Journal Pone 0282951

PLOS ONE
RESEARCH ARTICLE
Trend and associated factors of cesarean

section rate in Ethiopia: Evidence from 2000–
2019 Ethiopia demographic and health survey
data
Rahel Mezemir ID1,2*, Oladapo Olayemi3, Yadeta Dessie4
1 Pan African University, Life and Earth Sciences Institute (Including Health and Agriculture), Ibadan, Nigeria,
2 St. Paul’s Hospital Millennium Medical College, School of Nursing, Addis Ababa, Ethiopia, 3 Department of
Obstetrics and Gynaecology, College of Medicine, Pan African University Life and Earth Sciences Institutes,
a1111111111 University of Ibadan, Ibadan, Nigeria, 4 College of Health and Medical Sciences Haramaya University, Harar,
a1111111111 Ethiopia
a1111111111
a1111111111 * rahelmezemir7@gmail.com, rahel.mezemir@sphmmc.edu.et
a1111111111
Abstract
OPEN ACCESS
Background
Citation: Mezemir R, Olayemi O, Dessie Y (2023)
Trend and associated factors of cesarean section The world health organization considers cesarean section (CS) prevalence of less than 5%
rate in Ethiopia: Evidence from 2000–2019 Ethiopia suggests an unmet need. On the other hand, a prevalence of more than 15% may pose to
demographic and health survey data. PLoS ONE
risk to mother and child, however, access to CS in a resource-limited country like Ethiopia
18(3): e0282951. https://doi.org/10.1371/journal.
pone.0282951 was much lower than the aforementioned level, Therefore, this was the first study to deter-
mine the trend of CS, and factors that influence it.
Editor: Temesgen Muche Ewunie, Dilla University,
ETHIOPIA
Received: March 17, 2022

Methods
Accepted: February 28, 2023
This was done based on the five Ethiopia Demographic and Health Surveys. Trend analysis
was done separately for rural and urban. The significance of the trend was assessed using
Published: March 16, 2023
the Extended Mantel-Haenszel chi-square test. The factors on CS delivery were identified
Peer Review History: PLOS recognizes the based on DHS 2016 data. A multi-level logistic regression analysis technique was used to
benefits of transparency in the peer review
process; therefore, we enable the publication of
identify the factors associated with cesarean section delivery. The analysis was adjusted for
all of the content of peer review and author the different individual- and community-level factors affecting cesarean section delivery.
responses alongside final, published articles. The Data analysis was conducted using STATA 14.1 software.
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0282951
Result
Copyright: © 2023 Mezemir et al. This is an open
access article distributed under the terms of the The rate of cesarean section increased from 5.1% in 1995 to 16% in 2019 in an urban area
Creative Commons Attribution License, which and 0.001 in 1995 to 3% in a rural area, the overall increment of CS rate was 0.7% in 1995
permits unrestricted use, distribution, and
to 2019 at 6%. The odds of cesarean section were higher among 25–34 years (AOR = 2.79;
reproduction in any medium, provided the original
author and source are credited. 95% CI: 1.92, 4.07) and 34–49 years (AOR = 5.23;95% CI: 2.85,9.59), among those edu-
cated at primary school level (AOR = 1.94; 95% CI: 1.23,3.11), secondary education
Data Availability Statement: All datasets and
material used in the present study that support the (AOR = 2.01; 95% CI: 1.17, 3.56) and higher education (AOR = 4.12; 95% CI: 2.33–7.29)
findings are available in the paper. with multiple pregnancies (AOR = 11.12; 95% CI: 5.37, 23.), with obesity (AOR = 1.73; 95%
PLOS ONE | https://doi.org/10.1371/journal.pone.0282951 March 16, 2023 1 / 17

PLOS ONE Trend and associated factors of cesarean section rate in Ethiopia: Evidence from EDHS
Funding: The authors received no specific funding CI: 1.22, 2.45), living in an urban area (AOR = 2.28; /95% CI: 1.35–3.88), and increased
for this work. with the number of ANC visit of 1–3 and 4th(AOR = 2.26; 95% CI: 1.12, 4.58), (AOR = 3.34;
Competing interests: The authors have declared 95% CI: 1.12, 4.58), respectively. The odds of cesarean section are lower among parity of
that no competing interests exist. 2–4 children (AOR = 0.54; 95% CI: 0 .37, 0.80) and greater than four birth order (AOR =
Abbreviations: AOR, Adjusted Odds Ratio; CI, 0.42;95% CI: 0.21,0.84).
Confidence Interval; CS, Caesarian Section; EDHS,
Ethiopia Demographic and Health Survey; EOC,
emergency and obstetric care; ICC, Intra Class Conclusion
Correlation Coefficient; LLR, Log-Likelihood Ratio;
In Ethiopia, the CS rate is below the WHO recommended level in both urban and rural
MOR, Median odds ratio; OBGY, obstetrics and
gynecology; OR, Odds Ratio; PVC, Proportional areas, thus, intervention efforts need to be prioritized for women living in a rural area,
Change in Variance; SNNPR, Southern Nations, empowering women’s education, encouraging co-services such as ANC usage could all
Nationalities, and Peoples’ Region.
help to address the current problem.
Introduction
In obstetrical care, Cesarean section (CS) is the most routinely performed surgery, it is the
delivery of a fetus through a surgical incision in a pregnantwomen’s abdominal wall and uter-
ine wall. It is commonly done for maternal or fetal reasons to avert maternal and neonatal
morbidity and mortality rate [1]. Globally, the use of CS among delivery women have continu-
ously increased, and it is predicted to continue to rise over the next decade, in both developed
and developing countries [2] although the availability of safe CS in the resource-limited coun-
try is still much lower [3]. Recent data from 154 countries show that the global average CS rate
of 21.1%, with averages of 8.2% at least, 24.2% in less, and 27.2% in more developed countries.
Sub-Saharan Africa has the lowest rates (5.0 percent, 39 nations, 88.6 percent birth coverage),
while, Latin America and the Caribbean have the highest rates (42.8 percent, 23 countries, 91.2
percent birth coverage [3]. The world health organization considers (CS) prevalence of less
than 5% suggests an unmet need. On the other hand, a prevalence of more than 15% may pose
to risk to mother and child [4]. Reports from the population-based study also support this
finding CS rates greater than roughly 10% in the population are not associated with lower
maternal and neonatal mortality rates [5]. Another ecological study finds a negative and statis-
tically significant linear correlation between CS rate (the number of CS deliveries per 100
births) and neonatal mortality [6]. Despite all of these facts, in the recent years, the medically
non-indicted CS section is significantly practiced [7]. Evidence from the WHO survey shows
this worldwide increase in medically non-indicated CS can have a substantial impact on awo-
men’s health and medical costs, like, increased rate of infection, longer healing time, signifi-
cant bleeding, increased iatrogenic injury, increased breathing difficulties, and even death [8,
9]. Similarly, a multi-country facility-based survey came to the same conclusion [2]. Several
studies show that medically and non-medically indicated factors including the type of health
institution, socio-demographic characteristics, and maternal health of women, have been
linked to an increase in CS. Some of these factors are the mother’s age, birth order, place of res-
idence, socioeconomic status, maternal educational level, previous CS, obstetric problems,
maternal request, and income level [9–11]. These variables also differ depending on the popu-
lation [12]. In Ethiopia, research from the available resource on the prevalence of CS indicates
a figure well below the WHO’s recommended threshold of 10% [4]. Furthermore, for numer-
ous years, there has been no notable increase in the country’s population-based CS rates. for
example, in the 2016 and 2000 Ethiopia Demographic and Health Surveys (EDHS), national

CS rates were found to be very low (1.9 percent and 0.7 percent, respectively) [13, 14]. This fig-
ure is lower than that of several African countries, including Ghana (13% in 2014) [15], Nigeria
(2.1% in 2013) [16], and Mozambique (4.7 in 2014) [17]. The relatively low prevalence of CS in
the Ethiopian population reflects unmet demands, which may contribute to the country’s poor
maternal and newborn outcomes [18]. Evidence from hospital-based and population-based
cross-sectional studies in Ethiopia shows, delivery by CS most common in women aged 35–49,
first-parity births, births for which women had more than three Antenatal Care (ANC) visits,
births in urban areas, higher education, and higher economic status (15%) [10, 19, 20]. In Ethi-
opia, most study on CS section was hospital base data, this type of data was most of time used
small sample size and also subject to selection bias. Few studies were used population based
data, however, the studies had the some limitation, for instance, the study was not used higher
statistical software for analysis like multilevel analysis, which used to identify individual and
community level factors.
Using a nationally representative sample has several advantages over other institutional
sample data in terms of calculating the compiled trend to highlight national-level characteris-
tics, which could lead to policy decisions at the national level. Therefore, the present study
used to assess the trend of CS in the urban and rural area factors that influencing it.
Methods and material

Study setting
The study was done in Ethiopia. Ethiopia is a multi-ethnic country in east Africa with a diverse
population. It is bordered on the west by Sudan, on the east by Somalia and Djibouti, on the
north by Eritrea, and the south by Kenya. The country has a total area of 1,112,000 square
kilometers
Ethiopia is divided into eleven regions and two municipal governments. Tigray, Afar,
Amhara, Oromiya, Somali, Benishangul-Gumuz, Southern Nations Nationalities and People
(SNNP), Gambela, Sidama, South Western, and Harari are among the regions involved. Addis
Ababa and Dire Dawa are administrative cities [21]. According to the EDHS 2016 and 2011,
the prevalence of CS in Ethiopia was 1.9% [13] and 0.7% [22], respectively [13, 22].
Study design
The research was based on secondary data from the EDHS. Factors associated with CS were
identified using EDHS 2016 data, whereas trend analysis was done using EDHS 2000, 2005,
2011, 2016, and 2019 (mini EDHS) data. Since EDHS collected data about births in the previ-
ous 5 years, the data indicated CS from 1995 to 2019 [13].
Sample size and sampling methods

All EDHS surveys used a sample that was aimed to represent all of the country’s regions and
administrative cities. The survey participants were chosen using a two-stage stratified sampling
technique. The first stage was a selection of the enumeration areas. The enumeration areas
were stratified into urban and rural. In the second stage, households in the selected enumera-
tion area were selected. The sample size was then allocated using a probability-proportional
allocation method. 645 enumeration areas (EAs) were chosen for the 2016 DHS. There were
202 EAs from urban regions and 443 from rural areas. Six hundred twenty-four EAs were
included in the 2011 DHHS (187 from urban regions and 437 from rural areas) [13]. The 2005
EDHS had 540 EAs (145 from urban areas and 395 from rural areas), while the 2000 DHS
included 539 EAs (138 from urban and 401 from rural) [14, 22]. Then, on average 27 to 32

households per EA were selected from all surveys. The source population was all live births
from reproductive-age women within 5 years before the survey in Ethiopia. A total weighted
sample of 46,317 live births (12,260 in EDHS 2000, 11,163 in EDHS 2005, 11,872 in EDHS
2011, and 11,022 in EDHS 2016) was used for analysis. Detailed sampling procedure can be
found from the EDHS [13, 14, 22, 23].
Data collection
Five interviewer-administered questions were used by the EDHS: the household questionnaire,
thewomen questionnaire, the men questionnaire, the biomarker questionnaire, and the health
facility questionnaire [4, 14, 22, 23]. Data was collected for this study from children under the
age of five surveys, born to interviewed mothers who gave birth within five years of the survey
year 1995–2016, which was included in the kid records. The data collection tool was created in
English initially, then translated into the country’s three main languages: Amharic, Oromiffa,
and Tigrigna. The Somaligna and Afarigna languages were also used in the 2000 DHS [4, 22].
Variable of study
Outcome variable. The outcome variable in this study is the CS which was taken dichoto-
mous and coded by the value “1” (one) if the respondents underwent cesarean delivery and “0”
(zero) if not.
Independent variable. There were three categories of independent variables; institution-
related, socio-demographic and economic factors, and pregnancy-related factors. Institutional
factors include the place of delivery (public vs private), the number of antenatal care visits (no
visit, 1–3 and >4), pregnancy-related factors including parity (Primi-parous, multi-parous,
and Grand-multi-parous), birth order (first, second, third or higher), maternal, body–mass
index (normal, underweight and overweight), Size of the baby was determined from the mater-
nal recall of baby’s weight at birth (very large, average, smaller than the average), socio-demo-
graphic and economic factors consist of maternal education, maternal age at birth, marital
status, mothers’ employment status (yes/no), wealth index (poor, middle, rich), residences,
and region.
Statistical analysis. Completed EDHS questionnaires were meticulously tagged, entered,
and modified after data collection The distribution of study participants in the sample was
weighted to create nationally representative data [22]. STATA software version 14 was used to
analyze the data. Frequency and percentage were utilized as descriptive statistics. Using chi-
square analysis, the CS rate was compared across several socio-economic, maternal, and child
characteristics. The DHS surveys gathered information on the mode of delivery of birth within
the previous five years. The rate was calculated for each year between 1995 and 2019 based on
the specific year of delivery, 2019 mini DHS data was included for the trend analysis, however,
for determinate factors, the data was not completed.
The Extended Mantel-Haenszel chi-square test for linear trend was used to examine the sig-
nificance of the trend of the CS rate using the OpenEpi software (Version 3.01) dose-response
program [24]. A 95% significant probability of the existence of a trend was declared when the
p-value was less than 0.05. Further, the change in trend CS rate is presented in two ways, Abso-
lute increase of CS rate and relative increase as the average annual rate of increase (AARI), to
find the absolute change increase, subtract the latest CS rate from the earliest CS rate and to
find an average annual rate of increase, AARI = [(an / am) [1 / (n-m)]]-1; where am; is the first
observation of CS rate, and; is the latest observation of CS rate, m is the first observed year and
n is the latest observed year. The AARI is a geometric progression ratio that provides a con-
stant rate of change during the study period [3].

To identify factors associated with CS delivery, a Multi-level logistic regression analysis

technique was applied, since the data had hierarchical and clustering nature.
A total of four models were carried out. The first model was an empty model that was used
to calculate the random variability in the intercept. The second model estimated the influence
of individual-level factors on CS delivery. The third model looked at how community-level fac-
tors are associated with CS delivery. Finally, the fourth model computed the influence of indi-
vidual and community-level factors on cesarean delivery. The Intra-Cluster Correlation (ICC)
was determined to illustrate the correlation between clusters within a model, and the intra-
cluster correlation (ICC) is expected to be � 10% when using this model. The power of vari-
ables included in each model in predicting CS delivery was also determined using the Propor-
tional Change in Variance (PCV). To determine the factors that associated with cesarean
section, the model with the highest PCV value was used. Significant factors were considered as
variables with a p-value less than 0.05.
Ethical consideration. All Ethiopian Demographic and Health Surveys obtained ethical
approval from the Ethiopian Health and Nutrition Research Institute Review Board, the Min-
istry of Science and Technology, ICF International’s Institutional Review Board, and the CDC.
Data was collected after informed consent was obtained, and all information was kept private.
After reviewing the brief descriptions of the study provided to the DHS program, the Demo-
graphic, and Health Surveys Program granted authorization to access EDHS data for this spe-
cific research. The data sets were handled with the utmost confidentiality [13].
Result
Socio-demographic and economic characteristics of the study population
In the four EDHS, information on cesarean Section deliveries were collected from 46,316
women who had given birth in the five years before the survey period. The median ages
(+IQR) of women in the four surveys were similar with the most recent (2016 DHS) being
26.1 + 9 years. In all four surveys, three -fourth of live birth were from rural areas, the latest
report (2016 DHS) was 88.8% and most of the live births were from the Oromia region. On the
other hand, the percentage of women having primary education increased slightly from 13%
in 2000 to 26.8% in 2016. In all four surveys, the majority of women were married (Table 1).
Child characteristics and maternal health service usage

The median BMI of women were similar across the four surveys, the recent one (DHS 2016)
was 21.1kg/m2 with a range between 53.6 kg/m2 and 12.3kg/m2. Almost one-fifth of women
had one to three parity across the four surveys, the highest was in (DHS2011), 44.6%. Further-
more, of all live birth born from the interviewed women, more than half of them were single
birth across four surveys. Among the birth order, fourth or higher-order births accounted for
about half of all births (51.1%). The percentage of women giving birth at home decreased from
94.9% (in the first survey) to 72.2% (in the fourth survey). The percentage of women who had
one to four ANC visits increased from 16.4% in 2000 to 30.9% in 2016 (Table 2).
The magnitude of the cesarean section rate

CS rate in the urban area was (5.1% in 2000, 9.4% in 2005), and 10.6% (in 2016). Furthermore,
in all four survey years, the percentage of CS among women of overweight (from 7.6% in 2000
to 7.8% in 2016) with women of > 5 parity (from 0.1% in 2000 to 0.4% in 2016). The number
of ANC visits > 4 (from 1.8% in 2000 to 7.5% in 2016) (Table 3). The rate of CS delivery
among women in the age group of 25–34 and 35–49 years (0.3% in 2000 to 1.9 in 2016 and 0.1

Table 1. Sociodemographic and economic characteristics of the study population, finding from 2000 to 2016 DHS.
Variable Category Live birth in 2000DHS Live birth in 2005DHS Live birth in 2011DHS Live birth in 2016DHS
(n = 12,260) (n = 11,163) (n = 11,872) (n = 11,022)
(%) (%) (%) (%)
Mother’s age at birth Median 26 ±10 26 ±10 26±9 26±9
+IQR
Regions/ Tigray 788(6.4) 698 (6.3) 753 (6.3) 716 (6.5)
administrations Afar 126(1.0) 107 (1.0) 121 (1.0) 114 (1.0)
Amhara 3202(26.2) 2621 (23.5) 2656 (22.4) 2072 (18.8)
Oromiya 4999(40.8) 4411 (39.5) 5014 (42.2) 4851 (44.2)
Somali 142(1.1) 477 (4.3) 364 (3.1) 507 (4.6)
Ben-Gumz 124(1.0) 105 (0.9) 140 (1.2) 122 (1.1)
SNNP 2602(21.2) 2500 (22.4) 2494 (21.1) 2296 (20.8)
Gambela 29(0.2) 31 (0.3) 40 (0.3) 27 (0.2)
Harari 25(0.2) 22 (0.2) 29 (0.2) 26 (0.2)
Addis 182(1.5) 153 (1.3) 221 (1.9) 244 (2.2)
Dire Dawa 40(0.3) 37 (0.3) 39 (0.3) 47 (0.4)
Residence Urban 1277(10.4%) 815(7.3) 1,528(12.9) 1,216(11.0)
Rural 10,984(89.5) 10,348(92.7) 10,344(87.1) 9,807(88.8)
Highest education Illiterate 10,063(82.1) 8838(79.1) 8,227(69.3) 7,284(66.1)
Primary 1,596(13.1) 1845(16.2) 3,211(27.1) 2,951(26.8)
Secondary 573(4.7) 427(3.8) 266(2.2) 514(4.7)
Higher 28(0.2) 43(0.3) 168(1.4) 274(2.5)
Marital status Never 64(0.5) 37(0.3) 78(0.7) 57(0.5)
married
Married 11,270(91.9) 10,518(94.2) 10,989 (92.6) 10,462(94.9)
Widowed 189(1.5) 183(1.6) 229(1.9) 384(3.5)
Divorced 738(6.1) 424(3.8) 576(4.8) 274 (2.5)
Employment status Yes 6,858(55.9) 2,590(23.2) 4,060(34.2) 8,035(72.9)
No 5,397(44.1) 8,572(6.8) 7,803 (65.7) 2,988(27.1)
Wealth quantile Poorest NA 2,439 (21.9) 2,709(22.8) 2,636(23.9)
Poorer NA 2,356(21.1) 2,658(22.4) 2,519(22.9)
Middle NA 2,486 (22.3) 2,437(20.5) 2,279(20.7)
Richer NA 2,223(19.9) 2,272(19.14) 1,999(18.1)
Richest NA 1,659(14.9) 1,795(15.1) 1,588(14.4)
IQR-Interquartile range
https://doi.org/10.1371/journal.pone.0282951.t001
in 2000 to 1.8 in 2016) survey period respectively. The CS rate in private health facilities was
21.7% (Fig 1).
The trend of cesarean section

There was a significant variation in the trend of the rate of CS observed in the urban and rural
area in five DHS data (the 2019 mini DHS data was included). According to this report, the
trend of CS in an urban area over the preceding 5 years of the surveys had increased from 5.1%
(95% CI: 3.7–7.1) in 2000, 9.4% (95% CI: 6.5,13.4) in 2005, 8.1% (95% CI: 6.3,10.5) in 2011,
10.6. (95% CI: 8.5, 13.1) in 2016 and 10.1(95% CI: (7.2, 14.0) in 2019 although there is an over-
lapping of the confidence interval in the year 2000 and 2005 and also 2011 and 2016. Similarly,
the trend of CS in rural areas had increased from 0.2% (95% CI: 0.1–0.3) in 2000, 0.3% (95%

Table 2. Child and maternal, characteristics and health service usage finding from 2000 to 2016 DHS.
(n = 12,260) (n = 11,163) (n = 11,872) (n = 11,022)
(%) (%) (%) (%)
BMI Median 19.8 20.1±21.6–18.6 19.9+21.8–18.5 20.1+53.6–12.29
Parity 1 1,362 (11.1) 4576 (41.0) 5295 (44.6) 4836 (43.9)
2–4 4038(32.9) 3962 (35.5) 4014 (33.8) 3732 (33.9)
>5 2884(23.5) 2625 (23.5) 2564 (21.6) 2454 (22.2)
Size of the baby Very large 3,769(30.7) 3557(31.9) 3,805(32.1) 3,485(31.6)
Average 4376(35.7) 4462(39.9) 4,547(38.3) 4,580(41.6)
Very small 4035(33.3) 3096(27.7) 3,468.5(29.2) 2,866(26.0)
Birth order 1–2 4353(35.5) 3673(32.9) 4,279 (6.1) 3,842(34.8)
3 1,668(13.6) 1611(14.4) 1,677(14.1) 1,575(14.3)
4+ 6,239(50.9) 5879(52.6) 5,916(49.8) 5,605(50.9)
Child is twins Singleton 11,994(97.8) 10,963 (98.2) 11,597 (97.7) 10,730 (97.4)
Multiple 266(2.2) 200 (1.8) 275 (2.3) 292 (2.6)
Place of delivery Home 11,625(94.9) 10,502(94.0) 10,627(89.5) 7,997(72.6)
Public 575(4.7) 529.4(4.7) 1,005(8.5) 2,734(24.8)
sector
Private 40(0.3) 54(0.5) 144(1.2) 157(1.4)
sector
Others 11(0.1) 45(0.4) 50(0.42) 134(1.2)
Number of ANC No visit 5,789(72.6) 5225(71.5) 4,517 (57.1) 2,818(37.1)
visit 1–3 1,309(16.4) 1163(15.9) 1,856(23.5) |2,342(30.9)
�4 831(10.4) 888(12.1) 1,508(19.01) 2,415(31.8)
BMI- body mass index, ANC–antenatal care
CI: 0.2, 0.6) in 2005, 0.5% (95% CI: 0.3, 0.8) in 2011, 0.9% (95% CI: 0.3,1.6) in 2016 and 3.9%
(95% CI2.8,5.4) in 2019. Based on the chi-square test for linear trend, the increment was stati-
cally significant in urban (X2 = 20.72, p-value<0.0001) and rural (X2 = 52.72, p-value<0.0001)
areas respectively.
In addition to this, the rate sustainably increased among administration regions. For exam-
ple, Addis Ababa had the highest percentage of (24.1%) in 2019 and the biggest growth from
the year 2000 (7.9%). The rate was statistically significant at (p<0.0001) (Fig 2).
Fig 3 Presents a year-specific trend of CS rate, survey data illustrated the rate of CS in urban
had risen from 5.8% (in 1995) to 16% (in 2019). Similarly, the rate of CS in rural had risen
from 0.001% (in 1995) to 3% (in 2019) since there is no CS delivery in 1995 in the rural part.
The overall increment in CS rate was also observed from 0.8% (1995) to 6% (in 2019). Based
on the chi-square linear trend, the rate was statistically significant at (p<0.0001), (p<0.0001),
and (p<0.0001), in urban, rural, and overall respectively.
Furthermore, the absolute changes of CS rate in urban areas from (1995–2019) was 10.2%
whereas, the average annual rate of increased (AARI) from (1995–2019) was 4%. In rural area
from (1995–2019), 2.9% and 6.8% was the absolute change and AARI respectively. The overall
CS rate increment from (1995–2019) was 2.2% absolute change and 6.7% AARI.
Factors associated with cesarean section rate

Table 4 presents the findings of a multi-level logistic regression,the study evaluating the rela-
tionship between CS and a variety of individual factors and community-level contextual

Table 3. The magnitude of cesarean section rate across the various characteristics of the respondents in Ethiopia, finding from 2000 to 2016.
(n = 12,260) (n = 11,163) (n = 11,872) (n = 11,022)
(%) CI (%) CI (%) CI (%) CI
Age 18–24 1.3 0.9,1.9 1.2 0.8,1.7 1.9 1.4,2.6 1.7 1.2,2.5
25–34 0.3 0.2,0.5 1 0.7,1.5 1.1 0.8,1.5 2.2 1.7,2.8
35–49 0.1 0.0,0.2 0.5 0.2,1.2 1.3 0.6,2.9 1.9 1.1,3.2
Residence Urban 5.1 3.7,7.1 9.4 6.5,13.4 8.1 6.3,10.5 10.6 8.5,13.1
Rural 0.2 0.1,0.3 0.3 0.2,0.6 0.5 0.3,0.8 0.9 0.6,1.3
Highest education Illiterate 0.1 0.1,0.2 0.4 0.2,0.6 0.4 0.2,0.7 0.7 0.4,1.1
Primary 1.2 0.6,2.2 0.9 0.5,1.6 2.4 1.5,3 2.5 1.8,3.6
Secondary 8.4 5.1,13.6 12.1 8.5,16.8 14.6 10.0,21.0 6.3 4.2,9.5
Higher 18.8 7.1,41.5 23 11.7,40.1 13.7 8.3,21.9 20.8 15.7,26.9
Marital status Never married 3.9 0.6,20.5 4.2 0.6,23.2 7.2 2.3,20.1 14.2 6.4,28.7
Married 0.5 0.3,0.7 0.9 0.7,1.2 1.4 1.1,1.9 1.8 1.5,2.3
Widowed 2.5 0.4,12.6 1.3 0.3,6.5 1.2 0.4,4.3 0.5 0.1,3.7
Divorced 3.2 1.3,7.8 1.9 0.8,4.2 1.8 0.9,3.7 3 1.5,5.8
Employment status Yes 0.7 0.4,1.2 1.6 1.0,2.5 1.7 1.2,2.3 3.1 2.4,4.2
No 0.7 0.4,1.1 0.8 0.6,1.1 1.4 1.0,2.0 1.5 1.1,2.0
Wealth quantile Poorest NA NA 0 0.0,0.2 7.2 2.3,20.1 0.6 0.2,1.4
Poorer NA NA 0.3 0.1,0.8 1.4 1.1,1.9 1 0.4,2.4
Middle NA NA 0.2 0.1,0.5 1.2 0.4,4.3 1 0.5,2.0
Richer NA NA 0.5 0.2,1.0 1.8 0.9,3.7 1 0.5,1.9
Richest NA NA 5.3 3.9,7.2 7.2 2.3,20.1 8.1 6.6,9.9
BMI normal (18.05–24.09) 0.5 0.3,1.0 0.7 0.4,1.2 1 0.7,1.3 1.6 1.2,2.1
Underweight (<18.04) 0.5 0.3,0.8 0.6 0.2,1.7 0.9 0.4,2.0 0.9 0.3,2.5
overweight (>25.00) 7.6 3.1,17.5 8 3.9,16.0 8.6 5.8,12.5 7.8 5.5,11.1
Parity 1–3 1.5 1.1,2.1 2 1.5,2.7 2.7 2.1,3.3 3.7 3.0,4.5
4–6 0.1 0.0,0.3 0.1 0.1,0.4 0.7 0.3,1.5 0.7 0.4,1.3
>6 0.1 0.0,0.3 0.5 0.2,1.1 0.2 0.1,0.6 0.4 0.2,1.0
Size of the baby Very large 1 0.6,1.5 1.3 0.9,2.0 1.7 1.2,2.5 2.6 1.9,3.5
Average 0.7 0.4,1.1 0.9 0.6,1.4 1.6 1.0,2.6 1.7 1.2,2.4
Very small 0.5 0.3,0.9 0.7 0.4,1.2 1 0.7,1.5 1.5 1.0,2.2
birth order 1–2 1.8 1.3,2.6 2.4 1.8,3.2 2.9 2.3,3.7 3.7 2.9,4.7
3 0.1 0.0,0.3 0.4 0.2,0.8 1.1 0.6,1.9 2.5 1.6,3.8
4+ 0.1 0.0,0.2 0.3 0.1,0.6 0.6 0.3,1.1 0.6 0.3,0.9
Child is twin Singleton 0.7 0.5,0.9 1 0.7,1.3 1.4 1.1,1.8 1.8 1.4,2.2
Multiple 1.8 0.3,11.9 3.3 1.2,8.8 4.1 1.3,12.5 7.5 3.4,15.8
Place of delivery Public sector 14.4 10.7,19.1 18.9 15.1,23.5 14.6 11.5,18.3 6.5 5.3,8.1
Private sector 7.9 3.0,19.3 20 8.4,40.4 20.1 14.0,28.1 21.7 15.2,29.9
ANC visit No visit 0.2 0.1,0.4 0.2 0.1,0.4 0.2 0.1,0.5 0.5 0.2,1.2
1–3 1 0.4,2.6 1.5 0.7,2.9 2.4 1.5,3.8 1.3 0.8,2.2
�4 3.8 2.2,6.4 6.3 4.6,8.5 6 4.5,7.8 5.7 4.6,7.0
BMI- body mass index, ANC–antenatal care
factors (ModelsI-IV) using the recent 2016 DHS data. The association between the outcome
and explanatory variables examined by using bivariate regression analysis. Variables were
included in the multivariate multi-level regression analysis based on their association with the
bivariate level. Model I is an empty model, on the other hand, model II and III show the

Fig 1. Magnitude of CS rate among private hospital, public hospital (2000–2016) survey year.
https://doi.org/10.1371/journal.pone.0282951.g001
Fig 2. The trend of CS rate across the administrative region from (2000–20019) survey year.

Fig 3. The trend of CS rate in the Urban and rural part of Ethiopia data from (1995–2019).
findings of individual and community-level variables, whereas model IV presents the results of
all variables in the multilevel regression model. The ICC in Model I (empty model) revealed
63.9% variability in CS delivery which related to community variations (between-cluster vari-
ability). Similarly, the between-cluster variability in Model II 11.9%, in Model III, and Model
IV were 23.7% and 5.8%, respectively. According to the Proportional Change in Variance
(PCV’s) finding shows, the adding predictor variables to the empty model improved the expla-
nation of factors related to CS delivery. Model II (individual-level variables) had PCV of
92.3%, Model III (community-level factors) had 82.5% PCV and Model IV (combined individ-
ual and community-level factors) had PCV of 96.6%. Model IV reveals that individual and
community-level characteristics account for over 97% of the variability in CS delivery between
communities, so it is better to identify the factors related to CS birth. Therefore, variables like
the mother’s age at birth, education, BMI, parity, birth order, ANC visit, type of pregnancy,
residence, and geographical region were statistically associated with CS delivery. From the
final model, the odds of having CS delivery by women age group 34–49 years are 5.2 times
more likely compared to those age group of 18–24 years (AOR = 5.23; 95% CI:2.85, 9.59, p-
value <0.000). Those secondary and higher education increased the odds of CS delivery by 2
and 4.1 times than no education (AOR = 2.01;95% CI:1.17, 3.56, p-value <0.012) and
(AOR = 4.12;95% CI:2.33–7.29, p-value <0.000) respectively. Women who gave birth multiple
pregnancies have increased the odds of CS delivery by 11.2 times as compared to that singleton
(AOR = 11.12; 95% CI:5.37, 23.23, p-value < 0.000). The odds of CS decline with increasing
parity and birth order, that means women with 2–4 children CS lower by 46% as compared to
one child (AOR = 0.54; 95% CI:0 .37, 0.80, p-value < 0.002) and women with a birth order of
greater than 4, the odds of having CS decline by 58% as compared to those with a birth order
of one (AOR = 0.42;95% CI:0.21,0.84, p-value <0.023). Furthermore, women with a body
mass index greater than 25 the odds of delivery by CS were increased by 1.7 times than women
who had normal body mass index (AOR = 1.73;95% CI:1.22,2.45, p-value <0.002). Women
who had one to three and four or more ANC visits increased the odds of CS by 2.2 and 3.3

Table 4. Multilevel multivariable logistic regression output for cesarean section rate among live births in Ethiopia 2016.
Variable Null model Model II AOR (95% CI) Model II AOR (95% CI) Model IV AOR (95% CI)
Mother’s age at birth
18–24
25–34 2.79(1.92–4.06)�� 2.79(1.921–4.07)��
��
35–49 5.22 (2.85–9.59) 5.23(2.85–9.59)��
Highest educational level
Illiterate
Primary 2.29(1.45–3.63)�� 1.92(1.23–3.11)��
��
Secondary 2.57(1.49–4.41) 2.012(1.17–3.56)�
��
Higher 5.43(3.07–9.59) 4.12(2.33–7.29)��
Marital Status
Never married
Married 0.50 (0.19–1.33) 0.58(0.23–1.55)
Widowed 0 .12(.01–1.21) 0.16(0.016–1.64)
Divorced 0.45(.15–1.35) 0.55(0.18–1.64)
Wealth quantile
poor
Middle 1.11 (0.56–2.21) 1.04(0.53–2.079)
Rich 2.36(1.46–3.84)�� 1.16(0.65–2.053)
BMI
normal (18.05–24.09)
Underweight (<18.04) 0.47(0.25–0.88)� 0.53(0.28–1.00)
overweight (>25.00) 2.08(1.49–2.93�� 1.73(1.22–2.45)��
Parity
1
2–4 0.53 (0.36–0.79)�� 0.55(0.37–0.80)��
>5 0.41(0.18–0.94) 0.45(0.19–1.03)
birth order
1–2
3 0.52(0.31–0.89)� 0.50(0.35–0.99)
4+ 0.33(0.17–0.66)�� 0.42(0.21–0.84)�
Child is twin
Singleton
Multiple 12.38(6.04–25.34)�� 11.16(5.37–23.23)��
Number of ANC visit
No visit
1–3 2.71(1.34–5.46)�� 2.26(1.12–4.58)
�4 4.23(2.15–8.33)�� 3.34(1.67–6.66)��
Residence
Urban 10.19(6.58–15.80)�� 2.28(1.35–3.88)��
Rural
Region
Tigray
Affar 0.28(0.09–0.81)� 0.71(0.26–1.96)
Amhara 1.01(0.47–2.22) 0.96(.45–2.04)
Oromiya 0.56(0.25–1.25) 0.92(0.43–1.99)
Somali 0.11(.04–0.33)�� 0.39(0.12–1.25)
Ben-Gumz 0.45(0.16–1.24) 0.610(.21–1.72)
(Continued )

Table 4. (Continued)
Variable Null model Model II AOR (95% CI) Model II AOR (95% CI) Model IV AOR (95% CI)
SNNP 1.30(0.63–2.72) 1.24(0.62–2.47)
Gambela 0.40(0.16–1.04) 0.37(0.13–0.99)
Harari 3.11(1.53–6.33)�� 3.00(1.55–5.81)��
Addis Ababa 3.14(1.56–6.30)�� 1.51(0.81–2.81)
Dire Dawa 1.14(0.524–2.46) 1.73(0.87–3.38)
Random effect
Community variance(SE) 5.83(0.93) 0.45(0 .22) 1.02(0.25) 0.21(0 .21)
ICC 63.9% 11.99% 23.73% 5.76%
PCV Reference 92.32 82.46 96.55
Model fitness
Log likelihood -1194.06 -750.55 -1036.49 -722.52
AIC 2392.13 1549.10 2098.96 1515.06
BIC 2406.68 1712.99 2193.53 1754.07
�
p <0.05,
��
p< 0.01,
��
p< 0.001.
AIC Akaike’s Information Criterion, BIC Bayesian Information Criterion, ICC Intra-Cluster Correlation, PCV Proportional Change in Variance, SE Standard Error
times than those women with no ANC visit(AOR = 2.26; 95% CI:1.12, 4.58, p-value <0.023)
and (AOR = 3.34; 95% CI:1.12, 4.58, p-value <0.001) respectively.
The variation of CS delivery also observed across the different regions in-country and resi-
dence. The odds CS delivery increased for those women who were living Harari region by 3
times as compared to women who were living Tigray region (AOR = 3.00; 95% CI:1.55, 5.81,
p-value <0.001). Regarding residence, the urban women had 2.3 times higher than
(AOR = 2.28; 95% CI: 1.35–3.88, p-value <0.002) odds to deliver by CS compared to those
women who were living in the rural area.
Discussion
This study used the EDHS data to analyze the trend of CS rate and identify the factors that
associated with CS delivery. The finding of this study indicate that CS rate increased from
0.8% to 6% in 1995–2019 respectivey over 24 years of the survey period. This indicate that CS
availability has slightly improved. The finding is similar study conducted in Uganda 5.22%
[25], in Mozambique 4.7% [17]. Whereas, higher than the study conducted in Egypt 40.1%
[26], Nepal 9% [27], and Bangladesh 63% [28]. The low prevalence of CS rate at present study
might be due to, the facility and expertise for emergence obstetrics service including CS deliv-
ery insufficient and/or sparsely scattered throughout the country; equipment and medicines in
the emergency obstetric health centers are insufficient; lack of competent birth attendants and
services as well as length of distances and poor landscape without adequate transportation
could create a significant geographic barrier to emergency obstetric treatment [29]. Addatin-
ally, lacks information about CS delivery contributing to low acceptance of CS among Ethio-
pian women, for example, women may be fear of mortality, anxiety about complications, a
poor impression of CS as an unnatural technique of delivery, and the expensive expense of the
surgery.

The study observed women who were living in the urban area increased CS rate from 5.8%
(1995) to 16% (2019) with an absolute change was 10.2%, likewise, women who were living in
the rural area CS rate increased from 0.001% (1995) to 3.9% (2015–2016) with absolutely
changed 3.8%. Some studies support this finding, a study in Vietnam shows that living in an
urban area doubles the likelihood of undergoing a CS [30], and similar findings in Nepal and
Mozambique [17, 31], The increasing of CS rate in an urban area compared to that of a rural
in Ethiopia might be due to, in rural area have shortage of skilled health workers, high concen-
tration of less experienced doctors and community health workers. Whereas, in urban area the
health workforce is disproportionately concentrated, home to all significant private and public
health institutions [32] in addition to this, the majority of cesarean births are performed in
urban health facilities, notably private clinics [9] although 78.3% of the population lives in
rural regions [33].
The finding of this study also indicates a considerable disparity in the service uptake of CS
among maternal education, age, parity, body mass index, ANC visit, multiple pregnancy,
birth order, and geographical region. Few studies support this finding [16, 26, 31]. This study
finding revealed that mothers aged 25 or more had higher odds of delivering by CS compared
to women aged less than 25 years old. This finding supported the study in Vietnam [30],
Mozambique [17], and Egypt [26]. The reason might be since the risk of delivery problems as
well as the chance of premature birth and infant death increased as women got older, exces-
sive bleeding during labor prolonged labor lasting more than 20 hours, and dysfunctional
labor that does not progress to the next stage. Furthermore, diabetes and hypertension during
pregnancy were more common in older pregnant women, this may lead to increased delivery
CS [34, 35].
The odds of women who had completed primary, secondary, or higher education had
more likely delivered by cesarean section than women who had not been educated. This
finding support study conducted by a global, regional and national representative of 150
countries using secondary data from 1990–2014 [3], similar study from Ethiopia [36], study
from Tanzania [37]. The possible reason a higher degree of education enhances the possibil-
ity of CS delivery might be women who had received education aware of the costs and bene-
fits of using maternity services and also have more confidence and self-reliance for any
decision provided by a health care provider, which in turn, may raise the chance that could
get CS service, besides, evidence from health literature demonstrates the fact that health lit-
eracy is linked to educational achievement could lead to believe that highly educated women
are more likely to seek health services such as CS delivery than their no educated counter-
parts [29, 38]. ANC visits a significant predictor of cesarean delivery in this study, women
who had greater than one ANC visits during pregnancy had more than double likelihood of
delivery by CS than those who did have ANC visits. A similar finding reports from a study in
Nepal [31] and Nigeria [16]. The possible reason for this could be women get more informa-
tion about early detection of complications during pregnancy, birth preparedness, complica-
tions at each ANC visits. Hence, they may prefer methods of delivery, such as cesarean
section. Furthermore, the study also showed, compared to women who had one successful
birth, those who had two and four successful births were less likely to undergo a cesarian sec-
tion similarly, CS delivery declined with increased birth order, those with birth order of
greater 4, the odd of having CS delivery was less likely as compared to those with birth order
of one. some studies support this finding, including a study in Nigeria [16], a population-
based study in Ethiopia [9], Study in Ghana [11]. The possible reason is that women who
have not previously given spontaneous successful deliveries have had less experience with
methods of delivery and may fear labor pain related to vaginal delivery, thus, this leads to CS
delivery.

In this finding, multiple pregnancies were significant factors for CS delivery, the odds of
women who deliver twin pregnancies eleven times increased the likelihood of delivery by CS
delivery as compared to singleton birth. Few studies support this finding, a study in Nigeria
[9], a study in Egypt [27]. The possible reason for this could be multiple pregnancies have been
linked to obstetric complications like preterm labor, premature rupture of membranes, malpo-
sition, and malpresentation of the fetus. It also increased risks of complications to the mother
like gestational diabetes, gestational hypertension, preeclampsia, and intrahepatic cholestasis,
all of which may increase the likelihood of giving birth via CS [39, 40]. This study also investi-
gates body mass index greater than 25 as a significant predictor for CS delivery. Women with a
body mass index greater than 25 are more likely to deliver by cesarean section as compared to
women who had a normal body mass index, little evidence support this finding study in Egypt
[26], a population-based study in Ethiopia [10]. The reason for the finding could be obese
mothers have a higher risk of pregnancy complications like anemia, hypertension, pre-eclamp-
sia, preterm delivery, emergency cesarean section, and gestational diabetes. Another study also
investigated obesity increases the rate of cesarean section, with a rate of 20.7% in a normal
weight control group, 33.8% in obese women, and 47.4% in morbidly obese women
(BMI>35kg/m2) [41].
This research have some advantages. First, the research was based on big, nationally repre-
sentative datasets, giving it sufficient statistical power. Second, the study estimates completed
after the data had been weighted to allow for probability sampling and nonresponse to make it
representative at national and regional levels.
The limitation of this study: for trend analysis the study employed 2019 mini demographic
data; however, to assess factors that affecting CS delivery, the study used 2016 data because
some factors’ data did not complete in the 2019 mini EDHS data.
Conclusion
In Ethiopia in both urban and rural areas CS rate was low, which did not fall within the
WHO’s recommended range although a slight improvement observed in the urban area. Fac-
tors associated with low prevalence and decrease in the odds of CS delivery included residence
in a rural area, lack of ANC visits, and first parity. on the other hand, factors associated with
higher prevalence and increased odds of CS delivery included, region, multiple births, mater-
nal overweight, higher educational status, and women of >25 years. The current study reflects
unmet needs, which are a known risk factor for increasing maternal and newborn mortality,
this highlights the critical need for increased provision and better utilization of life-saving CS
in Ethiopia. As result, enhanced availability and access to obstetric care services like CS deliv-
ery especially, in rural areas need to be further pursued by meeting the WHO’s
recommendations.
The research also highlights the importance of addressing the geographic and socioeco-
nomic variables that contribute to Ethiopia’s low CS prevalence, thus, empowering women,
educating women, implementing health promotion programs aimed at preventing/reducing
maternal overweight/obesity, increasing co-services such as ANC usage, and improving mater-
nal awareness could all help to address the current problem.
Acknowledgments
We’d also want to express our gratitude to the MEASURE DHS Program and ICF Interna-
tional for allowing us to use the EDHS data. We’d like to thank the academic and non-aca-
demic staff at the Pan African University Life and Earth Science Institute (PAULESI) at the
University of Ibadan in Nigeria.

Author Contributions
Conceptualization: Rahel Mezemir.
Data curation: Rahel Mezemir.
Formal analysis: Rahel Mezemir, Yadeta Dessie.
Methodology: Oladapo Olayemi, Yadeta Dessie.
Validation: Oladapo Olayemi, Yadeta Dessie.
Visualization: Rahel Mezemir, Oladapo Olayemi, Yadeta Dessie.
Writing – original draft: Rahel Mezemir.
Writing – review & editing: Oladapo Olayemi, Yadeta Dessie.
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PLOS ONE

Trend and associated factors of cesarean

Received: March 17, 2022

PLOS ONE | https://doi.org/10.1371/journal.pone.0282951 March 16, 2023 1 / 17

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Methods and material

Sample size and sampling methods

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To identify factors associated with CS delivery, a Multi-level logistic regression analysis

Child characteristics and maternal health service usage

The magnitude of the cesarean section rate

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The trend of cesarean section

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BMI- body mass index, ANC–antenatal care

Factors associated with cesarean section rate

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BMI- body mass index, ANC–antenatal care

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