Association between caesarean section and neonatal mortality in low- and middle-income countries
1
School of Public Health, College of Health, Adelaide University, Adelaide, Australia
2
Robinson Research Institute, College of Health, Adelaide University, Adelaide, Australia
3
Department of Nursing, College of Medicine and Health Sciences, Samara University, Samara, Ethiopia
Popul. Med. 2026;8(Supplement Supplement 1):A2244
ABSTRACT
BACKGROUND:
Although cost-effective interventions could prevent over half of neonatal deaths in resource-constrained contexts, neonatal mortality remains persistently high across low- and middle-income countries (LMICs).
METHODS:
We analysed 778,392 birth records from nationally representative household surveys conducted between 2015 and 2024 in 48 LMICs. For each country, we used a modified Poisson regression model to estimate adjusted prevalence ratios (aPRs) for neonatal mortality associated with CS, accounting for key maternal, neonatal, and sociodemographic variables. Country-specific aPRs were then pooled using random-effects inverse-variance weighted meta-analysis.
RESULTS:
CS rates ranged from 1·2% in Angola to 51·5% in Turkey, while neonatal mortality ranged from 3 deaths per 1,000 live births in Armenia to 42 per 1,000 in Pakistan. Country-specific associations between CS and neonatal mortality varied widely, with aPRs ranging from a lower risk in Bangladesh (0·28, 95% CI 0·13–1·60) to a substantially higher risk in Papua New Guinea (3·38, 1·58–7·22). Increased risks among caesarean births were also observed in Ethiopia (2·76, 1·01–7·57), Tajikistan (2·58, 1·02–6·53), Zimbabwe (2·54, 1·34–4·80), and the Democratic Republic of the Congo (2·51, 1·61–3·92). In pooled analyses, CS was associated with a 38% higher prevalence of neonatal death (pooled aPR 1·38, 95% CI 1·20–1·58). Subgroup analyses showed stronger associations in low-income countries (1·54, 1·22–1·95) and lower-middle-income countries (1·37, 1·11–1·70). Moreover, the association was most pronounced in countries with CS rates below 10%, where neonatal mortality was 70% higher among caesarean births (1·70, 1·49–1·93) compared with vaginal births.
CONCLUSIONS:
A naïve interpretation of these findings is that caesarean delivery directly increases the risk of neonatal death across LMICs. However, the association more likely reflects severely compromised births, late presentation, and delays in accessing emergency obstetric care, particularly in countries with very low CS coverage.
Although cost-effective interventions could prevent over half of neonatal deaths in resource-constrained contexts, neonatal mortality remains persistently high across low- and middle-income countries (LMICs).
METHODS:
We analysed 778,392 birth records from nationally representative household surveys conducted between 2015 and 2024 in 48 LMICs. For each country, we used a modified Poisson regression model to estimate adjusted prevalence ratios (aPRs) for neonatal mortality associated with CS, accounting for key maternal, neonatal, and sociodemographic variables. Country-specific aPRs were then pooled using random-effects inverse-variance weighted meta-analysis.
RESULTS:
CS rates ranged from 1·2% in Angola to 51·5% in Turkey, while neonatal mortality ranged from 3 deaths per 1,000 live births in Armenia to 42 per 1,000 in Pakistan. Country-specific associations between CS and neonatal mortality varied widely, with aPRs ranging from a lower risk in Bangladesh (0·28, 95% CI 0·13–1·60) to a substantially higher risk in Papua New Guinea (3·38, 1·58–7·22). Increased risks among caesarean births were also observed in Ethiopia (2·76, 1·01–7·57), Tajikistan (2·58, 1·02–6·53), Zimbabwe (2·54, 1·34–4·80), and the Democratic Republic of the Congo (2·51, 1·61–3·92). In pooled analyses, CS was associated with a 38% higher prevalence of neonatal death (pooled aPR 1·38, 95% CI 1·20–1·58). Subgroup analyses showed stronger associations in low-income countries (1·54, 1·22–1·95) and lower-middle-income countries (1·37, 1·11–1·70). Moreover, the association was most pronounced in countries with CS rates below 10%, where neonatal mortality was 70% higher among caesarean births (1·70, 1·49–1·93) compared with vaginal births.
CONCLUSIONS:
A naïve interpretation of these findings is that caesarean delivery directly increases the risk of neonatal death across LMICs. However, the association more likely reflects severely compromised births, late presentation, and delays in accessing emergency obstetric care, particularly in countries with very low CS coverage.
| eISSN: | 2654-1459 |
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