**2. Prevalence and factors associated with CS**

Low-income countries (LICs) especially sub-Saharan Africa have historically had very low CS rates, probably reflecting inadequate availability [19–21], whereas high income countries (HICs) generally have higher CS rates, indicating overuse [22]. In 2010, an estimated 3.5–5.7 million unnecessary caesarean sections were done in high and middle income countries (HMICs), whereas 1–3.5 million caesarean sections were needed, but not performed in LICs which is an indication of global extremes [23]. However, the burden of maternal mortality was high in countries with low caesarean section rates. In regions such as Sub-Saharan Africa, despite only 3.5% of all pregnant women delivering by caesarean section, 20% of all who died from any cause were delivered by caesarean section [11, 24]. The very high

#### *Magnitude, Factors Associated with Cesarean Delivery and Its Appropriateness DOI: http://dx.doi.org/10.5772/intechopen.98286*

rates of stillbirths and perinatal deaths in caesarean section births are of concern, particularly in Sub-Saharan region where up to one in ten babies delivered by caesarean section are stillborn. When the fetus is no longer alive, caesarean section is considered only if the birth needs to be rapidly expedited to avoid complications, or when vaginal birth is not appropriate. The high stillbirth and perinatal mortality may reflect conditions where caesarean sections were carried out despite a diagnosis of stillbirth or when the procedure was done far too late to save the baby [11]. Evidence shows increasing overuse of potentially harmful interventions especially caesarean section in facility births and one of the critical knowledge gaps identified for research priority in LMIC is over-medicalization of birth leading to increased rates of unnecessary CS [4, 25]. Overall, CS rates are lower in poorer women and tend to increase with rising economic status [26]. Disparities within countries and hospital-level variations in CS rates even within the same socio-demographic or economic groups, implied that TLTL and TMTS can coexist within countries and facilities [27, 28]. These indicates that, some women might be exposed to unnecessary CS while others do not get the CS they need [29]. Therefore, optimizing and ensuring the availability of a CS service while reducing the unnecessary CS for women is a global concern [30].

In Ethiopia physician-led obstetric care is provided by a four-tier healthcare system organized as primary health care units or health centers, district hospitals, general hospitals, and specialized hospitals. Ethiopia is one of the countries where CS practice is rising and reached 46% in the private for-profit sector and 18% in government institutions [31, 32]. The population-based CS rate of Ethiopia is still one of the lowest in the world (2%), since many women in need of CS never reach facilities (institutional delivery rate of 26%) and the disparities within a country might masked the national averages [29, 33]. This overall low coverage of CS indicates TLTL, however, a stark disparities with higher rates in private practice and higher wealth quintiles, suggesting TMTS for wealthy women [4, 29]. These differences have been linked to insufficient adherence to, or absence of, clear evidencebased guidelines and reflect weak regulatory capacity especially in the private sector [4, 34–36]. Previous research undertaken by the applicant in support of this proposal reported a higher CS rate (47.6%) in Dessie town, Ethiopia with a significant discrepancy between public (18.2%) and private (76.1%) sectors. Fetal distress was the leading cause of caesarean birth possibly due to over-diagnosis of abnormal fetal heart rate patterns in the absence of an electronic fetal monitoring system. Additionally, mothers having a history of previous caesarean birth had higher odds of having caesarean birth which may be associated with the obstetrician's fear of attempting a trial of vaginal birth in facilities with limited fetal monitoring capabilities. Furthermore, mothers whose labour was not monitored using partograph (a labour monitoring tool used to identify and intervene abnormal labour) had higher odds of CS as most of these women were referred from the primary health care facility to the nearby hospitals with a labour complication where emergency CS would be done without further monitoring of progress [37].

Evidences have shown the contribution of non-clinical factors to the rising trend of CS and suggested that identifying the determinants of caesarean birth is the priority to improve the efficacy of this obstetric intervention [38]. However, the determinants of CS are very complex and include not only clinical indications, but also multiple factors: demographic, economic, social, logistical, and health system affect CS rates. On the other hand, most of the clinical indications are not absolute and very subjective, and disagreement sometimes exists between clinicians about when to use CS. This nature of clinical factors coupled with multiple non clinical factors including providers' practice differences at facility and individual levels, financial incentives (private providers), and inadequate adherence to clear evidence-based

guidelines contributes to significant variability among hospitals and countries concerning CS rates for particular medical indications [27, 39]. This, in turn, leads to inequities in the use of the procedure, not only between countries but also within countries with an additional financial burden upon the overstretched health system particularly in LMIC [40, 41]. Therefore, rising trends of caesarean birth impose an inappropriate allocation of scarce resources in the poor economy countries [40, 41].
