of CS. However, a global concern around CS rates has developed since a large part of CS is considered to be not medically justified  . Urbanization is related not only to a population that moves from a rural to an urban area and an increased concentration of people who live in urban areas but also to the entire process of societal adaptation to the subsequent changes, and urbanization has been identified as a prominent contributing factor to CS practices in several countries and areas       . However, this influence is controversial   .
For several decades, living in urban areas in low- and middle-income countries in Asia, Africa and Latin America has been associated with higher CS rates  , even after controlling for multiple factors     . In many cases, this involves CS deliveries for nonabsolute medical indications . However, the relationship between high CS rates and urbanization appears to be nonsignificant in various settings  . Further analyses that consider the level of urbanization complement these results. A study that use data from 29 countries in Asia, Africa and Latin America showed higher CS rates in urban areas than in periurban areas  whereas the reverse prevailed in Cambodia .
The overall CS rate among the women who delivered in healthcare facilities was particularly high (29.2%). It was almost twice as high in urban (42.4%) than in rural areas (22.9%). Overall, almost one-third of the women lived in the urban areas (30.7%). Table 1 provides an overview of the social and demographic profiles of the women who delivered in healthcare facilities and the corresponding rates of CS.
The overall CS rate among the women who delivered in healthcare facilities in Vietnam in 2014 was particularly high (29.2%) compared with many low- and middle-income countries  .
The overall CS rate among the women who delivered in healthcare facilities in Vietnam is particularly high (29.2%). Our paper aims to update the general trends regarding this phenomenon and better understand the correlates of the differences between rural and urban areas. Our results show that after controlling for significant characteristics, living in urban areas more than doubles the likelihood of undergoing a CS. Maternal age at delivery over 35 years is also a major positive correlate of CS. Beyond this common phenomenon, contrasting models exist regarding the determinants of the recourse to high levels of CS between rural and urban areas. This contrast suggests that actions to reduce unnecessary caesarean deliveries should be adapted to each context. Accordingly, our results show the importance of considering not only medical and demographic factors but also socioeconomic determinants when designing programs to improve women’s childbirth conditions. For example, the case of ethnicity needs to be addressed. This approach involves policies at many different levels regarding the regulation of the healthcare sector, the training of healthcare providers and the sensitization of the entire population, with means that are appropriate to their conditions of living. Further research must be conducted to design such programs and to provide guidance on this complex issue.