Accepted Article

DR. TAHMINA BEGUM (Orcid ID : 0000-0001-8106-2454)

K M SAIF-UR-RAHMAN (Orcid ID : 0000-0001-8702-7094)

Article type : Systematic review

Title: Global incidence of Caesarean deliveries on maternal request: a

systematic review and meta-regression

Tahmina Begum1,2,3, KM Saif-Ur- Rahman3,4, Yaqoot Fatima1,5, Jelle Stekelenburg6,7, Satyamurthy

Anuradha8, Tuhin Biswas1,2, Suhail A. Doi9, Abdullah Al Mamun1,2

1 Institute for Social Science Research, The University of Queensland, Australia

2ARC Centre of Excellence for Children and Families over the Life Course Centre, UQ, Australia

3Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh

4Graduate School of Medicine, Nagoya University, Japan

5Centre for Rural and Remote Health, James Cook University, Mount Isa, Australia
6Department of Health Sciences, Global Health unit, University Medical Center Groningen. The
Netherlands

7Department Obstetrics & Gynaecology. Leeuwarden Medical Centre, The Netherlands

8School of Public Health, The University of Queensland, Australia

9Department of Population Medicine. College of Medicine, QU Health, Qatar University. Doha, Qatar

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/1471-0528.16491
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 Corresponding author:
Accepted Article
Tahmina Begum
80 Meiers Rd | Long Pocket Precinct | Indooroopilly | Queensland- 4068
Email: t.begum@uqconnect.edu.au
Running title: Caesarean deliveries on maternal request

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 Abstract
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Background:
Caesarean delivery on maternal request (CDMR) is considered as a significant contributor to the
unprecedented increase in the caesarean deliveries (CD) for non-clinical reasons. Current literature
lacks a reliable assessment of the rate of CDMR, which hinders the planning and delivery of
appropriate interventions for reducing the CDMR rates.
Objectives:
Conduct a systematic review of literature and meta-regression to explore the global incidence of
CDMR.
Search Strategy:
Pubmed, Embase, CINAHL, Medline, Google scholar and grey literature were searched from
January 1985 to May 2019.
Selection Criteria:
Observational studies that report CDMR data were included. We excluded non- English articles, case
notes, editorial reviews and articles reporting elective CDs from pregnancy risk factors.
Data Collection and Analysis:
Two reviewers independently conducted the screening and quality appraisal using a validated tool.
The weighted average of CDMR over total deliveries (absolute proportion)and by total CDs (relative
proportion) were generated. Quality effect meta-regression was used to explain the variability of the
CDMR estimates by moderators, including study methodology and demography of study participants.
Results:
We identified 31 articles from 14 countries that include 5 million total births. The absolute proportion
of CDMR varies between 0.2% to 42% with significant variations across studies and sub-groups.
The economic status of the country and study year both together explained 84% of absolute and
76% of the relative proportion of CDMR variations.
Conclusions
An appropriate reporting of CDMR should be a key priority in maternal health policies and practices.
Funding statement: None
Keywords: Caesarean section, maternal request, the global incidence

Tweetable abstract:

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 Globally,maternal requested caesarean delivery proportion has mostly been influenced by the
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economic status of the country

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 Introduction:
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Caesarean delivery (CD) can save the mother and newborn lives when labour gets complicated (1).
Women with critical clinical conditions such as major placenta praevia, transverse lie and gross
cephalo-pelvic disproportion will need caesarean delivery to reduce maternal and neonatal
mortalities and morbidities (2). However, being a major abdominal surgery, the CD has some health
risks (3, 4) and is reported to be associated with a three-fold increased risk of maternal death
compared to vaginal birth due to possible complications (5, 6). Moreover, the healthy child delivered by
CD carries more risk of chronic diseases like asthma, obesity, diabetes and autoimmune disorders
as they lack natural immunity acquired from the maternal birth canal (6-8). In addition to this health
impact, the higher economic cost of unrequired CDs mandates that the rate be kept under an
optimum range (9). The recommendation is to keep the all causes CD rate below 20% at the
population level (10, 11).

Globally, the CD rate has doubled in the last 15 years to 21% and is increasing annually by 4%(12). Of
29·7 million globally performed CDs; around 6.2 million unrequired CDs were done in 2008 (9).
According to professional and press media, CD on maternal request (CDMR) is a significant
contributor on the unprecedented increase of unrequired CDs(13, 14). In some European countries,
CDMR constitutes 7-22% of CDs and is related to fear of childbirth (15). Citing obstetricians self-
reported data, a study from Australia has reported the CDMR rate as 17.3% (16). However, the
reliability of data is a concern due to methodological variation in defining CDMR (17)and in some
cases, proxy indications were used when it was not mentioned explicitly in the medical records (13, 14).
The recent systematic review findings on maternal preference on mode of birth raises a further
debate where globally only 15.6% of women reported CDMR as their first choice (18). However, to
rule out the widely criticqued statement on CDMR, an actual estimation of CDMR rate is required
instead of reporting subjective preference which has not been studied systematically yet(13, 17). To fill
this knowledge gap, we conducted a systematic review of the literature on global CDMR incidences
using a valid and reliable definition (13, 19). Meta-regression was used to explore the variation in
CDMR proportion by different subgroups and to identify significant predictors of CDMR. Knowing this
burden and its variation will be helpful for resource allocation and effective planning on the reduction
of CDMR rates.

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 Methods
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The study protocol was registered with the PROSPERO (International prospective register of
systematic reviews) to avoid duplication ( ID: CRD42018106145) (20). There was no involvement of
patients and public in this secondary review of literature.

Search Strategy

A comprehensive search strategy was developed using Boolean operators incorporating the key
search terms such as "caesarean delivery", "caesarean section", "caesarean birth", "maternal
request", "maternal demand", "patient demand", "patient request", "self-request", elective, planned,
"maternal decision". We used different combinations of free text and MeSH term for the key search
term. Five databases; PubMed, Embase, CINAHL, Medline and Google Scholar, were searched from
January 1985 to May 2019. Grey literature was searched from Grey Net International and ProQuest
online database. The lower limit was set to the year 1985 as the World health organisation (WHO)
brought the discussion on the adverse effect of un-necessary CDs for the first time during this year
(21). (Appendix S1).

Study selection criteria

The CDMR definition used in this review was approved by system experts during State of Science
Conference in 2006. A panel of 18 members representing different disciplines of medicine and public
health sat together to investigate the scientific evidence to recommend an easily applicable and valid
CDMR definition. The approved CDMR definition was "elective caesarean deliveries performed at
term for a singleton pregnancy without obstetric and or any medical reasons" (13). Accordingly, we
set our study inclusion and exclusion criteria under the format of population, intervention,
comparison, outcome and study design (PICOS)(22). We included observational studies that provide
complete information to compute CDMR proportion. However, articles reporting elective CDs from
pregnancy risk factors (2) and physician recommendation were excluded. The further exclusion
criteria were non- English articles, case notes, editorial review and conference abstract. We did not
include articles that talked about mother and physician's perception of CDMR instead of reporting
actual numbers of CDMR (Table S1, screening criteria).

Screening procedure and data extraction

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 Two reviewers (TB and KMSUR) independently conducted the screening of articles using
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prioritisation and sequential exclusion technique (23). The third reviewer (AAM) resolved the
disagreements between two reviewers. After removing the duplicates, the full-text articles that met
our inclusion criteria were included in the review list (24). Reference lists of included articles and
excluded systematic reviews were traced to identify any relevant missing articles. In the case of
multiple articles from the same research project with a similar data source, the one that provided
maximum sample size was chosen.

We extracted CDMR data when it was mentioned explicitly in the caesarean section indication lists
and matched with our operational definition. However, four studies contradicted our CDMR case
definition, where the previous CD was mentioned as the cause of CDMR (25-28). We subtracted the
previous CD from total CDMR cases for those four articles.

Quality assessment

Two reviewers independently did the quality appraisal by using "risk of bias assessment" tool
proposed by Hoy et al. (29). The validity of the tool was reported most precise among all available
quality assessment checklists used for evaluation of prevalence studies (29). Accordingly, a ten-point
scale was used to assess both the external and internal validity of the study. External validity was
evaluated through the first four items consisting of representativeness, sampling strategy and non-
response bias. Internal validity was appraised subsequently by measurement and analytic bias
highlighted under items five to nine and item10 respectively (Table S2A). The individual articles
were assessed against all ten potential safeguards and assigned one summary quality count which
had a possible maximum of ten points. Of course, a study with a maximum count will not necessarily
be devoid of bias, and this count was used to rank studies between one and zero with the best study
having rank one (30).

Outcome variable:

We defined two CDMR proportion: 1) Absolute proportion of CDMR by the number of CDMR over
total deliveries (CDMR-TD) and 2) Relative proportion of CDMR; the number of CDMR over total
CDs (CDMR-CD). We also report CDMR proportion out of total elective CDs depending on data

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 availability. The Elective CD was defined as CD performed before the onset of labour in a term
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pregnancy (31).

Moderator variables

Geographical region, economic region, study site, study design, data source, study years, study
population and mean maternal age. World- Bank classification of 2015 was used to classify studies
by economic status and geographical region (32). By economic category, each study could fall under
any of the categories: high income (HI), upper middle income (UMI), lower middle income (LMI) or
low income (LI) group. The geographical region was specified as; Europe and Central Asia, North
America, East Asia, Middle East, Sub Saharan Africa. Whereas, to describe the study site as an
urban or rural setting, we utilised the study reported data. The variable "data source" re-categorised
into two categories, namely, national where a representative number of delivering women from a
country were surveyed and health facility, which did the survey among selected health facilities. The
study year was grouped into two; studies conducted before and after 2010. The study design was
assessed by data collection nature, either prospective or retrospective. Since mean parity was not
available from all studies, we categorised study by their study population; nulliparous and parous.
Whereas, mean maternal age was retrieved directly from the individual study.

Statistical analysis

Initially, an estimate of the logit transformed CDMR proportions were generated using MetaXL
software version 5.3 (33). The software also computes the standard error of the logit transformed
proportions as well as a quality effects weight for each study under the quality effects model. The
latter makes use of the quality rank generated for each study from the bias assessment (34). Since the
CDMR proportion from an individual study was expected to be small, the logit transformation helps to
stabilise the variance and avoid pooled estimates outside the 0 – 1 range. The advantage of using
the quality effects model is that the between-study variability is adjusted based on observed study
quality instead of the random variable assigned by the random-effects model. Another benefit of the
quality effects model is that it avoids overdispersion and spurious statistical significance (35, 36).

Subsequently, a quality effect weighted meta-regression was done to investigate the possible
sources of variability in CDMR proportions observed between studies. The transformed pooled
estimate of CDMR along with all other moderator variables was imported in Stata software (version
16.0) to run the meta-regression analyses. Since all moderators were categorical, the meta-

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 regression analysis was equivalent to a subgroup analysis and the subgroup CDMR proportions are
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presented as the meta-regression output. A backward stepwise regression was used to discard the
least important variables, and finally, two variables were retained in a multivariable meta-regression
model. In the latter model, interaction terms between the two moderators were modelled. The
retrieved co-efficient and 95% confidence intervals (95% CIs) were back-transformed to the
proportion (presented as a percentage) for the easier interpretation. For meta-regression, a robust
(Huber-Eicker-White-sandwich) standard errors were used to allow for correct error estimation and
quality effects analytical weights were applied. Heterogeneity in between studies was large, as
assessed by the I-squared value (I2) that measures the proportion of observed variance that is not by
chance due to sampling error (37).

Results

Search outcome

In total, 615 articles were retrieved from the initial search, and among them, 158 were discarded as
the duplicates. From the initial screening of title and abstract, 53 articles added for full-text review.
The full text was not available for 16 studies and 13 more articles excluded from eligibility screening.
One study from low-income countries did not meet eligibility as CDMR was grouped under CD from
non- medical causes (3). Additionally, seven more articles added from reference tracking that made
the final count of 31 articles. (Figure 1)

[Figure 1: about here]

Systematic review findings

The highest number of articles were from the continent "East Asia" (n=12) followed by "Europe and
Central Asia" (n=10). In the economic subgroup, 15 articles were from HI, 14 from UMI and two from
LMI countries; none was from the LIC group. At the country level, one-third of our included articles
were from China (n=11). The data collection period for individual article ranged from 2 months (38) to
18 years(39). The majority of the studies used data from health facilities, whereas nine of them used
population-level data (25, 27, 39-45). The studies done in the urban context were higher in number
(n=12). Few population-based studies used specific code to report CDMR (25, 27, 41). In Taiwan, the
code 0373B was assigned by the national insurance company and consistently being used in

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 medical records(41). Similarly, the ICD 10 code, O82.8 was used across all hospitals in Sweden (25,
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27).

Around five million total births from 14 countries constituted the study sample. The absolute
proportion of CDMR ranged from 0.2% to 42%, and the majority of them (20 articles) had a rate
below 5%. The relative proportion ranged from 0.9% to 60%. The study with the lowest CDMR
percentage was from Ireland (46) while China had the highest CDMR percentage (42). Most
importantly, more than 50% of CDs were reported to be from the maternal request in three Chinese
studies (42, 47, 48). Elective CD proportion was available for 16 articles and ranged in between 2% to
64%. Summary findings are presented in Table S3.

Not all but some studies mentioned the reason for CDMR. The study from Ghana stated that
unavailability of the assisted vaginal delivery and proper labour monitoring facilities made the mother
less confident in choosing normal birth (49). Whereas, physician incompetency to handle complicated
labour was suspected in one study from China (42) Study from Nigeria documented that when women
prefer CD obstetricians were less likely to oppose this(50).

Only eight of 31 articles (25, 27, 38-40, 44, 47, 48) explained the determinants of CDMR. In general, the
commonly cited determinants were increasing maternal age(40, 44), primi mother(27, 38, 44, 47), residing in
urban area(38), excess pregnancy weight gain(38, 44), fear of childbirth(25, 26) and delivering in a well-
equipped health facility (38).

Study quality

Out of ten available safeguards, the lowest achieved count was six (50-52), and the highest was ten(40,
41, 44, 53). Only few of the studies mentioned their representativeness to national population(25, 27, 40, 41,
43, 44, 53, 54) and some did not discuss about representativeness against target population(26, 28, 45, 46, 48-52,
55-60), that jeopardized external validity. Outcome definition of CDMR did not match in four articles,
and the previous CD was included as a cause of CDMR there (25-28). Two other studies used maternal
self-reported data that suggest possible reporting bias (42, 43) Quality appraisal findings are depicted
in (Table S2B)

CDMR proportions and predictors of between-study variability:

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 Out of five million births reported through 31 studies, the proportion of CDMR-TD was 3% (95% CI:
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0.1%-9%). The Pooled incidence of caesarean deliveries (CD) was 31% (95% CI: 20%-43%). Out of
the total reported CDs, the CDMR-CD proportion was 11% (95% CI: 2%-26%). Considerable
statistical heterogeneity across studies was evident with I2 values up to 100%.

We explored the reason for heterogeneity by doing meta-regression based subgroups analysis
across eight subgroups (Table 1). The absolute proportion of CDMR was 11 folds higher in upper-
middle-income countries (11.71, 95% CI: 5.34-23.52) than in high-income countries. Across five
geographical regions, the Middle East had the highest CDMR estimates, followed by East Asia. The
articles that reported data beyond 2010 had higher CDMR proportion than those published before
that. Studies reporting CDMR proportion from nulliparous women had higher rates than the studies
with parous study populations. Similarly, CDMR was higher among women with mean age below 28
years. As suggested by R2 value, economic region individually explained 81% variation in CDMR-TD
and 74% in CDMR-CD proportion.

[Table 1:Here]

Table 2 on multivariable metaregression shows that studies from high-income countries reporting
CDMR beyond 2010 had a lower proportion of CDMR-TD ( 0.39%, 95% CI: 0.12-1.26) than their
counterpart (1.53%; 95% CI:1.12-2.09). A similar pattern was observed for the rest of the economic
regions. Economic region and study year together explained 84% of the variation in the CDMR-TD
and 76% of the variation in CDMR-CD. Comparison between Random and Quality Effect output from
univariable and multivariable models are presented in Table S4 & Table S5.

[Table 2: Here]

Discussion

Main findings

To our knowledge, this is the first systematic review and meta-regression that reports the proportion
and major factors associated with CDMR using evidence across the globe. The absolute CDMR
proportion varied significantly (0.2% to 42%) across the countries. The economic region and study
year contributed around 84% of the variability in the CDMR rates. The upper-middle-income

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 countries reported eleven times higher incidence of absolute CDMR proportions than the high-
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income countries.

Strengths and limitations

This study followed a standard protocol and methodology of systematic review and meta-regression
analysis (20, 61, 62). The methodological challenges and validity of data around CDMR were addressed
by using a valid and reliable definition of CDMR. We checked the comparability of our work with
other related reviews. Two systematic reviews on CDMR can be mentioned, one by Viswanathan,
2006(63), and another by Schantz et al., 2019 (17). The first review only focused on developed
countries’ CDMR rates, whereas the 2nd review examined the methodological variation of CDMR
data collection. As a secondary outcome, Schantz et al. reported the range of global CDMR rates
though their search strategy was not comprehensive. Their review was based on a single search
engine and done by a single reviewer (17). We addressed the limitations of these two reviews in our
study . Additionally a main strength of this review is the use of the quality effects meta-regression to
explain the observed variability across studies.

One of the limitations of our review is that non-English articles were not included. Ability to include
articles in Spanish or Portuguese language could have captured more data from Brazil and Latin
America, where the epidemic rise of CD has been noticed (12, 64). The other limitation of our review is
that it relies on the study reported data that can vary according to the medical record-keeping system
of that country. Since the majority of the articles explicitly mentioned the maternal request as the
cause of CD, there is less chance of reporting bias. However, to cite this review as global CDMR
incidence needs cautious interpretation as data from low-income countries are missing, and a wide
range of CDMR incidence is noted across the studies.

Interpretation

The Lancet global series on CD rate reported that 106 out of 169 countries in the world had their CD
above the threshold level(12). Our review on the subgroups of CD has identified that data on CDMR is
rarely reported, only 14 countries across the world reported CDMR proportions. Thus claiming
maternal request as a major driver of increasing CD rate needs more evidence. Our review identified
a higher CDMR proportion after 2010 compared to 2010. However, when we used interaction terms
in between economic region and study year, the proportion of CDMR was always lower beyond 2010

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 across all economic categories. This variation can be explained from model fit value. In our
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univariable model, the economic region itself explain around 81% of the total absolute CDMR
estimate. By using the interaction term of the study year and economic region, only 3% of variation in
absolute CDMR (R 2 =84%) estimate was added. This implies time has less influence on CDMR than
does a country's economic status. Within the economic subcategories, upper-middle-income region
revealed higher CDMR proportion than high-income region. With regard to this, earlier studies
reported that maternal decision on CD has also been influenced by physician choice and health
system capacity(38). This could mean that in high-income countries, usually having stringer health
care systems, women’s choice for CD in absence of a valid indication more frequently does not lead
to CD. On the contrary, in the absence of a proper regulatory framework, patient autonomy on
decision making are sometimes appears to be misused in upper-middle-income country settings
(38). Our review on series of articles from China supports this statement; (38) starting from high
CDMR proportion with one child policy in place; china could overcome their "secular trend of CD"
through several interventions. These include; health education, mandatory written informed consent,
painless delivery, presence of support person during birth and focused training for midwives and
obstetricians (65). The influence of health care providers on decision making was successfully
reduced through "price transparency policy" with mandatory reporting of the delivery expenditure for
all type of facility-based births (38)

We found fewer studies that report population-level data (25, 26, 41). The challenge of reporting CDMR
using population-level data was mentioned as a unavailability of specific ICD code for CDMR under
national vital statistics (61). In the absence of specific code, CDMR data extracted from medical
records followed the exclusion method, by excluding CDs done from clinical indications(40). The data
collected by this method carry more chance of bias when maternal requests are omitted; instead,
relative clinical conditions are recoded as CD indication (31). The opposite example also persists in
the context of high CD rate, medical practitioners, when obliged to justify CD indications, tend to
swing CD indications as maternal request (57). Both these forms of misclassification provide incorrect
CDMR estimates (57).

The evidence around risk vs benefit of CDMR is also not comprehensive that hinders better maternal
engagement in decision making process (66). With an attempt to generate robust evidence, the
recent Cochrane systematic review could not produce a single trial on CDMR vs planned vaginal
birth(67). However, sporadic data reported higher maternal and neonatal health risk from CDMR

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 comparing to other modes of births (65). Women having CDMR tend to suffer worse mental health in
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lack of protective effect of oxytocin hormone relasing from labour pain(68). CDMR also increases the
chance of a baby to be delivered preterm or early term (before 39 weeks) and hence increases the
risk of neonatal complication (69-71).

To overcome the current research gap, future research should focus on the appropriate reporting of
CDMR using a consistent definition and prospectively designed research (72, 73). A stable reduction of
CDMR rate should be supported by the improved maternal and neonatal health indicators.
Additionally, women who opted for CD on their own should be interviewed to learn about the level of
engagement of physician in the decision-making process(46, 47, 74). But, even more important, women’s
preference for the mode of birth should be explored during early week of pregnancies to identify the
prospective risk group of women who may need more counselling and support around childbirth(43).

Conclusion

Caesarean delivery on maternal request seems commonly discussed but less reported as
highlighted by our systematic review. Unfortunately, the bulk of current evidence is derived from
sources using an unreliable definition of CDMR that makes it difficult to differentiate the actual
contribution of maternal request on the medically no indicated caesarean sections. That, in turn, will
have implications for adequate planning and dissemination of interventions to reduce CDMR
incidence. Therefore, appropriate reporting of CDMR should be a key priority in maternal health
policies and practices. Moreover, better maternal engagement and supports are required to reduce
CDMR incidence and related health and financial burden.

Contribution to authorship

TB1, KMSUR and AAM wrote the protocol. TB1 and KMSUR independently did the article screening
and quality check. TB1 extracted data. Differences in opinion were resolved by discussion between
TB1, KMSUR, AAM and SD. Data analysis was done by TB1, YF, AAM and SD Data interpretation
and manuscript writing by TB1, AAM, SD, SUR, JS, YF, SA and TB 2.

Disclosure of interests

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 None declared. Completed disclosure of interest forms are available to view online as supporting
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information

Details of ethics approval

None

Funding

None

Acknowledgement

Authors admit the contribution of Marcos Riva, librarian of the University of Queensland for his help
during the literature search.

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Caption list:

Figure 1: PRISMA flow diagram on the article screening process and output on the global incidence
of caesarean deliveries on maternal request

Table 1: Univariable meta-regression analysis of CDMR by various variables of interest

Table 2: Multivariable meta-regression§ analysis of CDMR by the interaction of economic region and
study year

Online Supporting Material

Table S1: Study inclusion criteria for systematic review on the global incidence of CDMR using
PICOS format

Table S2A: Risk of Bias assessment tool to do quality appraisal of the observation studies on on
caesarean deliveries for maternal request

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 Table S2B: Quality appraisal findings of the observational studies on caesarean deliveries for
Accepted Article
maternal request

Table S3: Summary of the observational studies reporting the incidence of caesarean deliveries on
maternal request

Table S4: Model comparison on univariable analysis findings on caesarean deliveries for maternal
request by subgroups

Table S5: Model comparison on multivariable analysis findings on caesarean deliveries for maternal
request by subgroups

Appendix S1: Search Strategy for the global incidence of the caesarean deliveries on maternal
request

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 Table 1. Univariable meta-regression analysis of CDMR by various variables of interest
Accepted Article
Subgroups Number Total Caesarean CDMRa-TDb CDMRa-CDc
of deliveries deliveries
studies
d d
N=31 N=4950424 N=1570706 % (95% CI ) % (95% CI )
Geographical region
North America 3 497550 119182 0.51 (0.08-3.16) 2.12 (0.34-11.82)
Sub-Saharan Africa 2 4737 1264 0.72 (0.10-5.19) 2.74 (0.37-17.11)
Europe 10 678172 100769 1.27 (0.19-7.86) 8.39 (1.38-37.38)
East Asia 12 3615057 1275699 7.18 (3.02-16.00) 17.51 (8.02-33.85)
Middle East 4 154908 73792 15.32 (2.06-60.82) 30.36 (4.97-78.07)
Economic region
Lower Middle income 2 4737 1264 0.72 (0.25-2.02) 2.93 (1.13-6.34)
High income 15 3440297 917748 1.49 (1.06-2.06) 6.30 (4.82-7.06)
Upper middle income 14 1505390 651694 11.71 (5.34-23.52) 27.49 (16.88-37.85)
Study year
< 2010 17 3393782 908818 1.71 (1.37-2.13) 6.48 (5.09-8.10)
>=2010 14 1556642 661888 10.95 (6.16-18.73) 24.97 (15.43-37.64)
Study design
Retrospective 21 4682194 1489123 5.79 (0.53-41.32) 15.45 (2.66-54.20)
Prospective 10 268230 81584 11.30 (4.11-27.32) 27.09 (14.48-44.57)
Study area
Urban & rural 12 4625016 1436963 5.37 (0.6-34.25) 14.68 (1.91-60.13)
Urban 17 319898 131948 11.51 (4.86-24.64) 25.92 (12.19-46.81)
Rural 2 5510 1796 25.54 (3.10-78.68) 43.54 (7.6-88.03)
Data collection site
National level 9 4419867 1346237 5.32 (0.87-26.14) 15.45 (3.00-49.27)
Health facility 22 530557 224470 9.45 (5.12-16.69) 21.42 (12.63-32.98)
Study population
Nulliparous 11 1998692 695830 3.05 (1.48-42.23) 9.11 (4.38-18.59)
Parous 20 2951732 874876 9.53 (1.21-7.38) 23.15 (5.34-61.04)
Mean maternal age
>=28 years 12 507456 106096 10.63 (2.02-40.7) 25.67 (8.10-57.58)
<28 years 17 4431730 1462763 37.95 (18.6-62.07) 60.68 (41.60-76.96)
a b c d
CDMR (Caesarean Delivery on Maternal request), TD (Total Deliveries), CD (Caesarean Deliveries) CI (Confidence interval)
§Quality effect weights were used for meta-regression

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 Table 2. Multivariable meta-regression§ analysis of CDMR by the interaction of economic region and
Accepted Article
study year

*
Subgroups CDMRa-TDb **
CDMR-CDc
d d
% (95% CI ) % (95% CI )
High income & study year<2010 1.53(1.12-2.09) 5.98(4.87-7.31)
High Income & Study year >=2010 0.39(0.12-1.26) 1.82(0.52-6.2)

Upper-middle Income & <2010 24.02(8.91-50.54) 41.64(21.99-64.36)

Upper-middle Income & >=2010 11.48(5.33-22.98) 25.77(16.29-38.25)

Lower-middle Income & <2010 1.15(0.62-2.15) 4.36(2.88-6.56)

Lower-middle Income &>=2010 0.50(0.27-0.94) 1.86(1.22-2.84)
a b c d
CDMR (Caesarean Delivery on Maternal request), TD (Total Deliveries), CD (Caesarean Deliveries) CI (Confidence interval)
*R-squared for Adjusted CDMR-TD= 83% ; **R-squared for Adjusted CDMR-CD=76%
§Quality effect weights were used for meta-regression

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Accepted Article

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