Geographic and socioeconomic inequalities in cesarean birth rates in Peru: A comparison between 2009 and 2018

Background: There is a global concern about the high rates of cesarean birth (CB). This study aimed to investigate the geographic and socioeconomic inequalities in CB rates in the Peruvian population. Methods: We conducted a population-based study using the Peruvian Demographic and Family Health Surveys (ENDES, the Spanish acronym for Encuesta Demográfica y de Salud Familiar) between 2009 and 2018. ENDES reported data from births registered in the five years preceding survey execution. For the years 2009 (n = 10 289) and 2018 (n = 23 077), we calculated the weighted rates of CB among variables such as natural geographic domain (Coast, Andean, or Amazon), area of residence (rural or urban), wealth index quintile (quintile 1 is poorest, and quintile 5 is richest), and educational level. To assess inequalities, we calculated the concentration index (CIs), the slope index of inequality (SII), and the relative index of inequality (RII). Results: The CB rates by year were 21.4% (95% confidence interval [CI]: 20.0-22.9) in 2009 and 34.5% (95% CI: 33.4-35.5) in 2018. Women living in urban and coastal regions and with a higher education level had the highest CB rates. All the CIs were positive, reflecting a prowealthy inequality in CB rates, and both SII and RII were positive, indicating a gap between the use of cesarean in women in the higher wealth quintile compared with those in the lower quintile. Conclusions: Cesarean birth rates have increased by 60% during the last decade in Peru. The richest wealth quintiles had the highest CB rates during the study years, which were well above global recommendations.