Caesarean section use increased but absolute wealth inequality widened in Ghana, 2003–2022: a repeated cross-sectional study
Although caesarean section use increased across all wealth groups in Ghana between 2003 and 2022, the absolute wealth-based inequality in access widened significantly despite universal insurance coverage, highlighting the need to monitor both proportional and absolute disparities while addressing factors beyond financial entitlement such as facility capacity and service organization.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In many parts of the world, a Caesarean section is a life-saving surgery. It is the tool doctors use when a baby cannot be born safely through the normal route, or when a mother faces a dangerous complication during labor. For this surgery to happen, a woman needs more than just a medical order; she needs a hospital with a surgeon, an anesthesiologist, a blood supply, and a way to get to that hospital quickly. When these things are missing, women and babies can die. When they are present, lives are saved. But having the surgery available does not mean everyone gets it. In many countries, who receives this care depends heavily on how much money a family has. The question researchers often ask is whether removing the cost of the surgery helps the poorest women catch up to the richest, or if the gap between them simply grows wider in a different way.
A team of researchers in Ghana set out to answer this question by looking at two decades of change. They examined data from over 14,000 mothers who gave birth between 2003 and 2022. During this time, Ghana tried two different ways to make childbirth free. First, the government stopped charging fees for delivery in the poorest regions, then across the whole country. Later, they switched to a national health insurance system where pregnant women were exempt from paying premiums. The researchers wanted to see if these changes helped poor women get Caesarean sections as often as rich women. They did not try to prove that the policies caused the changes, but rather to describe exactly what happened to the numbers over time.
The story the data tells is complex. On one hand, the use of Caesarean sections rose dramatically across the entire country. In 2003, only about 4 out of every 100 babies were born this way. By 2022, that number had jumped to 20 out of every 100. This increase happened for everyone, including the poorest families. The rate for the poorest fifth of the population went from 2.6 percent to 12.4 percent. That is a huge proportional gain, more than quadrupling the rate. However, the richest families also saw a massive jump, going from 12.3 percent to 35.7 percent. Because the rich started with a higher rate and gained even more in raw numbers, the actual distance between the rich and the poor grew larger. In 2003, the gap between the richest and poorest groups was about 10 percentage points. By 2022, that gap had widened to 23 percentage points.
This creates a situation where two different ways of looking at the data tell opposite stories. If you look at the ratio, or how many times more likely a rich woman is to get the surgery compared to a poor one, the inequality actually improved. The ratio dropped from nearly 5 to 1 down to about 3 to 1. But if you look at the simple difference in the number of surgeries, the inequality got worse. The researchers explain that both statements are true at the same time. The poorest women are getting the surgery more often than before, which is good news. But the richest women are getting it even more often, leaving a larger absolute gap in the total number of procedures performed.
The study also looked at why this gap exists. It is not just about having health insurance. By 2022, nearly every woman in the survey had health insurance coverage, yet the gap remained. The researchers found that education and where a woman lived explained only part of the problem. A significant portion of the inequality came from where women chose to give birth. Private hospitals, which are used more often by wealthy families, performed a much higher share of Caesarean sections than public hospitals. Even though private hospitals made up only about 12 percent of all facility births in 2022, they were responsible for a large share of the inequality between rich and poor. The data showed that wealthy women were far more likely to go to a private facility, and those facilities performed the surgery at higher rates than public ones.
The researchers were careful to note what they could not know. The surveys they used did not record the medical reasons for the surgeries. They do not know if the poor women who did not get a Caesarean section needed one but could not get it, or if the rich women who did get one needed it or if it was done for other reasons. They also could not measure the hidden barriers that surveys often miss, such as the cost of transportation to a hospital, the time it takes to get a referral, or whether a hospital has a surgeon available at the moment a woman arrives. The study suggests that while removing the price tag on delivery helped increase the total number of surgeries, it did not fix the deeper issues of access, referral, and capacity that keep the gap between rich and poor wide. The results show that making a service free is only the first step; ensuring that everyone can actually reach the care they need requires looking beyond insurance cards to the roads, the hospitals, and the people who work there.
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