Trend and associated factors of cesarean section rate in Ethiopia: Evidence from 2000–2019 Ethiopia demographic and health survey data

**Background:** Cesarean section (CS) is a critical obstetric intervention, but rates below 5% suggest unmet need, while rates above 15% may pose risks. In Ethiopia, previous national CS rates were very low (0.7% in 2000, 1.9% in 2016), far below the WHO recommended 10-15%. This study aimed to determine the trend of CS rates from 1995 to 2019 and identify associated factors using nationally representative data.

**Methods:** The study used five Ethiopia Demographic and Health Surveys (EDHS) from 2000, 2005, 2011, 2016, and 2019 (mini EDHS). Trend analysis was performed separately for urban and rural areas using the Extended Mantel-Haenszel chi-square test for linear trend. Factors associated with CS were identified using the 2016 EDHS data (n=11,022 live births) via multilevel logistic regression, accounting for individual- and community-level factors. The analysis was adjusted for clustering and sampling weights. Data were analyzed using STATA 14.1 and OpenEpi software.

**Key Results:** The overall CS rate increased from 0.7% in 2000 to 6% in 2019. In urban areas, CS rose from 5.1% (95% CI: 3.7-7.1) in 2000 to 10.6% (95% CI: 8.5-13.1) in 2016 and 16% in 2019 (year-specific). In rural areas, CS increased from 0.2% (95% CI: 0.1-0.3) in 2000 to 0.9% (95% CI: 0.3-1.6) in 2016 and 3% in 2019. The linear trend was significant in both urban (X²=20.72, p<0.0001) and rural (X²=52.72, p<0.0001) areas. The absolute change from 1995 to 2019 was 10.2% in urban and 2.9% in rural areas, with average annual rate increases of 4% and 6.8%, respectively.

In the final multilevel model (Model IV, PCV=96.6%), factors significantly associated with higher CS odds included: maternal age 25-34 years (AOR=2.79; 95% CI: 1.92-4.07) and 35-49 years (AOR=5.23; 95% CI: 2.85-9.59); primary education (AOR=1.94; 95% CI: 1.23-3.11), secondary education (AOR=2.01; 95% CI: 1.17-3.56), and higher education (AOR=4.12; 95% CI: 2.33-7.29); multiple pregnancy (AOR=11.12; 95% CI: 5.37-23.23); overweight (BMI>25) (AOR=1.73; 95% CI: 1.22-2.45); urban residence (AOR=2.28; 95% CI: 1.35-3.88); and ANC visits 1-3 (AOR=2.26; 95% CI: 1.12-4.58) and ≥4 (AOR=3.34; 95% CI: 1.67-6.66). Factors associated with lower CS odds included parity 2-4 (AOR=0.54; 95% CI: 0.37-0.80) and birth order >4 (AOR=0.42; 95% CI: 0.21-0.84). Regional variation was also observed, with Harari region having higher odds (AOR=3.00; 95% CI: 1.55-5.81) compared to Tigray.

**Clinical Implications:** The CS rate in Ethiopia remains below WHO recommendations, particularly in rural areas, indicating substantial unmet need for life-saving obstetric care. The findings highlight the need to improve access to CS in rural areas, enhance women's education, promote antenatal care utilization, and address geographic and socioeconomic disparities. Interventions should target older women, those with higher education, multiple pregnancies, and overweight women, while also ensuring that CS is available when medically indicated. The low CS rate in rural areas (0.9% in 2016) suggests that many women who need CS may not be receiving it, potentially contributing to maternal and neonatal mortality.