Use and Quality of Cesarean Delivery in a Low and Middle Income Setting: National Results from Two Emergency Obstetric and Newborn Care Assessments

Use and Quality of Cesarean Delivery in a Low and Middle Income Setting: National Results from Two Emergency Obstetric and Newborn Care Assessments | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Use and Quality of Cesarean Delivery in a Low and Middle Income Setting: National Results from Two Emergency Obstetric and Newborn Care Assessments Misrak Getnet Beyene, Theodros Getachew Zemedu, Azmach Hadush Gebregiorgis, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-103142/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Aug, 2021 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 11 You are reading this latest preprint version Abstract Background: Cesarean delivery (CD) rates have reached epidemic levels in many high and middle income countries while increasingly, low income countries are challenged both by high urban CD rates and high unmet need in rural areas. The managing authority of health care institutions often plays a role in these disparities. This paper shows changes between 2008 and 2016 in CD rates and the capacity of the Ethiopian health system to deliver quality CD services, highlighting the role of the management sector. Methods: We compare results from two national cross-sectional emergency obstetric and newborn care assessments using descriptive statistics. The sample includes 111 hospitals in 2008 and 316 hospitals in 2016, and 275 CD case reviews in 2008 and 568 in 2016. Our primary outcome measures include population- and institutional-based CD rates; hospital readiness to perform CD; quality of clinical management; and the relative size of Robson classification groups Results: The national population-based rate increased (< 1% to 2.7%) as did all regional rates. Rates ranged from 24% in urban settings to less than 1% in several rural regions. The institutional rate was 54% in the private for-profit sector in 2016, up from 46% in 2008. Hospital readiness to perform CDs increased in public and for-profit hospitals. Only half of the women whose cases were reviewed received uterotonics after delivery of the baby, but use of prophylactic antibiotics was high. Partograph use increased from 9% to 42% in public hospitals, but was negligible or declined elsewhere. In 2016, a third of case reviews from the public sector were among low-risk nulliparous women (Robson group 1). Conclusions: Between 2008 and 2016, government increased the availability of CD services, improved public hospital readiness and some aspects of clinical quality. Strategies tailored to further reduce the high unmet need for CD and what appears to be an increasing number of unnecessary cesareans are discussed. Adherence to best practices and universal coverage of water and electricity will improve the quality of hospital services while the use of the Robson classification system may serve as a useful quality improvement tool. Maternal & Fetal Medicine CD rates readiness Robson public/private sector Figures Figure 1 Figure 1 Background Increasingly, low and middle income countries face the two extremes of unmet need for and unnecessary cesareans, or “too little too late and too much too soon” ( 1 ). Just what the number of cesareans should be has evolved ( 2 , 3 ). The World Health Organization (WHO) began producing global guidance on this topic as early as 1985 ( 4 ). In 2015, backed by evidence that rates greater than 10% were not associated with a reduction in maternal and newborn mortality, the WHO stressed that all women who need a CD should receive one, while cautioning against pursuing specific targets ( 5 , 6 ). Women who have a cesarean undergo perioperative risks such as blood loss, anesthetic accidents, wound infection and iatrogenic fistula, and put future pregnancies at risk due to uterine scaring ( 7 – 9 ). A prospective study in Norway found that 1 in 5 women experienced at least short-term complications as a result of cesarean surgery ( 10 ). Nonclinical consequences as well as the health of newborns and children are of equal concern ( 11 ). Sub-Saharan Africa has marginally increased its CD rate from 2.3–4.1% between 1990 and 2015 ( 11 , 12 ). The slow rise has been attributed to weak health systems and the lack of resources to ensure quality of care. Recent global and regional studies on surgery have highlighted extensive unmet need for surgery. They also documented safety concerns when undertaken too late or in environments where deficits in surgical personnel and resources are common, such as oxygen, medical equipment and electricity ( 11 , 12 ). Ethiopia is a country with high maternal and newborn mortality, high prevalence of fistula and historically low cesarean and institutional delivery rates. According to the 2016 Demographic and Health Survey, the CD rate was 2% based on births during the five years prior to the survey ( 13 ). Earlier trend data from the capital indicated rising cesarean rates that were positively correlated with income and education, as in many other country settings ( 14 , 15 ). The current Health Sector Transformation Plan set a population-based cesarean target of 8% for 2020 as a step towards addressing the unmet need for life-saving surgery ( 16 ). This paper presents a broad overview of recent changes in the service coverage and quality of CD, with a focus on differences across public and private sectors. We describe changes in national and regional CD rates; institutional rates; the readiness of hospitals to provide obstetric surgery; and the quality of CD services. Methods Study design and data collection This secondary data analysis draws on two Emergency Obstetric and Newborn Care (EmONC) assessments from 2008 and 2016 (17,18). Both were national cross-sectional censuses of public and private health facilities. The data collection instruments for 2008 were adapted from a set of standard modules previously used in many countries (19). The 2016 assessment used the same core tools administered in 2008 that underwent a global revision with local adaptation in 2016. The six modules relevant to this study were: M1 - basic infrastructure; M2 - human resources; M3 - inventory of drugs, equipment and supplies; M4 - summary service statistics; M5 - performance of signal functions; and M8 - case review for CDs. All facilities received modules 1-5; only facilities that performed CDs received M8. The latter was modified in 2016 to include information not in 2008 such as a woman’s characteristics needed to classify her into one of the Robson 10 groups, type of anesthesia and professional cadre who performed the operation. The first assessment was launched October 1, 2008 and completed by January 15, 2009; the 2016 survey commenced in mid-May and was completed by mid-December 2016. In 2008, a private company conducted the assessment and prepared the databases (20) and in 2016, this responsibility shifted to the Ethiopian Public Health Institute. Details about the data collector training and survey execution can be found in the final reports (17, 18). Study population and setting If the Ethiopian Food, Medicine and Health Control Authority approved a facility as a site to deliver routine and/or operative childbirth services, it was eligible for the assessment. Between 2008 and 2016 the Ministry of Health led a massive infrastructure expansion, adding about 3000 health centers and 200 hospitals (21,22). In 2008, 751 health facilities with childbirth services were visited, including 111 hospitals. In 2016, 3,804 were visited, 316 of which were hospitals. This paper focuses on hospitals designated to provide comprehensive emergency obstetric care. Although we call both assessments a census, in 2008 15 facilities were not visited because they did not appear on the master list of licensed facilities, 12 of which were in the capital of Addis Ababa. In 2016, 11 facilities were not visited due to civil unrest but few if any of these service sites were hospitals. Finally, two hospitals refused to participate in the 2016 assessment. In each hospital, a subset of women who delivered by cesarean had their records reviewed. In 2008 data collectors identified three women per hospital and in 2016 only two cases per hospital were selected because of the increase in the number of hospitals. The selection criteria remained the same: 1) cases occurred in the previous 12 months, and 2) they were the last women who had had a cesarean but were no longer under postoperative care, regardless of survival. Processes and comparisons This paper features three units of analysis: aggregated hospital service statistics, hospitals and individual women who delivered by cesarean. Aggregated service statistics (M4) covered 12 consecutive months prior to the assessment (July 2007–June 2008 and January-December 2015). Service data included the number of deliveries by mode of delivery; these data were used to estimate CD rates. Modules 1, 2, 3 and 5 provided information to assess hospital readiness to perform CD while the CD chart review (M8) was the information source for service quality and record-keeping at the individual level. Variables and index creation For both population-based and institutional CD rates, the numerator was the sum of all CDs performed at each hospital. The denominator for the population-based rate was the number of expected births in each region, calculated from population figures from the Planning and Programming Department of the Federal Ministry of Health and the crude birth rate established by the 2016 Demographic and Health Survey (13,23). The denominator for the institutional CD rate was the sum of all births at each hospital that had provided cesarean services in the three months prior to the assessment. To assess health system readiness to provide CD services, we created a binary summary score (yes or no), based on an algorithm defined by the availability of at least one health professional able to perform the operation and another to provide anesthesia, plus readiness items that had to be functioning and included EITHER an anesthesia machine + (halothane or ketamine) OR regional anesthesia (lignocaine/ lidocaine 4% or bupivacaine) AND an oxygen cylinder with manometer and flowmeter (low flow) tubes and connectors, an operating table and a functioning adjustable light (20). Although not included in the algorithm, interruptions in water and electricity in the operation theaters were assessed. Quality of clinical management was measured by use of a partograph, administration of prophylactic antibiotics and uterotonics, time interval from decision to incision, type of anesthesia, clinician who performed the CD and maternal and newborn outcomes. A final analysis of clinical management was based on the Robson 10-group classification scheme, designed to determine institutional cesarean rates for clinically relevant and mutually exclusive groups (24). The classification system depends on six characteristics of women that are easily captured: parity (nulliparous/multiparous), number of fetuses (singleton/multiple), onset of labor (spontaneous or induced/CD before labor started), previous CD (yes/no), fetal lie (cephalic/ transverse/breech) and gestational age ( 37 weeks). Because the 10 groups (see Figure 1) tend to have different cesarean rates, the classification scheme is used to inform where changes in clinical management should be made. One of the goals of its usage is to reduce cesareans among nulliparous women (groups 1 and 2), who are known to be vulnerable to unnecessary CDs, and who are often the biggest group (25). Overuse of CD among these women sets up a domino effect that contributes to repeated cesareans. Our aim in using the Robson classification was to determine the distribution of cases according to the 10 groups to show their relative size, if and how the group sizes varied across managing authority, and the extent to which the group sizes aligned with other studies. Our key stratifying variable – hospital managing authority – was defined with three categories: public or government, private for-profit and private not-for-profit management by non-governmental organizations and/or religious missions. To produce descriptive statistics (frequencies, percentages, means and medians) we used SPSS version 24. Since our data sources were censuses and not random samples, nor did they represent some theoretical population, we performed no statistical tests. Ethical considerations This paper utilizes secondary data; permission to use the data was granted by the Ethiopian Public Health Institute and the Family Health Division at the Federal Ministry of Health. Results In 2008, 87 of the 111 hospitals provided cesarean deliveries (66 public sector, 15 for-profit and 6 not-for-profit). In 2016, 253 out of 316 hospitals provided cesarean services (188, 52 and 13, respectively). Coverage: Cesarean delivery rates The national population-based cesarean rate in 2008 was 0.6% and 2.7% in 2016 (Table 1 ). The highly urbanized regions of Harari, Addis Ababa and Dire Dawa exhibited the highest rates in 2016: 17%, 24%, and 10%, respectively. Elsewhere, rates increased but remained very low. At the national level, 72% and 74% of the cesareans were performed in the public sector in 2008 and 2016, respectively. Half of the cesareans performed in Addis Ababa took place in the private sectors. The CD rate in Addis Ababa was likely underestimated in 2008 due to the 12 private hospitals not eligible for the assessment. Table 1 Cesarean deliveries (CD), expected births and population-based CD rates, by region and assessment year Region Public Private for-profit Private not-for-profit Total CDs Expected births Rates National 2008 12,316 2,864 1,965 17,145 2,638,891 0.6% 2016 58,667 13,914 6,335 78,916 2,928,303 2.7% Tigray 2008 1,179 2 0 1,181 160,929 0.7% 2016 5,298 106 0 5,404 163,802 3.3% Afar 2008 22 0 0 22 52,634 0.0% 2016 133 0 96 229 56,222 0.4% Amhara 2008 1,503 28 0 1,531 642,084 0.2% 2016 9,993 533 437 10,963 660,518 1.7% Oromia 2008 2,654 22 1,000 3,676 1,013,011 0.4% 2016 16,447 1,042 1,751 19,240 1,099,485 1.7% Somali 2008 104 8 0 112 165,580 0.1% 2016 488 39 0 527 178,048 0.3% Benishangul-Gumuz 2008 166 0 0 166 25,023 0.7% 2016 700 0 0 700 32,913 2.1% SNNP 2008 1,822 100 536 2,458 561,086 0.4% 2016 10,258 98 2,507 12,863 595,296 2.2% Gambella 2008 76 0 0 76 11,448 0.7% 2016 135 0 0 135 13,420 1.0% Harari 2008 648 0 0 648 6,545 9.9% 2016 915 381 0 1,296 7,568 17.1% Addis Ababa 2008 3,918 2,607 429 6,954 97,755 7.1% 2016 13,243 11,351 1,544 26,138 106,625 24.5% Dire Dawa 2008 224 97 0 321 12,239 2.6% 2016 1,057 364 0 1,421 14,405 9.9% Notes: SNNP = Southern Nations, Nationalities, Peoples' region The institutional CD rate is the percentage of institutional births delivered by cesarean and is influenced by patient mix and provider practice (Table 2 ). Patterns of institutional CD rates in 2008 and 2016 were similar: the private for-profit sector had the highest rates (46% and 54%, respectively) and the public sector had the lowest (15% and 19%, respectively). The greatest percentage increase occurred among public hospitals (23%). Table 2 Cesarean deliveries (CDs), institutional deliveries and rates among hospitals,* by managing authority and assessment year 2008 2016 Managing Authority CDs Institutional deliveries Institutional CD rate CDs Institutional deliveries Institutional CD rate Public 12,316 80,135 15.4% 54,983 290,150 18.9% Private for-profit 2,864 6,212 46.1% 13,810 25,384 54.4% Private not-for-profit 1,965 7,342 26.8% 6,335 22,523 28.1% Total 17,145 93,689 18.3% 75,128 338,057 22.2% *Among hospitals that performed CDs in the 3 months preceding the survey Hospital readiness to perform cesarean delivery Approximately 80% of hospitals in both time periods provided CD services in the 3 months prior to the assessments (Table 3 ). Among hospitals that had performed CDs, the availability of surgeons, obstetricians and medical doctors declined between 2008 and 2016 when emergency surgical officers (ESOs) began to play a major role, especially in the public sector. The private for-profit hospitals relied almost entirely on obstetricians, while the not-for-profit hospitals increased their reliance on both obstetricians and ESOs. An increase from 95–100% of hospitals reported at least one professional on staff to administer anesthesia. The availability of drugs and equipment did not change dramatically between the two assessments. In 2016, public sector hospitals were at some disadvantage compared to private hospitals. For example, in 2016 85% of public hospitals had vaporizers compared to 96–100% among private hospitals. According to the readiness algorithm, hospital readiness increased in the public sector from 70–85% and among for-profit facilities from 87–97%, but only 67–68% of not-for-profit facilities were staffed and equipped to provide CDs. Although not included in the readiness algorithm, we also examined whether hospitals experienced interruptions in electricity and running water. In 2008 virtually all hospitals that regularly performed cesareans had functioning water and electricity in the operation theater or in the hospital itself on the day of the assessment. In 2016 the percentage dropped to closer to 90% for both electricity and water. Table 3 Hospitals providing cesarean delivery, and among those, characteristics of readiness, by managing authority and year Total number of hospitals Managing authority Public Private for-profit Not-for-profit 2008 2016 2008 2016 2008 2016 2008 2016 n = 111 n = 316 n = 90 n = 236 n = 15 n = 61 n = 6 n = 19 Performed CD in last 3 months 78% 80% 73% 80% 100% 85% 100% 68% n = 87 n = 253 n = 66 n = 188 n = 15 n = 52 n = 6 n = 13 Hospital has HR for surgery 1 Ob/gyn 72% 50% 68% 36% 100% 96% 50% 77% General surgeon 39% 9% 41% 9% 27% 4% 67% 46% Medical doctor 29% 6% 35% 6% 7% 2% 17% 8% ESOs na 63% na 80% na 6% na 39% Health officer 9% 2% 11% 2% 0% 0% 17% 0% Midwife 3% 0% 3% 1% 7% 0% 0% 0% Nurse 2% 0% 3% 1% 0% 0% 0% 0% At least one person can provide 98% 99% 97% 100% 100% 96% 100% 100% Hospital has HR for anesthesia 1 Anesthesiologist/anesthetist 91% na 91% na 87% na 100% na Anesthesiologist na 13% na 10% na 25% na 8% Anesthetist na 95% na 94% na 96% na 100% Other professional 2 30% 3% 29% 3% 33% 2% 33% 8% At least one person can provide 95% 100% 95% 100% 93% 100% 100% 100% Hospital has anesthesia and equipment Anesthetic vaporizer 79% 88% 79% 85% 87% 96% 67% 100% Halothane 84% 87% 83% 86% 87% 89% 83% 85% Ketamine 94% 85% 94% 84% 93% 90% 100% 85% Lignocaine/lidocaine 4% 3 95% 19% 97% 18% 87% 15% 100% 46% Bupivacaine na 76% na 73% na 83% na 85% Oxygen cylinder, manometer, flowmeter, tubes, connectors 94% 98% 94% 98% 100% 96% 83% 100% Operating table 97% 100% 96% 100% 100% 100% 100% 100% Adjustable shadowless overhead light 90% 94% 86% 92% 100% 100% 100% 100% Met readiness requirements 4 72% 86% 70% 85% 87% 97% 67% 68% OT with electricity at visit 5 99% 92% 100% 94% 100% 94% 83% 100% OT with water at visit 99% 89% 99% 86% 100% 94% 100% 100% Note: na = not applicable/not included in 2008, CD = cesarean delivery, ob/gyn = obstetrician/gynecologist, HR = human resources, OT = operating theater, ESOs = emergency surgical officers 1 The 2016 human resource module was worded differently from 2008 and additional questions were used. 2 Ob/gyns, pediatricians, medical doctors, general surgeons, ESOs, health officers and nurses. 3 In 2008, the question asked about lidocaine 1 or 2%. 4 Defined as [at least 1 professional to conduct operation + 1 for anesthesia] AND [EITHER an anesthesia machine + halothane or ketamine OR regional anesthesia (lignocaine/lidocaine 4% or bupivacaine)] AND [an oxygen cylinder with manometer, flowmeter, tubes and connectors + an operating table + overhead light]. 5 In 2008, the question referred to functioning power in the facility on day of interview, not the OT. Case reviews: quality of clinical care and record-keeping In 2008, 95 hospitals provided a total of 275 case reviews while in 2016, 288 hospitals provided 568 cases. The average age of the women was 26 years in both assessments. However, women whose cesareans were performed in the private for-profit hospitals were on average 28 years of age. In 2016 nearly half (46%) of the women attending public hospitals were nulliparous, while only 25–28% of women attending private hospitals were nulliparous. In both EmONC assessments, more than 75% of women had an emergency cesarean (Table 4 ). Emergency cesareans were least frequent in the private for-profit settings (47% in 2008 and 53% in 2016); emergency cesareans in public and not-for-profit hospitals ranged from 83–85% in 2008 to 90–91% in 2016. Proportionally, about three times as many cases with a previous cesarean or uterine scar were seen in the private hospitals compared to public hospitals. This pattern repeated itself in 2016. Indications for CD did not change dramatically although the proportion of CPD/prolonged labor cases increased (34–45%) while breech cases decreased (14–3%). Table 4 Percent distribution of cesarean deliveries reviewed according to indication, by managing authority and assessment year Type and indication for cesareans All cesareans reviewed Managing authority Public Private for-profit Not-for-profit 2008 2016 2008 2016 2008 2016 2008 2016 n = 275 n = 566 n = 209 n = 409 n = 45 n = 125 n = 21 n = 32 Type of cesarean Emergency 77% 82% 83% 90% 47% 53% 85% 91% Elective 21% 12% 15% 6% 51% 32% 15% 6% No information 2% 6% 2% 4% 2% 15% 0% 3% Maternal indications CPD/prolonged labor 1 34% 45% 36% 50% 27% 28% 26% 40% Previous cesarean 11% 13% 7% 8% 27% 26% 21% 22% Placenta praevia/abruption 7% 6% 7% 7% 2% 4% 16% 3% Severe PE/E 6% 4% 7% 4% 4% 2% 0% 6% Other maternal indications 2 9% 5% 10% 3% 8% 11% 0% 5% Fetal indications Fetal distress 3 15% 13% 13% 14% 20% 11% 21% 12% Breech 14% 3% 17% 4% 2% 2% 11% 3% Cord prolapse 2% 2% 3% 2% 0% 2% 0% 3% Multiple gestation 0% 3% 0% 3% 0% 2% 0% 0% Other fetal indications 4 2% 3% 1% 2% 8% 4% 5% 6% No information 0% 4% 0% 3% 2% 7% 0% 0% 1 Cephalo-pelvic disproportion, malpresentation, prolonged 1st and 2nd stages of labor, arrest disorders, failure to progress, failed assisted vaginal delivery, failed induction, and uterine rupture. 2 Failed induction and assisted vaginal delivery, fistula, medical disease, maternal request and trauma. 3 Fetal distress, severe intrauterine growth restriction and non-reassuring biophysical state. 4 Meconium stained amniotic fluid, post-term, intrauterine fetal death, HIV + mother and premature rupture of membranes. Information related to the quality of clinical care is found in Table 5 . In 2016, 52% of the women in the public hospitals were administered prophylactic uterotonics after the baby was delivered. The percentage was 46% among women in for-profit hospitals and 41% in the private not-for-profit sector. The use of prophylactic antibiotics was higher overall, with an increase from 87% in 2008 to 94% in 2016. Increases occurred only in public and private not-for-profit hospitals. Among women whose cesareans were an emergency, defined by having gone into labor, partograph use increased from 9–42% in public hospitals, was negligible in the private for-profit hospitals and declined from 47–27% in the private not-for-profit sector. We analyzed the time from decision to surgery for women with emergency cesareans, despite a high rate of missing information (58% in 2008 and 66% in 2016). The median interval in 2008 was 56 minutes; it increased to 76 minutes in 2016. The median increased across all sectors. In 2016 the longest median interval was in public hospitals (80 minutes) and the shortest in private not-for-profit hospitals (45 minutes). The mean interval decreased between 2008 and 2016 from 310 minutes to 210. Questions regarding the type of anesthesia administered and the cadre of the surgeon were asked only in 2016. Sixty percent of the women in public hospitals received a spinal while 24% were administered general anesthesia. In the private not-for-profit sector 81% received a spinal and 9% general while 49% of women received a spinal in the private for-profit hospitals. In public hospitals, 25% of women had an obstetrician in attendance, 38% had a general surgeon and 29% an emergency surgical officer. In the private for-profit hospitals, 88% of women were attended by an obstetrician and in the not-for-profit hospitals the percentage was 69%. Fetal outcomes improved over time with live births increasing from 79–95%. The improved fetal outcomes were most evident in government hospitals where perinatal deaths among the reviewed cases declined from 18–3%. Two maternal deaths were documented in 2008 and one in 2016 (data not shown). Table 5 Cesarean deliveries reviewed according to selected aspects of quality of care, by managing authority and assessment year All cesareans reviewed Managing authority Public Private-for-profit Not-for-profit 2008 2016 2008 2016 2008 2016 2008 2016 n = 275 n = 568 n = 209 n = 409 n = 45 n = 127 n = 21 n = 32 Prophylactic uterotonics administered after baby delivered na 50% na 52% na 46% na 41% Prophylactic antibiotics administered 1 87% 94% 86% 94% 93% 91% 85% 94% Partograph use among women with non-elective cesareans n = 211 n = 499 n = 172 n = 383 n = 22 n = 86 n = 17 n = 30 Partograph used 11% 35% 9% 42% 0% 6% 47% 27% Partograph not used 88% 55% 90% 49% 100% 78% 53% 60% Planned elective went into labor na 6% na 5% na 9% na 7% No information 1% 4% 1% 4% 0% 7% 0% 6% Time interval between decision and operation 2 n = 82 n = 148 n = 64 n = 130 n = 11 n = 9 n = 7 n = 9 Mean (minutes) 310 210 277 202 441 308 289 232 Median (minutes) 56 76 60 80 45 60 30 45 Type of anesthesia used Spinal/epidural (1 case) na 59% na 60% na 49% na 81% General na 28% na 24% na 36% na 9% Ketamine na 4% na 5% na 2% na 6% No information na 9% na 8% na 13% na 3% Type of surgeon Ob/gyn na 41% na 25% na 88% na 69% General surgeon na 31% na 38% na 7% na 25% ESO na 21% na 29% na 0% na 3% Health officer na 3% na 4% na 0% na 0% General practitioner na 1% na 2% na 0% na 3% MSC midwife na 1% na 1% na 0% na 0% No information na 2% na 1% na 5% na 0% Fetal Outcomes n = 275 n = 566 n = 209 n = 409 n = 45 n = 125 n = 21 n = 32 Live birth 79% 95% 78% 94% 93% 93% 71% 91% Stillbirth 9% 2% 11% 3% 2% 2% 5% 3% Neonatal death 5% < 1% 5% 0% 4% 0% 5% 0% Live birth + death 2% < 1% 2% 0% 0% 0% 0% 0% No information 5% 3% 5% 2% 0% 6% 19% 6% Note: na = not applicable/not included in 2008; ESO = emergency surgical officer; MSC = BSc midwife with surgical training 1 In 2008, the timing of antibiotics was not specified. In 2016, timing reflects antibiotics given either pre- or post-operatively. If no documentation of antibiotics was recorded, we assumed the woman did not receive them. 2 Asked of emergency cesarean deliveries only. Robson classification Figure 1 shows the relative contribution of each Robson group by managing authority. In the public sector, Robson group 1 accounted for 33% of the cesareans reviewed, followed by group 8 (12%). In the for-profit hospitals, group 5 dominated (28%), followed by group 2 (17%). This aligns with the findings on indications (Table 4 ), in which “previous cesarean” was the second most frequent indication in for-profit hospitals. Forty-two percent of the reviewed cesareans from the not-for-profit hospitals were women belonging equally to groups 1 and 5. As stated earlier, about a third of the cases suffered missing information and could not be grouped. Discussion Nationally, Ethiopia exhibits a large unmet need for cesarean delivery. When disaggregated by region, CD rates ranged from 24% in Addis Ababa to under 1% in pastoralist regions. Where rates were highest, the private sectors contributed between 25 and 50% of all cesareans. Although the public sector provides the bulk of obstetric services, by 2016 more than half (54%) of all deliveries in private for-profit hospitals were cesareans. These two extremes – widespread underutilization of life-saving surgical care and the overutilization of a costly procedure not without risk – are faced by other low and middle income settings, and is an example of how the obstetric transition fails to follow a linear trajectory ( 26 ). Cesarean delivery rates, like the maternal mortality ratio, are also indicators for social and wealth disparities. Despite the tripling of the overall number of hospitals between 2008 and 2016, both assessments indicated that about four out of five hospitals provided CD services ( 18 ). The lack of universal water and electricity in hospitals in 2016 may be a result of the rapid expansion in infrastructure. Hospital readiness to perform a cesarean showed signs of improvement, and a larger proportion of hospitals in 2016 met minimum staffing and equipment requirements than in 2008. One enabling factor was likely the establishment of the emergency surgical officer ( 22 ). Four out of five public hospitals with CD services employed ESOs. A large push to prepare anesthetists also took place during this time period ( 22 ). Chart reviews revealed how patient profiles and provider practices varied by managing authority. The for-profit and not-for-profit hospitals disproportionately attracted women with a previous CD and non-emergency cases. The case reviews also pointed to mixed results regarding the practice of evidence-based interventions. The use of partographs to monitor labor more than tripled in the public sector while they were hardly used or declined in private hospitals. Uterotonics administered after the baby was delivered and prophylactic antibiotic use were also more evident in public hospitals than elsewhere. These three interventions help prevent serious complications and all women should receive them. Thus, it is encouraging that contrary to other experiences ( 27 ), the public sector performed as well if not better than private hospitals. The inclusion of the Robson classification parameters in 2016 enabled us to see clearly the perpetuation of “once a cesarean, always a cesarean,” especially among the women from the private hospitals and the contribution of group 5 to these two groups of hospitals. Typically, groups 1, 2, 3 and 5 contribute heavily to the overall CD rate, while groups 6–10 account for a smaller proportion of all cesareans. According to a WHO multi-country study from 21 countries and 287 hospitals, groups 6–10 accounted for only 20% of the cesareans ( 28 ). In our case, groups 6–10 accounted for 38% of the cases. This might reflect Ethiopia’s overall low cesarean rate and that higher risk women contributed more to the pool of cesareans than in the WHO multicenter study. As the overall cesarean rate increases, the contribution of groups 6–10 relative to other groups may decline. Nevertheless, the largest Robson group in the public sector was group 1, a group vulnerable to unnecessary cesarean deliveries. Strengths and Limitations A strength of this paper is the richness of its data sources: two national health facility censuses that enabled comparisons between public and private sectors. Analyses drew on data from interviews with health workers, observation of infrastructure, 12 months of service statistics, and individual level data from women who had undergone a cesarean, resulting in a multifaceted overview of how the use and quality of cesarean delivery changed and suggesting some steps going forward. Although each assessment was designed as a census of facilities, we know that about 15 facilities where cesarean services were provided were not eligible and therefore not visited in 2008 and at least two in 2016. These omissions affected 2008 more than 2016 and probably caused us to underestimate the 2008 population-based CD rate for Addis Ababa. However, we do not believe that their inclusion would modify our conclusions. We recognize that observation generally produces more accurate results than reporting, especially if recall is required. Hospital readiness depended heavily on responses from staff rather than observation, for example, whether an oxygen cylinder was both available and functional. Furthermore, readiness results will change as does the definition of the algorithm, and we encourage strengthening this definition. Data quality of the primary sources – admission, operating theater and discharge logbooks – is a well-recognized limitation when working with health facility data. We are not clear why an increase in missing information occurred between the two assessments, especially among the case reviews. The inability to classify a third of the cesareans reviews into one of the 10 Robson groups points to omissions in record-keeping, even though the six parameters used to group women are considered standard data points. The group that suffered the least amount of missing information (20 cases) was group 8, defined only by singleton or multiple gestation. Group 5 suffered the most from missing information: 132 of 568 cases lacked at least one of the five variables that defined group 5, with “previous cesarean” the most frequently missing. The case reviews were systematically selected but were technically a convenience sample, and do not represent all cesareans, especially those conducted in the private sectors where missing data tended to be higher. Similar studies have struggled with the use of non-randomly selected chart reviews but also recognized their value when presenting an overview of a single service delivery intervention ( 29 , 30 ). Conclusions During the 8-year interval between assessments, the government tripled the number of hospitals, raised the CD delivery rate in underserved regions, and improved both the readiness to perform obstetric operations and the quality of clinical care. The data also point to dangerously low CD rates in underserved rural areas. More equitable access to cesarean services can be achieved through strengthened referral systems, hospital maternity waiting homes and the continued expansion of facilities that fill geospatial gaps ( 31 , 32 ). Meanwhile, high institutional CD rates in the private sector suggest that not all cesareans may be medically indicated. Federal normative bodies as well as professional societies should investigate local conditions to identify what is driving the demand: financial incentives on the supply side, professional inexperience with non-routine vaginal births, or other forces. The use of the Robson classification would be a useful tool for future quality improvement efforts – to ensure that the right women are receiving this procedure while others are protected from unnecessary procedures. Abbreviations CD Cesarean Delivery EmONC Emergency Obstetric and Newborn Care ESOs Emergency Surgical Officers HR Human Resources ob/gyn Obstetrician/Gynaecologist OT Operating Theatre WHO World Health Organization Declarations Ethics approval and consent to participate This paper is the result of secondary data analysis of two national assessments. We received permission to access and use the data from the Ethiopian Public Health Institute and the Family Health Division of the Federal Ministry of Health. Consent to publish Not applicable. Availability of data and materials The datasets generated and analyzed for this study are available from the Ethiopian Public Health Institute Director on reasonable request. Competing interests None of the authors has any competing interests. Funding The Bill and Melinda Gates Foundation provided initial support to all of the authors. But the Foundation did not influence the writing process or substantive content. Authors’ contribution MGB took the lead on conceptualizing the paper and writing the first draft. TGZ, AH, ALR and PB reviewed and revised. TGZ and PB did the statistical analyses. All authors have read and approved the manuscript. Acknowledgements We would like to thank EPHI and the Ministry of Health for their sharing of the datasets. In addition, we thank the Bill and Melinda Gates Foundation and Averting Maternal Death and Disability for their support of the paper writing workshop. References Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388(10056):2176–92. Betran AP, Torloni MR, Zhang J, Ye J, Mikolajczyk R, Deneux-Tharaux C, et al. What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reprod Health. 2015;12(1). Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA - J Am Med Assoc. 2015;314(21):2263–70. Appropriate Technology for Birth. Lancet [Internet]. 1985 Aug 24 [cited 2019 Dec 24];326(8452):436–7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673685927503 Ye J, Betrán AP ila., Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41(3):237–44. World Health Organization Human Reproduction Programme 10 April 2015. WHO Statement on caesarean section rates. Reprod Health Matters [Internet]. 2015;23(45):149–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26278843 Rijken MJ, Meguid T, Van Den Akker T, Van Roosmalen J, Stekelenburg J. Global surgery and the dilemma for obstetricians. Lancet [Internet]. 2015;386(10007):1941–2. Available from: http://dx.doi.org/10.1016/S0140-6736(15)00828-4 Wright J, Ayenachew F, Ballard KD. The changing face of obstetric fistula surgery in Ethiopia. Int J Womens Health. 2016;8:243–8. Belizán JM, Althabe F, Cafferata ML. Health consequences of the increasing caesarean section rates. Epidemiology. 2007;18(4):485–6. Häger RME, Daltveit AK, Hofoss D, Nilsen ST, Kolaas T, Øian P, et al. Complications of cesarean deliveries: Rates and risk factors. Am J Obstet Gynecol. 2004;190(2):428–34. Delport S. Global epidemiology of use of and disparities in caesarean sections. Lancet [Internet]. 2019;394(10192):23–4. Available from: http://dx.doi.org/10.1016/S0140-6736(19)30717-2 Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990-2014. PLoS One. 2016;11(2):1–12. Central Statistical Agency and ICF. Ethiopia Demographic and Health Survey. 2016. Gebremedhin S. Trend and socio-demographic differentials of Caesarean section rate in Addis Ababa, Ethiopia: Analysis based on Ethiopia demographic and health surveys data. Reprod Health [Internet]. 2014;11(1):1–6. Available from: Reproductive Health WHO. WHO | Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Who [Internet]. 2014;(August 2013):914–22. Available from: http://www.who.int/bulletin/volumes/91/12/13-117598/en/ Ethiopian Federal Ministry of Health. Health Sector Transformation Plan (2015/16-2019/20). Vol. 20. 2015. Ministry F. National Baseline Assessment for Emergency Obstetric & Newborn Care. 2008; FMOH of Ethiopia EPHI and AMDD. ETHIOPIAN Emergency Obstetric and Newborn Care (EmONC) Assessment 2016. 2016;1–456. AMDD. Averting Maternal Death and Disability (AMDD) Toolkit 2016 [cited 2016 15 November].Available from: https://www.mailman.columbia.edu/research/averting-maternal-death-and-disability-amdd/toolkit. Keyes EB, Haile-Mariam A, Belayneh NT, Gobezie WA, Pearson L, Abdullah M, et al. Ethiopia’s assessment of emergency obstetric and newborn care: Setting the gold standard for national facility-based assessments. Int J Gynecol Obstet. 2011;115(1):94–100. EMoH. Health Sector Development Program: 2010/11 -2014/15 [Internet]. Vol. IV, Federal Democratic Republic of Ethiopia Ministry of Health. 2010. Available from: http://phe-ethiopia.org/admin/uploads/attachment-721-HSDP IV Final Draft 11Octoberr 2010.pdf Ministry of Health Ethiopia, PMNCH, World Health Organization, World Bank, AHPSR. Success Factors for Women’s and Children’s Health Ethiopia. 2015;28. Health FM of. Health and Health Related Indicators – 2012/2013. Planning and Programming Department: 2014. 2014; Robson M. Classification of caesarean sections. Fetal Matern Med Rev [Internet]. 2001 Feb 17 [cited 2019 Dec 24];12(1):23–39. Available from: https://www.cambridge.org/core/product/identifier/S0965539501000122/type/journal_article Vogel JP, Betrán AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. Use of the robson classification to assess caesarean section trends in 21 countries: A secondary analysis of two WHO multicountry surveys. Lancet Glob Heal. 2015;3(5):e260–70. Souza J, Tunçalp Ö, Vogel J, Bohren M, Widmer M, Oladapo O, et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG An Int J Obstet Gynaecol. 2014;121:1–4. Kruk ME, Leslie HH, Verguet S, Mbaruku GM, Adanu RMK, Langer A. Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. Lancet Glob Heal. 2016;4(11):e845–55. Betran AP, Gulmezoglu AM, Robson M, Merialdi M, Souza JP, Wojdyla D, et al. WHO global survey on maternal and perinatal health in Latin America: Classifying caesarean sections. Reprod Health. 2009;6(1):4–11. Kim YM, Tappis H, Zainullah P, Ansari N, Evans C, Bartlett L, et al. Quality of caesarean delivery services and documentation in first-line referral facilities in Afghanistan: A chart review. BMC Pregnancy Childbirth [Internet]. 2012;12(1):14. Available from: http://www.biomedcentral.com/1471-2393/12/14 Fesseha N, Getachew A, Hiluf M, Gebrehiwot Y, Bailey P. A national review of cesarean delivery in Ethiopia. Int J Gynecol Obstet [Internet]. 2011;115(1):106–11. Available from: http://dx.doi.org/10.1016/j.ijgo.2011.07.011 Tiruneh GT, Getu YN, Abdukie MA, Eba GG, Keyes E, Bailey PE. Distribution of maternity waiting homes and their correlation with perinatal mortality and direct obstetric complication rates in Ethiopia. BMC Pregnancy Childbirth. 2019;19(1):1–11. Bailey PE, Keyes EB, Parker C, Abdullah M, Kebede H, Freedman L. Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia. Int J Gynecol Obstet. 2011;115(3):300–9. Cite Share Download PDF Status: Published Journal Publication published 19 Aug, 2021 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Major revision 05 Apr, 2021 Review # 3 received at journal 04 Apr, 2021 Review # 2 received at journal 30 Nov, 2020 Reviewer # 3 agreed at journal 09 Nov, 2020 Reviewer # 2 agreed at journal 05 Nov, 2020 Review # 1 received at journal 05 Nov, 2020 Reviewers invited by journal 04 Nov, 2020 Reviewer # 1 agreed at journal 04 Nov, 2020 Editor assigned by journal 28 Oct, 2020 Submission checks completed at journal 28 Oct, 2020 Editor invited by journal 28 Oct, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-103142","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":4401799,"identity":"b701c213-72a2-45b0-bf1e-c855d54669d4","order_by":0,"name":"Misrak Getnet Beyene","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYDACZhBxgEGOjb0ByDCwIF6LMR/PAZAWCWKtOsCQOE8iAcQiQotuO/uzDz/O1BqzST6/uuFHgQQDf3t3Al4tZod5jGf23DguxyadU3azB+gwiTNnNxDSwszA8+GYMVBL2g0eoBYDiVxCWtgfM/75cCyxTfJM2s0/xGlhMGbmuVGT2CbBfuw2kbbwGDPLnDlgzMaTw3ZbxkCCh7Bfzh9/zPjmWJ2cfPvxZzff/LGR42/vxa8FCg4DMY8BiMVDjHIQqANi9gfEqh4Fo2AUjIIRBgDRC0ep2jJalgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-6629-756X","institution":"Ethiopian Public Health Institute","correspondingAuthor":true,"prefix":"","firstName":"Misrak","middleName":"Getnet","lastName":"Beyene","suffix":""},{"id":4401800,"identity":"87e3dfa6-54da-41ad-ba6c-5be8776ed530","order_by":1,"name":"Theodros Getachew Zemedu","email":"","orcid":"","institution":"Ethiopian Public Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Theodros","middleName":"Getachew","lastName":"Zemedu","suffix":""},{"id":4401801,"identity":"58ec4f4e-54c5-403e-8920-1fbc333372b1","order_by":2,"name":"Azmach Hadush Gebregiorgis","email":"","orcid":"","institution":"World Health Organization: Organisation mondiale de la Sante","correspondingAuthor":false,"prefix":"","firstName":"Azmach","middleName":"Hadush","lastName":"Gebregiorgis","suffix":""},{"id":4401802,"identity":"aea889a0-774a-4ab6-a7fa-572898be3f78","order_by":3,"name":"Ana Lorena Ruano","email":"","orcid":"","institution":"University of Bergen: Universitetet i Bergen","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Lorena","lastName":"Ruano","suffix":""},{"id":4401803,"identity":"df180376-e49c-463d-b1fd-6131e16e7b95","order_by":4,"name":"Patricia E Bailey","email":"","orcid":"","institution":"Columbia University Mailman School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"E","lastName":"Bailey","suffix":""}],"badges":[],"createdAt":"2020-11-04 21:43:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-103142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-103142/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-021-04008-9","type":"published","date":"2021-08-19T15:04:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3477148,"identity":"0dec5d87-c2ce-446f-915e-bdb1b13034e3","added_by":"auto","created_at":"2020-11-09 23:47:54","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40311,"visible":true,"origin":"","legend":"Relative size of the 10 Robson groups by managing authority (n=371) \nGroup 1: parity 0, no previous CD, singleton, cephalic, \u003e 37 weeks, spontaneous labor\nGroup 2: parity 0, no previous CD, singleton, cephalic, \u003e 37 weeks, induced or CD before labor\nGroup 3: parity \u003e 1, no previous CD, singleton, cephalic, \u003e 37 weeks, spontaneous labor\nGroup 4: parity \u003e 1, no previous CD, singleton, cephalic, \u003e 37 weeks, induced or CD before labor\nGroup 5: parity \u003e 1, previous CD, singleton, cephalic, \u003e 37 weeks, any onset of labor\nGroup 6: parity 0, no previous CD, singleton, breech, any gestational age, any onset of labor\nGroup 7: parity \u003e 1, yes or no previous CD, singleton, breech, any gestational age, any onset of labor\nGroup 8: any parity, yes or no previous CD, multiple fetuses, any fetal lie, any gestational age, any onset of labor\nGroup 9: any parity, yes or no previous CD, singleton, transverse or oblique lie, any gestational age, any onset of labor\nGroup 10: any parity, yes or no previous CS, singleton, cephalic, \u003c 37 weeks, any onset of labor","description":"","filename":"Figure1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-103142/v1/54702dc3d38b3811e3fc8dc8.JPG"},{"id":3477146,"identity":"916749c0-2453-4dc2-b1dd-e5acdf146c7b","added_by":"auto","created_at":"2020-11-09 23:47:48","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40311,"visible":true,"origin":"","legend":"Relative size of the 10 Robson groups by managing authority (n=371) \nGroup 1: parity 0, no previous CD, singleton, cephalic, \u003e 37 weeks, spontaneous labor\nGroup 2: parity 0, no previous CD, singleton, cephalic, \u003e 37 weeks, induced or CD before labor\nGroup 3: parity \u003e 1, no previous CD, singleton, cephalic, \u003e 37 weeks, spontaneous labor\nGroup 4: parity \u003e 1, no previous CD, singleton, cephalic, \u003e 37 weeks, induced or CD before labor\nGroup 5: parity \u003e 1, previous CD, singleton, cephalic, \u003e 37 weeks, any onset of labor\nGroup 6: parity 0, no previous CD, singleton, breech, any gestational age, any onset of labor\nGroup 7: parity \u003e 1, yes or no previous CD, singleton, breech, any gestational age, any onset of labor\nGroup 8: any parity, yes or no previous CD, multiple fetuses, any fetal lie, any gestational age, any onset of labor\nGroup 9: any parity, yes or no previous CD, singleton, transverse or oblique lie, any gestational age, any onset of labor\nGroup 10: any parity, yes or no previous CS, singleton, cephalic, \u003c 37 weeks, any onset of labor","description":"","filename":"Figure1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-103142/v1/b4d986883af82b9aaa088fa0.JPG"},{"id":13611955,"identity":"6dcc964d-2f57-4078-8eb1-2345ac8c12da","added_by":"auto","created_at":"2021-09-17 06:30:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":783869,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-103142/v1/59ebe972-46da-4896-a395-e3d3c7b8c1f8.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eUse and Quality of Cesarean Delivery in a Low and Middle Income Setting: National Results from Two Emergency Obstetric and Newborn Care Assessments\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eIncreasingly, low and middle income countries face the two extremes of unmet need for and unnecessary cesareans, or \u0026ldquo;too little too late and too much too soon\u0026rdquo; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Just what the number of cesareans should be has evolved (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The World Health Organization (WHO) began producing global guidance on this topic as early as 1985 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In 2015, backed by evidence that rates greater than 10% were not associated with a reduction in maternal and newborn mortality, the WHO stressed that all women who need a CD should receive one, while cautioning against pursuing specific targets (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Women who have a cesarean undergo perioperative risks such as blood loss, anesthetic accidents, wound infection and iatrogenic fistula, and put future pregnancies at risk due to uterine scaring (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A prospective study in Norway found that 1 in 5 women experienced at least short-term complications as a result of cesarean surgery (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Nonclinical consequences as well as the health of newborns and children are of equal concern (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSub-Saharan Africa has marginally increased its CD rate from 2.3\u0026ndash;4.1% between 1990 and 2015 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The slow rise has been attributed to weak health systems and the lack of resources to ensure quality of care. Recent global and regional studies on surgery have highlighted extensive unmet need for surgery. They also documented safety concerns when undertaken too late or in environments where deficits in surgical personnel and resources are common, such as oxygen, medical equipment and electricity (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEthiopia is a country with high maternal and newborn mortality, high prevalence of fistula and historically low cesarean and institutional delivery rates. According to the 2016 Demographic and Health Survey, the CD rate was 2% based on births during the five years prior to the survey (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Earlier trend data from the capital indicated rising cesarean rates that were positively correlated with income and education, as in many other country settings (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The current Health Sector Transformation Plan set a population-based cesarean target of 8% for 2020 as a step towards addressing the unmet need for life-saving surgery (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis paper presents a broad overview of recent changes in the service coverage and quality of CD, with a focus on differences across public and private sectors. We describe changes in national and regional CD rates; institutional rates; the readiness of hospitals to provide obstetric surgery; and the quality of CD services.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis secondary data analysis draws on two Emergency Obstetric and Newborn Care (EmONC) assessments from 2008 and 2016 (17,18). Both were national cross-sectional censuses of public and private health facilities.\u003c/p\u003e\n\u003cp\u003eThe data collection instruments for 2008 were adapted from a set of standard modules previously used in many countries (19). The 2016 assessment used the same core tools administered in 2008 that underwent a global revision with local adaptation in 2016. The six modules relevant to this study were: M1 - basic infrastructure; M2 - human resources; M3 - inventory of drugs, equipment and supplies; M4 - summary service statistics; M5 - performance of signal functions; and M8 - case review for CDs. All facilities received modules 1-5; only facilities that performed CDs received M8. The latter was modified in 2016 to include information not in 2008 such as a woman\u0026rsquo;s characteristics needed to classify her into one of the Robson 10 groups, type of anesthesia and professional cadre who performed the operation.\u003c/p\u003e\n\u003cp\u003eThe first assessment was launched October 1, 2008 and completed by January 15, 2009; the 2016 survey commenced in mid-May and was completed by mid-December 2016. In 2008, a private company conducted the assessment and prepared the databases (20) and in 2016, this responsibility shifted to the Ethiopian Public Health Institute. Details about the data collector training and survey execution can be found in the final reports (17, 18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIf the Ethiopian Food, Medicine and Health Control Authority approved a facility as a site to deliver routine and/or operative childbirth services, it was eligible for the assessment. Between 2008 and 2016 the Ministry of Health led a massive infrastructure expansion, adding about 3000 health centers and 200 hospitals (21,22). In 2008, 751 health facilities with childbirth services were visited, including 111 hospitals. In 2016, 3,804 were visited, 316 of which were hospitals. This paper focuses on hospitals designated to provide comprehensive emergency obstetric care.\u003c/p\u003e\n\u003cp\u003eAlthough we call both assessments a census, in 2008 15 facilities were not visited because they did not appear on the master list of licensed facilities, 12 of which were in the capital of Addis Ababa. In 2016, 11 facilities were not visited due to civil unrest but few if any of these service sites were hospitals. Finally, two hospitals refused to participate in the 2016 assessment.\u003c/p\u003e\n\u003cp\u003eIn each hospital, a subset of women who delivered by cesarean had their records reviewed. In 2008 data collectors identified three women per hospital and in 2016 only two cases per hospital were selected because of the increase in the number of hospitals. The selection criteria remained the same: 1) cases occurred in the previous 12 months, and 2) they were the last women who had had a cesarean but were no longer under postoperative care, regardless of survival.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcesses and comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper features three units of analysis: aggregated hospital service statistics, hospitals and individual women who delivered by cesarean. Aggregated service statistics (M4) covered 12 consecutive months prior to the assessment (July 2007\u0026ndash;June 2008 and January-December 2015). Service data included the number of deliveries by mode of delivery; these data were used to estimate CD rates. Modules 1, 2, 3 and 5 provided information to assess hospital readiness to perform CD while the CD chart review (M8) was the information source for service quality and record-keeping at the individual level.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVariables and index creation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor both population-based and institutional CD rates, the numerator was the sum of all CDs performed at each hospital. The denominator for the population-based rate was the number of expected births in each region, calculated from population figures from the Planning and Programming Department of the Federal Ministry of Health and the crude birth rate established by the 2016 Demographic and Health Survey (13,23). The denominator for the institutional CD rate was the sum of all births at each hospital that had provided cesarean services in the three months prior to the assessment.\u003c/p\u003e\n\u003cp\u003eTo assess health system readiness to provide CD services, we created a binary summary score (yes or no), based on an algorithm defined by the availability of at least one health professional able to perform the operation and another to provide anesthesia, plus readiness items that had to be functioning and included EITHER an anesthesia machine + (halothane or ketamine) OR regional anesthesia (lignocaine/ lidocaine 4% or bupivacaine) AND an oxygen cylinder with manometer and flowmeter (low flow) tubes and connectors, an operating table and a functioning adjustable light (20). Although not included in the algorithm, interruptions in water and electricity in the operation theaters were assessed.\u003c/p\u003e\n\u003cp\u003eQuality of clinical management was measured by use of a partograph, administration of prophylactic antibiotics and uterotonics, time interval from decision to incision, type of anesthesia, clinician who performed the CD and maternal and newborn outcomes.\u003c/p\u003e\n\u003cp\u003eA final analysis of clinical management was based on the Robson 10-group classification scheme, designed to determine institutional cesarean rates for clinically relevant and mutually exclusive groups (24). The classification system depends on six characteristics of women that are easily captured: parity (nulliparous/multiparous), number of fetuses (singleton/multiple), onset of labor (spontaneous or induced/CD before labor started), previous CD (yes/no), fetal lie (cephalic/ transverse/breech) and gestational age (\u0026lt;37 weeks/ \u003cu\u003e\u0026gt;\u003c/u\u003e37 weeks). Because the 10 groups (see Figure 1) tend to have different cesarean rates, the classification scheme is used to inform where changes in clinical management should be made. One of the goals of its usage is to reduce cesareans among nulliparous women (groups 1 and 2), who are known to be vulnerable to unnecessary CDs, and who are often the biggest group (25). Overuse of CD among these women sets up a domino effect that contributes to repeated cesareans.\u003c/p\u003e\n\u003cp\u003eOur aim in using the Robson classification was to determine the distribution of cases according to the 10 groups to show their relative size, if and how the group sizes varied across managing authority, and the extent to which the group sizes aligned with other studies.\u003c/p\u003e\n\u003cp\u003eOur key stratifying variable \u0026ndash; hospital managing authority \u0026ndash; was defined with three categories: public or government, private for-profit and private not-for-profit management by non-governmental organizations and/or religious missions.\u003c/p\u003e\n\u003cp\u003eTo produce descriptive statistics (frequencies, percentages, means and medians) we used SPSS version 24. Since our data sources were censuses and not random samples, nor did they represent some theoretical population, we performed no statistical tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper utilizes secondary data; permission to use the data was granted by the Ethiopian Public Health Institute and the Family Health Division at the Federal Ministry of Health.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn 2008, 87 of the 111 hospitals provided cesarean deliveries (66 public sector, 15 for-profit and 6 not-for-profit). In 2016, 253 out of 316 hospitals provided cesarean services (188, 52 and 13, respectively).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCoverage: Cesarean delivery rates \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe national population-based cesarean rate in 2008 was 0.6% and 2.7% in 2016 (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The highly urbanized regions of Harari, Addis Ababa and Dire Dawa exhibited the highest rates in 2016: 17%, 24%, and 10%, respectively. Elsewhere, rates increased but remained very low.\u003c/p\u003e\n\u003cp\u003eAt the national level, 72% and 74% of the cesareans were performed in the public sector in 2008 and 2016, respectively. Half of the cesareans performed in Addis Ababa took place in the private sectors. The CD rate in Addis Ababa was likely underestimated in 2008 due to the 12 private hospitals not eligible for the assessment.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCesarean deliveries (CD), expected births and population-based CD rates, by region and assessment year\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRegion\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePublic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePrivate for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePrivate not-for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal CDs\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eExpected births\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRates\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNational\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12,316\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,864\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,965\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17,145\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,638,891\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58,667\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13,914\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6,335\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78,916\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,928,303\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTigray\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,179\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,181\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e160,929\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5,298\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e106\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5,404\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e163,802\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAfar\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52,634\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e229\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56,222\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAmhara\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,503\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,531\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e642,084\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9,993\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e533\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e437\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10,963\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e660,518\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOromia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,654\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3,676\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,013,011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16,447\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,042\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,751\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19,240\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,099,485\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSomali\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e104\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e112\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e165,580\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e488\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e527\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e178,048\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eBenishangul-Gumuz\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e166\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e166\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25,023\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e700\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e700\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32,913\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSNNP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,822\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e536\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,458\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e561,086\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10,258\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,507\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12,863\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e595,296\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGambella\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11,448\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e135\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e135\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13,420\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHarari\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e648\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e648\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6,545\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e915\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e381\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,296\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7,568\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAddis Ababa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3,918\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,607\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e429\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6,954\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97,755\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13,243\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11,351\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,544\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26,138\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e106,625\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eDire Dawa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e224\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e321\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12,239\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,057\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e364\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,421\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14,405\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\" align=\"left\"\u003e\n\u003cp\u003eNotes: SNNP\u0026thinsp;=\u0026thinsp;Southern Nations, Nationalities, Peoples' region\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe institutional CD rate is the percentage of institutional births delivered by cesarean and is influenced by patient mix and provider practice (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Patterns of institutional CD rates in 2008 and 2016 were similar: the private for-profit sector had the highest rates (46% and 54%, respectively) and the public sector had the lowest (15% and 19%, respectively). The greatest percentage increase occurred among public hospitals (23%).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCesarean deliveries (CDs), institutional deliveries and rates among hospitals,* by managing authority and assessment year\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eManaging Authority\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCDs\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional deliveries\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional CD rate\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCDs\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional deliveries\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional CD rate\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePublic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12,316\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80,135\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54,983\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e290,150\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrivate for-profit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,864\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6,212\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13,810\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25,384\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrivate not-for-profit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,965\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7,342\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6,335\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22,523\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17,145\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93,689\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e75,128\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e338,057\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003e*Among hospitals that performed CDs in the 3 months preceding the survey\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHospital readiness to perform cesarean delivery \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproximately 80% of hospitals in both time periods provided CD services in the 3 months prior to the assessments (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Among hospitals that had performed CDs, the availability of surgeons, obstetricians and medical doctors declined between 2008 and 2016 when emergency surgical officers (ESOs) began to play a major role, especially in the public sector. The private for-profit hospitals relied almost entirely on obstetricians, while the not-for-profit hospitals increased their reliance on both obstetricians and ESOs. An increase from 95\u0026ndash;100% of hospitals reported at least one professional on staff to administer anesthesia.\u003c/p\u003e\n\u003cp\u003eThe availability of drugs and equipment did not change dramatically between the two assessments. In 2016, public sector hospitals were at some disadvantage compared to private hospitals. For example, in 2016 85% of public hospitals had vaporizers compared to 96\u0026ndash;100% among private hospitals.\u003c/p\u003e\n\u003cp\u003eAccording to the readiness algorithm, hospital readiness increased in the public sector from 70\u0026ndash;85% and among for-profit facilities from 87\u0026ndash;97%, but only 67\u0026ndash;68% of not-for-profit facilities were staffed and equipped to provide CDs.\u003c/p\u003e\n\u003cp\u003eAlthough not included in the readiness algorithm, we also examined whether hospitals experienced interruptions in electricity and running water. In 2008 virtually all hospitals that regularly performed cesareans had functioning water and electricity in the operation theater or in the hospital itself on the day of the assessment. In 2016 the percentage dropped to closer to 90% for both electricity and water.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eHospitals providing cesarean delivery, and among those, characteristics of readiness, by managing authority and year\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"4\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTotal number of hospitals\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eManaging authority\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePublic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePrivate for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNot-for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;111\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;316\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;90\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;236\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;61\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerformed CD in last 3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;253\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;188\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHospital has HR for surgery\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOb/gyn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral surgeon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical doctor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eESOs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMidwife\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNurse\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAt least one person can provide\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHospital has HR for anesthesia\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnesthesiologist/anesthetist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnesthesiologist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnesthetist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther professional\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAt least one person can provide\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHospital has anesthesia and equipment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnesthetic vaporizer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHalothane\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e84%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKetamine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e84%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLignocaine/lidocaine 4%\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBupivacaine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOxygen cylinder, manometer, flowmeter, tubes, connectors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOperating table\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAdjustable shadowless overhead light\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMet readiness requirements\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e72%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e97%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOT with electricity at visit\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOT with water at visit\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e89%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003eNote: na\u0026thinsp;=\u0026thinsp;not applicable/not included in 2008, CD\u0026thinsp;=\u0026thinsp;cesarean delivery, ob/gyn\u0026thinsp;=\u0026thinsp;obstetrician/gynecologist, HR\u0026thinsp;=\u0026thinsp;human resources, OT\u0026thinsp;=\u0026thinsp;operating theater, ESOs\u0026thinsp;=\u0026thinsp;emergency surgical officers\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e The 2016 human resource module was worded differently from 2008 and additional questions were used.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Ob/gyns, pediatricians, medical doctors, general surgeons, ESOs, health officers and nurses.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e In 2008, the question asked about lidocaine 1 or 2%.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Defined as [at least 1 professional to conduct operation\u0026thinsp;+\u0026thinsp;1 for anesthesia] AND [EITHER an anesthesia machine\u0026thinsp;+\u0026thinsp;halothane or ketamine OR regional anesthesia (lignocaine/lidocaine 4% or bupivacaine)] AND [an oxygen cylinder with manometer, flowmeter, tubes and connectors\u0026thinsp;+\u0026thinsp;an operating table\u0026thinsp;+\u0026thinsp;overhead light].\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003e In 2008, the question referred to functioning power in the facility on day of interview, not the OT.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase reviews: \u0026nbsp;quality of clinical care and record-keeping\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 2008, 95 hospitals provided a total of 275 case reviews while in 2016, 288 hospitals provided 568 cases. The average age of the women was 26\u0026nbsp;years in both assessments. However, women whose cesareans were performed in the private for-profit hospitals were on average 28\u0026nbsp;years of age. In 2016 nearly half (46%) of the women attending public hospitals were nulliparous, while only 25\u0026ndash;28% of women attending private hospitals were nulliparous.\u003c/p\u003e\n\u003cp\u003eIn both EmONC assessments, more than 75% of women had an emergency cesarean (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Emergency cesareans were least frequent in the private for-profit settings (47% in 2008 and 53% in 2016); emergency cesareans in public and not-for-profit hospitals ranged from 83\u0026ndash;85% in 2008 to 90\u0026ndash;91% in 2016. Proportionally, about three times as many cases with a previous cesarean or uterine scar were seen in the private hospitals compared to public hospitals. This pattern repeated itself in 2016. Indications for CD did not change dramatically although the proportion of CPD/prolonged labor cases increased (34\u0026ndash;45%) while breech cases decreased (14\u0026ndash;3%).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePercent distribution of cesarean deliveries reviewed according to indication, by managing authority and assessment year\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eType and indication for cesareans\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAll cesareans reviewed\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eManaging authority\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePublic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePrivate for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNot-for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;275\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;566\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;209\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;409\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;45\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;125\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eType of cesarean\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmergency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e82%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eElective\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo information\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal indications\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCPD/prolonged labor\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrevious cesarean\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePlacenta praevia/abruption\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSevere PE/E\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther maternal indications\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFetal indications\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFetal distress\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBreech\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCord prolapse\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMultiple gestation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther fetal indications\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo information\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Cephalo-pelvic disproportion, malpresentation, prolonged 1st and 2nd stages of labor, arrest disorders, failure to progress, failed assisted vaginal delivery, failed induction, and uterine rupture.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Failed induction and assisted vaginal delivery, fistula, medical disease, maternal request and trauma.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Fetal distress, severe intrauterine growth restriction and non-reassuring biophysical state.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Meconium stained amniotic fluid, post-term, intrauterine fetal death, HIV\u0026thinsp;+\u0026thinsp;mother and premature rupture of membranes.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformation related to the quality of clinical care is found in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e. In 2016, 52% of the women in the public hospitals were administered prophylactic uterotonics after the baby was delivered. The percentage was 46% among women in for-profit hospitals and 41% in the private not-for-profit sector. The use of prophylactic antibiotics was higher overall, with an increase from 87% in 2008 to 94% in 2016. Increases occurred only in public and private not-for-profit hospitals.\u003c/p\u003e\n\u003cp\u003eAmong women whose cesareans were an emergency, defined by having gone into labor, partograph use increased from 9\u0026ndash;42% in public hospitals, was negligible in the private for-profit hospitals and declined from 47\u0026ndash;27% in the private not-for-profit sector.\u003c/p\u003e\n\u003cp\u003eWe analyzed the time from decision to surgery for women with emergency cesareans, despite a high rate of missing information (58% in 2008 and 66% in 2016). The median interval in 2008 was 56 minutes; it increased to 76 minutes in 2016. The median increased across all sectors. In 2016 the longest median interval was in public hospitals (80 minutes) and the shortest in private not-for-profit hospitals (45 minutes). The mean interval decreased between 2008 and 2016 from 310 minutes to 210.\u003c/p\u003e\n\u003cp\u003eQuestions regarding the type of anesthesia administered and the cadre of the surgeon were asked only in 2016. Sixty percent of the women in public hospitals received a spinal while 24% were administered general anesthesia. In the private not-for-profit sector 81% received a spinal and 9% general while 49% of women received a spinal in the private for-profit hospitals. In public hospitals, 25% of women had an obstetrician in attendance, 38% had a general surgeon and 29% an emergency surgical officer. In the private for-profit hospitals, 88% of women were attended by an obstetrician and in the not-for-profit hospitals the percentage was 69%. Fetal outcomes improved over time with live births increasing from 79\u0026ndash;95%. The improved fetal outcomes were most evident in government hospitals where perinatal deaths among the reviewed cases declined from 18\u0026ndash;3%. Two maternal deaths were documented in 2008 and one in 2016 (data not shown).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCesarean deliveries reviewed according to selected aspects of quality of care, by managing authority and assessment year\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"4\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAll cesareans reviewed\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eManaging authority\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePublic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePrivate-for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNot-for-profit\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2016\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;275\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;568\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;209\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;409\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;45\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;127\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eProphylactic uterotonics administered after baby delivered\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eProphylactic antibiotics administered\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePartograph use among women with non-elective cesareans\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;211\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;499\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;172\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;383\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePartograph used\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePartograph not used\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePlanned elective went into labor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo information\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTime interval between decision and operation\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;148\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;130\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean (minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e310\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e210\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e277\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e202\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e441\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e308\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e289\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e232\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian (minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eType of anesthesia used\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpinal/epidural (1 case)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKetamine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo information\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eType of surgeon\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOb/gyn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral surgeon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eESO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth officer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneral practitioner\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMSC midwife\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo information\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ena\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFetal Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;275\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;566\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;209\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;409\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;125\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLive birth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStillbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeonatal death\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLive birth\u0026thinsp;+\u0026thinsp;death\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo information\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003eNote: na\u0026thinsp;=\u0026thinsp;not applicable/not included in 2008; ESO\u0026thinsp;=\u0026thinsp;emergency surgical officer; MSC\u0026thinsp;=\u0026thinsp;BSc midwife with surgical training\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e In 2008, the timing of antibiotics was not specified. In 2016, timing reflects antibiotics given either pre- or post-operatively. If no documentation of antibiotics was recorded, we assumed the woman did not receive them.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\" align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Asked of emergency cesarean deliveries only.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRobson classification \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the relative contribution of each Robson group by managing authority. In the public sector, Robson group 1 accounted for 33% of the cesareans reviewed, followed by group 8 (12%). In the for-profit hospitals, group 5 dominated (28%), followed by group 2 (17%). This aligns with the findings on indications (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e), in which \u0026ldquo;previous cesarean\u0026rdquo; was the second most frequent indication in for-profit hospitals. Forty-two percent of the reviewed cesareans from the not-for-profit hospitals were women belonging equally to groups 1 and 5. As stated earlier, about a third of the cases suffered missing information and could not be grouped.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNationally, Ethiopia exhibits a large unmet need for cesarean delivery. When disaggregated by region, CD rates ranged from 24% in Addis Ababa to under 1% in pastoralist regions. Where rates were highest, the private sectors contributed between 25 and 50% of all cesareans. Although the public sector provides the bulk of obstetric services, by 2016 more than half (54%) of all deliveries in private for-profit hospitals were cesareans. These two extremes \u0026ndash; widespread underutilization of life-saving surgical care and the overutilization of a costly procedure not without risk \u0026ndash; are faced by other low and middle income settings, and is an example of how the obstetric transition fails to follow a linear trajectory (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). Cesarean delivery rates, like the maternal mortality ratio, are also indicators for social and wealth disparities.\u003c/p\u003e\n\u003cp\u003eDespite the tripling of the overall number of hospitals between 2008 and 2016, both assessments indicated that about four out of five hospitals provided CD services (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). The lack of universal water and electricity in hospitals in 2016 may be a result of the rapid expansion in infrastructure. Hospital readiness to perform a cesarean showed signs of improvement, and a larger proportion of hospitals in 2016 met minimum staffing and equipment requirements than in 2008. One enabling factor was likely the establishment of the emergency surgical officer (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Four out of five public hospitals with CD services employed ESOs. A large push to prepare anesthetists also took place during this time period (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eChart reviews revealed how patient profiles and provider practices varied by managing authority. The for-profit and not-for-profit hospitals disproportionately attracted women with a previous CD and non-emergency cases. The case reviews also pointed to mixed results regarding the practice of evidence-based interventions. The use of partographs to monitor labor more than tripled in the public sector while they were hardly used or declined in private hospitals. Uterotonics administered after the baby was delivered and prophylactic antibiotic use were also more evident in public hospitals than elsewhere. These three interventions help prevent serious complications and all women should receive them. Thus, it is encouraging that contrary to other experiences (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e), the public sector performed as well if not better than private hospitals.\u003c/p\u003e\n\u003cp\u003eThe inclusion of the Robson classification parameters in 2016 enabled us to see clearly the perpetuation of \u0026ldquo;once a cesarean, always a cesarean,\u0026rdquo; especially among the women from the private hospitals and the contribution of group 5 to these two groups of hospitals.\u003c/p\u003e\n\u003cp\u003eTypically, groups 1, 2, 3 and 5 contribute heavily to the overall CD rate, while groups 6\u0026ndash;10 account for a smaller proportion of all cesareans. According to a WHO multi-country study from 21 countries and 287 hospitals, groups 6\u0026ndash;10 accounted for only 20% of the cesareans (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e). In our case, groups 6\u0026ndash;10 accounted for 38% of the cases. This might reflect Ethiopia\u0026rsquo;s overall low cesarean rate and that higher risk women contributed more to the pool of cesareans than in the WHO multicenter study. As the overall cesarean rate increases, the contribution of groups 6\u0026ndash;10 relative to other groups may decline. Nevertheless, the largest Robson group in the public sector was group 1, a group vulnerable to unnecessary cesarean deliveries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA strength of this paper is the richness of its data sources: two national health facility censuses that enabled comparisons between public and private sectors. Analyses drew on data from interviews with health workers, observation of infrastructure, 12 months of service statistics, and individual level data from women who had undergone a cesarean, resulting in a multifaceted overview of how the use and quality of cesarean delivery changed and suggesting some steps going forward.\u003c/p\u003e\n\u003cp\u003eAlthough each assessment was designed as a census of facilities, we know that about 15 facilities where cesarean services were provided were not eligible and therefore not visited in 2008 and at least two in 2016. These omissions affected 2008 more than 2016 and probably caused us to underestimate the 2008 population-based CD rate for Addis Ababa. However, we do not believe that their inclusion would modify our conclusions.\u003c/p\u003e\n\u003cp\u003eWe recognize that observation generally produces more accurate results than reporting, especially if recall is required. Hospital readiness depended heavily on responses from staff rather than observation, for example, whether an oxygen cylinder was both available and functional. Furthermore, readiness results will change as does the definition of the algorithm, and we encourage strengthening this definition.\u003c/p\u003e\n\u003cp\u003eData quality of the primary sources \u0026ndash; admission, operating theater and discharge logbooks \u0026ndash; is a well-recognized limitation when working with health facility data. We are not clear why an increase in missing information occurred between the two assessments, especially among the case reviews. The inability to classify a third of the cesareans reviews into one of the 10 Robson groups points to omissions in record-keeping, even though the six parameters used to group women are considered standard data points. The group that suffered the least amount of missing information (20 cases) was group 8, defined only by singleton or multiple gestation. Group 5 suffered the most from missing information: 132 of 568 cases lacked at least one of the five variables that defined group 5, with \u0026ldquo;previous cesarean\u0026rdquo; the most frequently missing.\u003c/p\u003e\n\u003cp\u003eThe case reviews were systematically selected but were technically a convenience sample, and do not represent all cesareans, especially those conducted in the private sectors where missing data tended to be higher. Similar studies have struggled with the use of non-randomly selected chart reviews but also recognized their value when presenting an overview of a single service delivery intervention (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions","content":" \u003cp\u003eDuring the 8-year interval between assessments, the government tripled the number of hospitals, raised the CD delivery rate in underserved regions, and improved both the readiness to perform obstetric operations and the quality of clinical care. The data also point to dangerously low CD rates in underserved rural areas. More equitable access to cesarean services can be achieved through strengthened referral systems, hospital maternity waiting homes and the continued expansion of facilities that fill geospatial gaps (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Meanwhile, high institutional CD rates in the private sector suggest that not all cesareans may be medically indicated. Federal normative bodies as well as professional societies should investigate local conditions to identify what is driving the demand: financial incentives on the supply side, professional inexperience with non-routine vaginal births, or other forces. The use of the Robson classification would be a useful tool for future quality improvement efforts \u0026ndash; to ensure that the right women are receiving this procedure while others are protected from unnecessary procedures.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eCD\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eCesarean Delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eEmONC \u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eEmergency Obstetric and Newborn Care\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eESOs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eEmergency Surgical Officers\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eHR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eHuman Resources\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eob/gyn \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eObstetrician/Gynaecologist\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eOT \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eOperating Theatre\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eWHO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"255\"\u003e\n\u003cp\u003eWorld Health Organization\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper is the result of secondary data analysis of two national assessments. We received permission to access and use the data from the Ethiopian Public Health Institute and the Family Health Division of the Federal Ministry of Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed for this study are available from the Ethiopian Public Health Institute Director on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors has any competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Bill and Melinda Gates Foundation provided initial support to all of the authors. But the Foundation did not influence the writing process or substantive content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMGB took the lead on conceptualizing the paper and writing the first draft. TGZ, AH, ALR and PB reviewed and revised. TGZ and PB did the statistical analyses.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank EPHI and the Ministry of Health for their sharing of the datasets. In addition, we thank the Bill and Melinda Gates Foundation and \u003ca href=\"https://www.publichealth.columbia.edu/research/averting-maternal-death-and-disability-amdd\"\u003eAverting Maternal Death and Disability \u003c/a\u003efor their support of the paper writing workshop.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMiller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comand\u0026eacute; D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388(10056):2176\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eBetran AP, Torloni MR, Zhang J, Ye J, Mikolajczyk R, Deneux-Tharaux C, et al. What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reprod Health. 2015;12(1).\u003c/li\u003e\n\u003cli\u003eMolina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA - J Am Med Assoc. 2015;314(21):2263\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eAppropriate Technology for Birth. Lancet [Internet]. 1985 Aug 24 [cited 2019 Dec 24];326(8452):436\u0026ndash;7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673685927503\u003c/li\u003e\n\u003cli\u003eYe J, Betr\u0026aacute;n AP ila., Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41(3):237\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization Human Reproduction Programme 10 April 2015. WHO Statement on caesarean section rates. Reprod Health Matters [Internet]. 2015;23(45):149\u0026ndash;50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26278843\u003c/li\u003e\n\u003cli\u003eRijken MJ, Meguid T, Van Den Akker T, Van Roosmalen J, Stekelenburg J. Global surgery and the dilemma for obstetricians. Lancet [Internet]. 2015;386(10007):1941\u0026ndash;2. Available from: http://dx.doi.org/10.1016/S0140-6736(15)00828-4\u003c/li\u003e\n\u003cli\u003eWright J, Ayenachew F, Ballard KD. The changing face of obstetric fistula surgery in Ethiopia. Int J Womens Health. 2016;8:243\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eBeliz\u0026aacute;n JM, Althabe F, Cafferata ML. Health consequences of the increasing caesarean section rates. Epidemiology. 2007;18(4):485\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eH\u0026auml;ger RME, Daltveit AK, Hofoss D, Nilsen ST, Kolaas T, \u0026Oslash;ian P, et al. Complications of cesarean deliveries: Rates and risk factors. Am J Obstet Gynecol. 2004;190(2):428\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eDelport S. Global epidemiology of use of and disparities in caesarean sections. Lancet [Internet]. 2019;394(10192):23\u0026ndash;4. Available from: http://dx.doi.org/10.1016/S0140-6736(19)30717-2\u003c/li\u003e\n\u003cli\u003eBetr\u0026aacute;n AP, Ye J, Moller AB, Zhang J, G\u0026uuml;lmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990-2014. PLoS One. 2016;11(2):1\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eCentral Statistical Agency and ICF. Ethiopia Demographic and Health Survey. 2016.\u003c/li\u003e\n\u003cli\u003eGebremedhin S. Trend and socio-demographic differentials of Caesarean section rate in Addis Ababa, Ethiopia: Analysis based on Ethiopia demographic and health surveys data. Reprod Health [Internet]. 2014;11(1):1\u0026ndash;6. Available from: Reproductive Health\u003c/li\u003e\n\u003cli\u003eWHO. WHO | Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Who [Internet]. 2014;(August 2013):914\u0026ndash;22. Available from: http://www.who.int/bulletin/volumes/91/12/13-117598/en/\u003c/li\u003e\n\u003cli\u003eEthiopian Federal Ministry of Health. Health Sector Transformation Plan (2015/16-2019/20). Vol. 20. 2015.\u003c/li\u003e\n\u003cli\u003eMinistry F. National Baseline Assessment for Emergency Obstetric \u0026amp; Newborn Care. 2008;\u003c/li\u003e\n\u003cli\u003eFMOH of Ethiopia EPHI and AMDD. ETHIOPIAN Emergency Obstetric and Newborn Care (EmONC) Assessment 2016. 2016;1\u0026ndash;456.\u003c/li\u003e\n\u003cli\u003eAMDD. Averting Maternal Death and Disability (AMDD) Toolkit 2016 [cited 2016 15 November].Available from: https://www.mailman.columbia.edu/research/averting-maternal-death-and-disability-amdd/toolkit.\u003c/li\u003e\n\u003cli\u003eKeyes EB, Haile-Mariam A, Belayneh NT, Gobezie WA, Pearson L, Abdullah M, et al. Ethiopia\u0026rsquo;s assessment of emergency obstetric and newborn care: Setting the gold standard for national facility-based assessments. Int J Gynecol Obstet. 2011;115(1):94\u0026ndash;100.\u003c/li\u003e\n\u003cli\u003eEMoH. Health Sector Development Program: 2010/11 -2014/15 [Internet]. Vol. IV, Federal Democratic Republic of Ethiopia Ministry of Health. 2010. Available from: http://phe-ethiopia.org/admin/uploads/attachment-721-HSDP IV Final Draft 11Octoberr 2010.pdf\u003c/li\u003e\n\u003cli\u003eMinistry of Health Ethiopia, PMNCH, World Health Organization, World Bank, AHPSR. Success Factors for Women\u0026rsquo;s and Children\u0026rsquo;s Health Ethiopia. 2015;28.\u003c/li\u003e\n\u003cli\u003eHealth FM of. Health and Health Related Indicators \u0026ndash; 2012/2013. Planning and Programming Department: 2014. 2014;\u003c/li\u003e\n\u003cli\u003eRobson M. Classification of caesarean sections. Fetal Matern Med Rev [Internet]. 2001 Feb 17 [cited 2019 Dec 24];12(1):23\u0026ndash;39. Available from: https://www.cambridge.org/core/product/identifier/S0965539501000122/type/journal_article\u003c/li\u003e\n\u003cli\u003eVogel JP, Betr\u0026aacute;n AP, Vindevoghel N, Souza JP, Torloni MR, Zhang J, et al. Use of the robson classification to assess caesarean section trends in 21 countries: A secondary analysis of two WHO multicountry surveys. Lancet Glob Heal. 2015;3(5):e260\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eSouza J, Tun\u0026ccedil;alp \u0026Ouml;, Vogel J, Bohren M, Widmer M, Oladapo O, et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG An Int J Obstet Gynaecol. 2014;121:1\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eKruk ME, Leslie HH, Verguet S, Mbaruku GM, Adanu RMK, Langer A. Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. Lancet Glob Heal. 2016;4(11):e845\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eBetran AP, Gulmezoglu AM, Robson M, Merialdi M, Souza JP, Wojdyla D, et al. WHO global survey on maternal and perinatal health in Latin America: Classifying caesarean sections. Reprod Health. 2009;6(1):4\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eKim YM, Tappis H, Zainullah P, Ansari N, Evans C, Bartlett L, et al. Quality of caesarean delivery services and documentation in first-line referral facilities in Afghanistan: A chart review. BMC Pregnancy Childbirth [Internet]. 2012;12(1):14. Available from: http://www.biomedcentral.com/1471-2393/12/14\u003c/li\u003e\n\u003cli\u003eFesseha N, Getachew A, Hiluf M, Gebrehiwot Y, Bailey P. A national review of cesarean delivery in Ethiopia. Int J Gynecol Obstet [Internet]. 2011;115(1):106\u0026ndash;11. Available from: http://dx.doi.org/10.1016/j.ijgo.2011.07.011\u003c/li\u003e\n\u003cli\u003eTiruneh GT, Getu YN, Abdukie MA, Eba GG, Keyes E, Bailey PE. Distribution of maternity waiting homes and their correlation with perinatal mortality and direct obstetric complication rates in Ethiopia. BMC Pregnancy Childbirth. 2019;19(1):1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eBailey PE, Keyes EB, Parker C, Abdullah M, Kebede H, Freedman L. Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia. Int J Gynecol Obstet. 2011;115(3):300\u0026ndash;9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"CD rates, readiness, Robson, public/private sector","lastPublishedDoi":"10.21203/rs.3.rs-103142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-103142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Cesarean delivery (CD) rates have reached epidemic levels in many high and middle income countries while increasingly, low income countries are challenged both by high urban CD rates and high unmet need in rural areas. The managing authority of health care institutions often plays a role in these disparities. This paper shows changes between 2008 and 2016 in CD rates and the capacity of the Ethiopian health system to deliver quality CD services, highlighting the role of the management sector.\u003c/p\u003e\u003cp\u003eMethods: We compare results from two national cross-sectional emergency obstetric and newborn care assessments using descriptive statistics. The sample includes 111 hospitals in 2008 and 316 hospitals in 2016, and 275 CD case reviews in 2008 and 568 in 2016. Our primary outcome measures include population- and institutional-based CD rates; hospital readiness to perform CD; quality of clinical management; and the relative size of Robson classification groups\u003c/p\u003e\u003cp\u003eResults: The national population-based rate increased (\u0026lt; 1% to 2.7%) as did all regional rates. Rates ranged from 24% in urban settings to less than 1% in several rural regions. The institutional rate was 54% in the private for-profit sector in 2016, up from 46% in 2008. \u0026nbsp;Hospital readiness to perform CDs increased in public and for-profit hospitals.\u0026nbsp;Only half of the women whose cases were reviewed received uterotonics after delivery of the baby, but use of prophylactic antibiotics was high. Partograph use increased from 9% to 42% in public hospitals, but was negligible or declined elsewhere. In 2016, a third of case reviews from the public sector were among low-risk nulliparous women (Robson group 1).\u003c/p\u003e\u003cp\u003eConclusions: Between 2008 and 2016, government increased the availability of CD services, improved public hospital readiness and some aspects of clinical quality.\u0026nbsp;Strategies tailored to further reduce the high unmet need for CD and what appears to be an increasing number of unnecessary cesareans are discussed. Adherence to best practices and universal coverage of water and electricity will improve the quality of hospital services while the use of the Robson classification system may serve as a useful quality improvement tool.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Use and Quality of Cesarean Delivery in a Low and Middle Income Setting: National Results from Two Emergency Obstetric and Newborn Care Assessments","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-11-09 23:47:47","doi":"10.21203/rs.3.rs-103142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-04-06T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-05T00:00:00+00:00","index":3,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nPEER REVIEWER ASSESSMENTS:\n\nOBJECTIVE - Full research articles: is there a clear objective that addresses a testable research question(s) (brief or other article types: is there a clear objective)?\nYes - there is a clear objective\n\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\nYes - the approach is appropriate\n\nEXECUTION - Are the experiments and analyses performed with technical rigor to allow confidence in the results?\nNo - there are minor issues\n\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\nYes - appropriate statistical analyses have been used in the study\n\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\nYes - the author's interpretation is reasonable\n\nOVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically sound? If not, can revisions be made to make the work technically sound?\nProbably - with minor revisions\n\nPEER REVIEWER COMMENTS:\n\nGENERAL COMMENTS:\nThis is a paper of high public health significance. This authors presented a broad overview of changes in the healthcare service coverage and quality of CD, with a focus on differences across public and private sectors. We describe changes in national and regional CD rates; institutional rates; the readiness of hospitals to provide obstetric surgery; and the quality of CD services.\nIn my opinion, the manuscript was well articulated in all aspects.\n\nREQUESTED REVISIONS:\nI only have few comments\n1. Abstract why use the world \"epidemic\"? Is it appropriate?\n2. How did you arrive at population-based estimates….your data was from institutions\n3. Recast \"In 2015, backed by evidence that rates greater than 10% were not…….\"\n4. Page 3 paragraph 2, why did you described the SSA progress as slow? Could you provide a comparative global as well as highly-developed countries statistics?\n5. Page 4 : In 2008\n6. \"Data collectors identified three women per hospital and in 2016 only two cases per hospital were\n7. selected because of the increase in the number of hospitals\"….which sampling methods was used to select 3 / 2 from each hospitals?\n8. L53 I do not agree strongly with ther term \"population-based\"…It appears inappropriate\n9. L56 Why use \"expected births in each region,\"since your study is secondary….why ndont you use numbers of all births in those years/region?\n10. The method section is mixed with introduction and discussion. For example : what is the role of \"Overuse of CD among these women sets up a domino effect that contributes to repeated cesareans.\" In the methods?\n11. Table 3, 4 \u0026 5: Remove all % signs from the table and rather indicate them in the column titles.\n12. Table 3, 4 \u0026 5: Statistically, all the 0% may be as a result of incorrect approximation. You should use at least one decimal point. That will allow readers and Ethiopian policy makers to know whether the rates are very low or non-existing…..\n13. Figure 1: include private for the profit and not for profit in the legend\n14. A major limitation of the study is non-availability of certain indicators in 2008. This must be stated and discussed.\n15. The authors should make a statement on the generalizability of the study for all the health institutions in Ethiopia\nADDITIONAL REQUESTS/SUGGESTIONS:\nnil* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-12-01T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nGeneral comments:\n\nThe reviewer would like to thank for the opportunity to review this important, very interesting, and generally well written manuscript, and apologize for the 4 days' postponement of the review deadline. The study subject is highly relevant in regard to \"too little too late and too much too soon.\" The study results and discussion shed an important a light on the under- and overuse of CD in Ethiopia as well as disparities in the access to evidence-based childbirth care in a low- and middle income setting. The approach used, describing data by region and type of service provider, gives an opportunity for analysis on either end of the spectrum, both of which can negatively impact women's and children's health and wellbeing. In a setting with limited resources, providing CD services to those who do not need them can literally be the cause of needs not being met in other regions and/or social groups.\n\nThe rationale for the study and its intended actions are described, but its aim, purpose and/or research questions are not clearly presented. The scope of the study is very extensive and its data sources and analysis diverse. This raises the question whether the subject would be better done justice in more than one publication, where descriptions of methods can be more extensive. If the authors choose to present this extensive study in one manuscript, a clear structure and consistency throughout the manuscript is of the essence, beginning with a clearly presented aim(s) and/or research question(s).\n\nThe text generally flows well, apart from structure and terminology issues, and is easily read by this non-native English speaking reviewer. The reviewer recommends the following revisions:\n\n\nAbstract:\n\nThe abstract is generally well written and representative of the article.\n\nP2L8 Suggest clarifying a little earlier in sentence that the study is on Ethiopian data (not low/middle income country countries' data in general): \"This paper shows changes between 2008 and 2016 in Ethiopian CD rates…\"\n\nP2L13 Please state the study design more clearly (see notes in methods section).\n\nP2L16-18 The primary outcome measures of the study are clearly stated in these lines. Suggest this be the guiding light when presenting aim(s) and/or research question(s) and structuring the methods, results and discussions sections (see notes in these sections on structure, clarity and consistent terminology).\n\nResults section of abstract: see notes on proposed summary paragraph at the beginning of discussions, which could also be useful here.\n\nP2L21 Suggest clarification: \"The national population-based rate increased from 2008 to 2016 (\u003c 1% to 2.7%) as did all regional rates.\"\n\n\nKeywords:\n\nKeywords are representative of the subject. Suggest adding terms describing over- and underuse and using keywords from a recognized thesaurus, if possible (e.g. MeSH database (PubMed) or Cinahl Boolean phrases (CINAHL)).\n\n\nBackground:\n\nP3L2-15 Suggest editing so that you are stating more concisely and clearly your general point in this paragraph, i.e. that while low CD rates are indicative of detrimentally insufficient access to care, rates higher that 10% indicate detrimental overuse of CD.\n\nSuggest adding, either here or in the discussion section, text on how while it is extremely important that low income regions improve availability of quality CD care and general coverage, presumably elevating CD rates, it is also important that low income regions use the valuable opportunity they have to learn from high income regions' mistakes in overusing CD. E.g. that it is important that the Ethiopian health sector avoids largely overshooting their 8% target when improving access to CD.\n\nPlease add at the end of the background section a clearly defined aim/purpose/objective of this secondary analysis study and what the study adds to previous knowledge on the subject (please use the words aim(s), purpose and/or objective(s) to guide the reader to this). Presenting a defined research question(s) might aid in focusing the aim(s) of the study.\n\n\nMethods:\n\nThe methods section needs clearer structure. A more clearly structured aim(s) or question(s) would help putting the study and its variables in context and present a more comprehensive picture of the study, i.e. this question was answered by analyzing these variables in this context… et.c.\n\nP3L47-50 Please state the study design more clearly, i.e. a national cross-sectional descriptive study which is a secondary data analysis of…\n\nP4L21 Please add text on the study definition of \"comprehensive emergency obstetric care.\"\n\nPlease state more clearly whether you are defining your study population as a national population or a sample (is presently only discussed in the context of data analysis).\n\nPlease add text, either in methods or results, on the N for individual women of this national study and how it is defined. This information does not appear in the methods section (only N of health facilities) and only appears in tables in the results section. Please also add in text the n for individual women in the study on facilities' CD rates.\n\nSuggest moving the stratifying variable description to the front of the variable section, since this variable seems to fit the role of control variable.\n\nP4L54-58 Please add rationale for using expected births rather than total number of births (which presumably were available to calculate the birth rate, which was available) as the denominator for population-based CD rates.\n\nP5L53-4 Please add permission numbers, if available.\n\n\nResults:\n\nIn the results section the structure of the study starts to emerge more clearly than in the methods section, although not fully in accordance with the abstract regarding terminology. Please coordinate so that the same topics/topic headings are described and listed in the same order in abstract, aim(s)/research question(s), methods section and results section. A clear and consistent structure is essential for the reader of a study with such a wide and diverse spectrum of descriptive analysis.\n\nFor all tables: Please be more precise in table titles so they will be able to stand on their own, outside the text of the manuscript. E.g. add reference to Ethiopia.\n\nP8L27 Please describe briefly the role and qualifications of the ESOs, since the use of this term seems to be largely confined to Ethiopia/Africa and less familiar to other international audience.\n\nP8L41 The term \"algorithm\" can indeed be used broadly to describe a procedure to solve a problem, but is mostly used in the field of mathematics and computer science. Suggest using another term. The terminology used in table 3, \"Met readiness requirements\" is more descriptive.\n\nSuggest going through the text and revising the use of the values/value names of the stratification variable. Sometimes information is presented on two values instead of three and other terms are used than in the methods section. Please write the variable names out in full or explain abbreviated versions when they appear, to avoid confusion. For example, when using the term \"not-for-profit\" without a \"private\" precursor it is unclear whether this is an abbreviation of \"private not-for-profit\" or a group term for \"private not-for-profit and public\", since both are not-for-profit (the reader should preferably not have to compare text and tables to grasp the meaning of the terms used in text).\n\nP10L9 Please revise: \"… more than 75% of women who had a CD had an emergency cesarean.\"\n\nP10L10 Please revise: \"Emergency cesareans as a proportion of all CD's were least frequent in the private for-profit settings.\" Unrevised this sentence seems to state that ECD's were less frequent in this setting than in others when presumably this is not the case (according to table 2 and figure 1).\n\nP10L20 In table title, suggest \"… according to type and indication…\" in line with the content of the table.\n\nP11L6 Suggest for clarification: \"Information related to the quality of clinical care in CD's is found in Table 5.\"\n\nResults presented in Table 5 are repeated to a higher degree in text that results from other tables. Suggest revising and reducing the text, creating space for additions from reviewers' other suggestions.\n\nP13L1 Add to sentence \"… relative contribution of each Robson group to all CD's…\" or similar, for clarification.\n\nOtherwise, the results chapter and accompanying tables were easily read and understood.\n\n\nDiscussion:\n\nParts of the first and second paragraphs summarize results, intertwined with discussion. Suggest that the first paragraph of the discussion section presents a concise summary of the main results before proceeding to putting the results into context and discussing implications. Suggest including text in this summary paragraph on: range of national rates in 2008 and 2016, mention rural vs urban; range of hospital rates in 2008 and 2016, mention for profit standing out; overall readiness rates rising between 2008 and 2016; high elective CD rates in for-profit hospitals; for-profit hospitals standing out regarding partograph use; and relative size of groups 2 and 5 in for-profit hospitals.\n\nP14P24-5 Please revise: \"These three interventions can help prevent serious complications in the presence of interventions and complications and all women having a CD should receive them.\"\n\nP14L35-6 All groups except group 4 are discussed as largely or minimally contributing to CD rates. Please also discuss where group 4 lies on this spectrum.\n\nP14L58 Suggest that the reason for facilities not being eligible for census be described in either methods or discussions.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-11-10T00:00:00+00:00","index":3,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-11-06T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-06T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nThe authors have performed the recommended revisions, the manuscript is now appropriate for publication.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. 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