To the best of our knowledge, this is the first study to estimate the level of CS delivery in Sudan based on population-based data. Although the national averages of CS rates in Sudan were lower than the global average, the CS rates increased steadily from 4.3% in 2006 to 9.1% in 2014, with substantial regional variations. Urban areas recorded a rapid increase in CS rates, while rates remained unchanged in the rural and relatively poor regions.
Sudan can be said to be experiencing a double burden of problems associated with CS interventions. While remarkable increases were noted in urban Sudan in particular among the richer and educated households, rural Sudan and poorer households experienced lower rates of CS. Some may argue that in the midst of the global surge of CS, lower surgical interventions for deliveries should not be of major concern. However, as concluded by Betran et al. in their systematic review, lower CS rates, below 9%, could be an indication of sub-optimal maternal healthcare and other socioeconomic levels .
More critically, the rapid increase in CS in urban Sudan could present significant public health implications. Despite heightened awareness created by WHO in 1985, the subsequent re-assessment carried out in 2018 found a dramatic increase in CS rates in many parts of the world, with a global average CS rate reaching 18.6% of all births . High CS rates highlight the extent of the problem that shocked the international public health community . There is mounting evidence that documents the negative implications of excess CS deliveries. Economic analyses pointed towards higher expenditure at individual and national levels due to unnecessary CS interventions .
CS rates in Sudan (9%), as documented in this study, appear to be similar to those reported in some other countries like Dijbouti (11%), lower than the Middle East and North Africa (MENA) rate (29.2%) but higher than Eastern and Southern Africa rate (6%) [3, 12, 34]. Such comparisons should be understood in the light that CS rates in Sudan maybe be under-reported due to the collapsing health care system in the country .
The increasing rates of CS over time documented in this study are somewhat concordant with the global trend and patterns observed in many other countries [1,2,3]. However, the AARI in Sudan (9.3%) during 2006–2014 is higher than the global AARI (3.7%) . Although there is no published national data from Sudan beyond 2014, it would not be surprising to find that the CS rates have escalated further. The Federal Ministry of Health in Sudan is responsible for guidelines and protocols aiming to reduce CS. To the best of our knowledge, there is no documented intervention in place to reduce CS rates in Sudan, particularly with the increasing health challenges after the recent political changes in the country .
The study showed that the increase in CS rate is equally attributed to both the increase in deliveries in health facilities and to the increase of CS in health facilities. The increase of CS in health facilities varies largely between countries. Contrary to our results, the increase in deliveries in health facilities in the MENA region contributed more to the increase in CS rate than the increase in CS in health facilities . The reason might be attributed to the high cost of surgeries and mothers’ reliance on out-of-pocket expenses in Sudan [17, 36].
In addition to regional variability, maternal age, maternal education, ANC visits, and child birth order were significant determinants of higher rates of CS in Sudan. Those determinants that led to the global surge in CS may also be driving the increase in CS among mothers from higher socioeconomic classes. Similar results are observed in several low-income countries, where CS rates were low—for example, in some countries in sub-Saharan Africa among rural and poorer women . In other studies, poverty was similarly associated with lower CS rates, as in our study [37, 38]. Although in our final adjusted model, area of residence and the wealth index were not significant, the six geographical regions were strongly significantly related to CS. Others studies found similar variations in CS rates by geographic regions [20, 22, 23]. Our study sample showed that about three-quarters (74%) of the population lives in rural areas. About three-quarter (76%) of the population in Khartoum is urban while regions like Kordofan and Darfur are predominantly rural (80% each of their population). Additionally, wealth varied considerably by region —for example, 74 and 81% of the study population in Kordofan and Darfur, respectively are in the poorest wealth category while 81 and 83% of those living in Khartoum and the Northern region are in the richest. As in other studies, it is expected that urban and richer women have better access the healthcare system compared rural and poorer women . It is thus clear that variation in wealth and area of residence among regions may be a possible explanation to higher CS rates in some regions like Khartoum and the Northern region and lower rates in other regions like Kordofan and Darfur. As such the regional variability in CS rates across these six regions played a role in reflecting the wealth and rural-urban divide in CS experience.
Lower CS rates were also attributed to weak health care infrastructure, availability of and poor access to surgical care and emergency obstetric service [17, 40, 41]. This is compatible with our findings showing higher educated mothers experiencing higher CS rates. Better education is associated with more exposure to health information, access to health facilities, better health-seeking behavior. Mothers’ education is also associated with a higher socioeconomic status that enables them to pay for their surgeries. Such an explanation is likely the case in Sudan, given its minimal national health insurance coverage . Such findings are in concordance with other studies [29, 42, 43].
Consistent with other studies, our results found lower CS rates with suboptimal ANC utilization [2, 44]. It would be alarming if the observed association is more driven by the lack of identification of clinical indications for mothers who do not attend ANC. Such situations would potentially lead to poor outcomes, including maternal and infant morbidity and mortality. Woman’s attendance to ANC in private health facilities was linked to increased probability for her to deliver by CS [3, 29]. In this study, as most of the CS deliveries were in public health facilities, attendance of ANC in private health may not be ruled as an explanation.
Our findings are significant, given the paucity of data on the CS utilization patterns in Sudan. Our reports should provide some important baseline data for the public health community to address the double burden problem of surgical interventions for childbirth in Sudan. Although the country has a full package of strategic plans, policies, and new initiatives to promote maternal health, this study highlights potential drawbacks in implementation [17, 45]. attention to this important issue and prioritize their efforts in directing effective utilization of resources. Findings from this study may motivate the initiation of more studies to assist in directing action plans of the Sudan National Health Policy 2017–2030 in the prioritization of maternal care services, particularly in specific regions in the country.
The main strength of this study is the national representation of its data over time, allowing for observing reliable regional estimates. However, our findings should be interpreted in light of some limitations. Some variables rely on the recall of past events. Although it is less likely that mothers forget their major experience of such surgery, they would sometimes misreport other information like ANC. Although in more than two-thirds of the study sample, a decision was made to perform CS before the onset of labor, no information was collected on the reason for this decision. Such information might have shed more light on the contribution of women’s preferences to the increase in CS rates .