Inequalities in the prevalence of Caesarean section and associated factors in rural and urban Nigeria: insights from the 2018 Nigeria Demographic and Health Survey

Abstract Introduction When medically indicated, caesarean section (CS) can be a lifesaving intervention for mothers and their newborns. This study assesses the within-population CS prevalence and associated factors with an emphasis on inequalities between rural and urban areas in Nigeria. Methods We disaggregated the 2018 Nigeria Demographic Health Survey and performed analysis separately for the overall, rural, and urban residences in Nigeria. Data were summarised using frequency tabulations, and factors associated with CS were identified through multivariable binary logistic regression analysis. Results The prevalence of CS was 2.7% in Nigeria (overall), 5.2% in urban and 1.2% in rural areas. The North-West region had the lowest prevalence, with 0.7% overall, 1.5% in urban, and 0.4% in rural areas, respectively. Mothers with higher education demonstrated a greater CS prevalence of 14.0% overall, 15.3% in urban and 9.7% in rural residences. Frequent internet use increased the prevalence of CS in Nigeria (14.3%), urban (14.1%) and rural (10.1%) residences. Across all residences, rich wealth index, maternal age ≥35, 8+ antenatal contacts and lower birth order increased the odds of a CS. In rural Nigeria, husbands' education, spouses’ joint healthcare decisions, birth size, and unplanned pregnancy were associated with higher CS odds. In urban Nigeria, multiple births, Christianity, frequent internet use, and ease of healthcare permission were associated with greater CS odds. Conclusion CS utilisation remains low and varies across rural-urban, regional, and socioeconomic divides in Nigeria. Targeted interventions are imperative for uneducated and socioeconomically disadvantaged mothers across all regions and Muslim mothers in urban areas. Health insurance was not a significant predictor; hence, rather than merely subsidising costs, a holistic intervention that confronts social inequalities (between rural and urban residents), fosters high-quality education, promotes access to the Internet, guarantees equal opportunities, and empowers individuals and communities to improve their socio-economic well-being, is likely to yield more impactful and sustainable outcomes.