DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2020 No. 167

Israa Al-Rawashdeh

Ibrahim Kharboush

Waqar Al-Kubaisy

August 2020

This document was produced for review by the United States Agency for

International Development.

Disparities in Cesarean Section among Women in Jordan:

Analysis of the 2017-18 Jordan Population 

and Family Health Survey (JPFHS) Data

DHS Working Paper No. 167 

Disparities in Cesarean Section among Women in Jordan: 

Analysis of the 2017-18 Jordan Population 

and Family Health Survey (JPFHS) Data 

Israa Al-Rawashdeh 1

Ibrahim Kharboush 1

Waqar Al-Kubaisy 1 

ICF 

Rockville, Maryland, USA 

August 2020 

1

 Department of Public Health, Faculty of Medicine, Mutah University, Jordan 

Corresponding author: Israa Al-Rawashdeh, Department of Public Health, Mutah University; email: 

israa.rawashdeh@mutah.edu.jo 
Acknowledgments: The authors wish to thank the United States Agency for International Development (USAID) 

for funding this research project through the Demographic Health Survey (DHS) Fellows Program. We wish to 

extend our gratitude to the facilitators (Shireen Assaf, Christina Juan, Flora Aninditya, and Madeleine Wayack) for 

their support and valuable advice during the workshops. We thank the reviewers, Lindsay Mallick and Shireen 

Assaf, the editors, and the formatter of this working paper. The authors would also like to acknowledge Mutah 

University for facilitating our participation in the Fellows Program. We are also thankful for our faculty’s assistance 

with the implementation of our capacity-building activities. 

Editor: Diane Stoy 

Document Production: Chris Gramer 

This study was implemented with support from USAID through The DHS Program (#720-0AA-18C00083). The 

views expressed are those of the authors and do not necessarily reflect the views of USAID or the United States 

Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate population, 

health, and nutrition programs. For additional information about The DHS Program contact: DHS Program, ICF, 

530 Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: +1-301-572-0950; fax: +1-301-572-0999; fax: 

+1-301-407-6501; email: reports@dhsprogram.com; internet: www.dhsprogram.com. 

Recommended citation: 

Al-Rawashdeh, Israa, Ibrahim Kharboush, and Waqar Al-Kubaisy. 2020. Disparities in Cesarean Section among 

Women in Jordan: Analysis of the 2017-18 Jordan Population and Family Health Survey (JPFHS) Data. DHS 

Working Paper No. 167. Rockville, MD, USA: ICF. 
iii 

CONTENTS 

TABLES ........................................................................................................................................................ v 

FIGURES .................................................................................................................................................... vii 

ABSTRACT ................................................................................................................................................. ix 

1 INTRODUCTION .............................................................................................................................. 1 

1.1 Background and research questions .................................................................................. 1 

1.2 Conceptual framework ........................................................................................................ 3 

2 DATA AND METHODS ................................................................................................................... 5 

2.1 Data ..................................................................................................................................... 5 

2.2 Variables ............................................................................................................................. 5 

2.2.1 Dependent variables .............................................................................................. 5 

2.2.2 Independent variables ............................................................................................ 5 

2.3 Statistical analysis ............................................................................................................... 6 

3 RESULTS ........................................................................................................................................ 7 

3.1 Descriptive statistics of the respondents............................................................................. 7 

3.2 Cesarean section by characteristics of the respondents .................................................... 9 

3.3 Cesarean section use by health system and decision making ........................................... 9 

3.4 Factors associated with cesarean section use ................................................................. 11 

4 DISCUSSION ................................................................................................................................. 13 

5 CONCLUSIONS ............................................................................................................................. 15 

REFERENCES ............................................................................................................................................ 17 

v 

TABLES 

Table 1 Percent distribution of women age 15-49 by selected sociodemographic 

characteristics (N=6,525) weighted, Jordan PFHS 2017-18 ..................................... 8 

Table 2 Cesarean section use by characteristics of the respondents, Jordan PFHS 

2017-18 .................................................................................................................... 10

Table 3 Adjusted logistic regression for various factors on C-section among women 

age 15-49 who had a live birth in the 5 years before the survey, for the most 

recent birth, Jordan PFHS 2017-18 ......................................................................... 12

vii 

FIGURES 

Figure 1 Conceptual framework ............................................................................................... 3

ix 

ABSTRACT 

Cesarean sections (C-sections) are surgical procedures that save maternal and infant lives. In some cases, 

C-sections are done when they are not necessary, while in other cases, some women are unable to access 

this life-saving intervention. Sociodemographic characteristics are associated with an increased use of 

C-section. Disparities in socioeconomic status and other factors exist in the rates of C-sections across 

diverse populations worldwide. Although C-sections are common in Jordan, there is limited evidence 

about the characteristics associated with C-sections. We aim to assess the factors related to the use of 

C-sections and to examine the sociodemographic disparities of these deliveries in Jordan. 

We analyzed data from the 2017-18 Jordan Population and Family Health Survey, which is the seventh to 

be conducted in Jordan. The analysis included a total of 6,525 women age 15-49 who delivered their most 

recent birth in a health facility in the 5 years before the survey. Statistical analyses used descriptive, 

bivariate, and logistic regression methods.

The results show that 27% of women were delivered by C-sections. C-section is significantly associated 

with older age groups, region, and place of delivery. No significant differences were found by wealth 

status, place of residence, educational level, employment, nationality, decision making on health, or 

health insurance. The odds ratio of C-section use for women age 40 and over is 3.3 (CI 2.0-5.5), 

compared to women under age 20. The odds of having a C-section is 40% higher for women who 

delivered in a private hospital compared to women who delivered in a public hospital (CI 1.2-1.8). The 

odds of C-section are 60% lower for women in Aqaba compared to women in Amman (CI 0.3-0.6), and 

60% higher for women in Madaba compared to the women in Amman (CI 1.2-2.1). 

This study assessed factors related to C-section among Jordanian mothers. Our findings highlight the 

increased practice of C-section in the private sector, and suggest the importance of developing national 

and subnational policies that include clear guidelines for performing C-sections, especially in the private 

sector. 

KEY WORDS: C-section, Jordan, JPFHS, cesarean, inequality, women 

1 

1 INTRODUCTION 

1.1 Background and research questions 

Cesarean sections (C-sections) can be a key requirement for safe childbirth. The rates of C-section 

deliveries are increasing worldwide. In developing countries, successful public health interventions that 

reduce maternal and neonatal mortalities and improve access to maternal health services have led to an 

increase in C-sections (Gebremedhin 2014). However, there are concerns that C-sections may pose an 

increased risk of maternal and neonatal health consequences. The risks of C-section mortalities and/or 

morbidities are greater in low- and middle-income countries (LMICs). This may be due to inadequate 

obstetric care in terms of capacity to perform the surgery safely or to treat surgical complications 

appropriately (Wells, Wibaek, and Poullas 2019). Many LMICs lack the facilities and the financial or 

human resources required for achieving the best outcomes from such a major surgical procedure. 

The World Health Organization (WHO) considers the ideal C-section rate to be between 10% and 15% 

(WHO 2018). This is based on evidence that showed an association between a reduced maternal mortality 

ratio (MMR) and neonatal mortality rate (NMR) when C-section rates rise toward 10%, and that 

C-section rates higher than 10% are not associated with reductions in maternal and newborn mortality 

rates. Nevertheless, many countries have exceeded this recommended threshold, particularly the LMICs 

(WHO 2018). This increase in C-sections has resulted in global concern. The WHO released a statement 

on C-section rates and provided a guideline on nonclinical interventions that can reduce unnecessary 

C-sections. The guideline’s recommendations are targeted to women, health-care professionals, and health 

organizations, facilities, and systems (WHO 2018). 

C-section should be performed when there is a risk to the mother or baby’s life (WHO 2018). A 

systematic review of 22 studies from 18 countries in 4 continents found that the majority of reported 

indications for C-section are maternal indications followed by fetal indications. The most frequently 

reported C-section indications were cephalopelvic disproportion, fetal distress, prior cesarean, 

dysfunctional labor, and elective cesarean (Vega 2015). C-section rates are also associated with other 

factors such as maternal obesity (Nkoka et al. 2019) and multiple pregnancies (Department Of Statistics 

Jordan and ICF 2019). In addition, increased maternal age and diabetes mellitus (Patel, Peters, and 

Murphy 2005) were also found to increase the odds of C-section. Differences in the style of professional 

practice and increased fear of medical litigation, as well as organizational and health system factors, have 

also been implicated in the use of C-section (Al Rifai 2017). Goyert et al. (1989) and De Muylder and 

Amy (1993) had previously reported that individual practice style might be an important determinant in 

the use of C-section by obstetricians. Moreover, Khawaja and Al-Nsour (2007) argued that countryspecific standards of practice, convenience of delivery, fear of litigation, and profitability may have 

contributed to an increasing rate of C-section. 

Beyond medically related factors, there is evidence that social and economic factors are important 

determinants of C-section rates in a country. Changes in the characteristics of the population may 

contribute to high rates of C-sections. These include delayed age of marriage, delayed age at first 

pregnancy, and older age at birth, which have led to an increased number of high-risk pregnancies and 

may have encouraged couples and health professionals to seek C-sections and positive outcomes (Al Rifai 
2 

2017). Demographic changes, such as the place of residence, have also been associated with increased 

C-sections related to cultural context (Amjad et al. 2018). Jadoon, Mahaini, and Gholbzouri (2019) 

reviewed literature from the WHO Eastern Mediterranean Region to explore disparities in C-sections 

among its 22 member states. Jadoon et al. (2019) found that cultural norms and traditional health beliefs, 

including attitudes toward health services and cultural, social, and family values, influence women’s 

choice of cesarean birth. For example, the patriarchal system in these regions, where decisions are made 

by husbands, fathers, and mothers-in-law, can be responsible for women’s limited decision-making power 

in seeking health care (Jadoon et al. 2019). There have also been reported differences in the rate of 

C-sections between urban and rural residence (Feng et al. 2012; Suparmi, Kusumawardhani, and 

Susiloretni 2019; Kang et al. 2019). 

Other researchers analyzed disparities in C-section deliveries within and between countries. There are 

disparities in C-section deliveries across and within African countries (Dankwah et al. 2019; Ushie, Udoh, 

and Ajayi 2019; Yaya et al. 2018), within middle eastern countries (Jadoon, Mahaini, and Gholbzouri 

2019), and across LMICs (Boatin et al. 2018; Boerma et al. 2018). Underuse of C-section among poor 

women compared to overuse among rich women was reported in Ghana (Dankwah et al. 2019). Boatin et 

al. (2018), who studied the C-section rates of 72 LMICs, found that rates are higher and change faster 

among the rich, and that the disparity varies among countries. 

The sustainable development goals (SDGs) have emphasized gender equality and women’s empowerment 

(Goal 5) and reducing inequalities within and among countries (Goal 10). With women’s empowerment, 

Qureshi and Shaikh (2007) found that the lack of control of Pakistani women over their own lives has a 

negative impact on their health and the health of their families. Pandey, Lama, and Lee (2011) in Nepal 

noted that women’s empowerment is related to women’s utilization of health-care services. To our 

knowledge, there are no available studies that address women’s empowerment and health-care utilization 

in Jordan. 

Jordan has one of the highest C-section rates in the Middle East. The most recent Population and Family 

Health Survey (JPFHS) shows that the C-section rate for all births is 26%, which is more than double the 

estimated rate by the WHO for an expected C-section rate in a population. The JPFHS report also shows a 

high ratio of planned to unplanned C-sections, which suggested that there might be a tendency toward 

unnecessary use of C-sections in Jordan (Department of Statistics Jordan and ICF 2019). In Jordan, there 

is some research on the levels and trends of C-sections, although research on the determinants is limited. 

A previous study from Jordan explored the levels and trends in the prevalence of C-section deliveries 

using DHS data from three surveys during 1990–2002. This study found an increase in the rate of 

C-section from 8.5% to 17.8% in 2002, with a slightly higher rates in private hospitals (Khawaja and AlNsour 2007). Nevertheless, our study is the most recent assessment of the C-section trends in Jordan, 

along with an investigation of variables that were not included in the previous studies such as women’s 

responsibility for decision making. 

Research on disparities in maternal health care and, more specifically, on the use of C-section among 

women in Jordan, is scarce. In addition to the evidence of socioeconomic disparities among women from 

different parts of the world, the displacement of many Syrian refugees to Jordan could add to the 

disparities by nationality. For example, one study found that C-section, anemia, lower weight of neonates, 

and lower APGAR scores were more prevalent among Syrian refugee women when compared to their 
3 

Jordanian counterparts (Alnuaimi et al. 2017). In contrast, a systematic review by Tappis et al. (2017) 

found that utilization of maternal health services was not different between Syrian refugees living in 

Jordan and Jordanian women. 

Our research will assess the use of C-section and the sociodemographic disparities of the C-section 

delivery rate in Jordan. 

The specific questions of this study are: 

1. What are the main factors associated with the use of C-sections in Jordan among women age 15-49? 

2. Are there disparities within the context of other social determinants of health related to C-section 

deliveries in Jordan? 

1.2 Conceptual framework 

Figure 1 shows the conceptual model for this study and describes the relationship between C-section and 

related nonclinical factors. In this model, the outcome is C-section use. The variables are categorized by 

the three factors identified in the literature as associated with the use of C-section: sociodemographic 

factors, factors related to health systems, and responsibility for decision making on health. 

The sociodemographic factors include mother’s age at birth, birth order, place of residence, region, 

education, employment, wealth status, and nationality. Health system factors include health insurance 

coverage and place of delivery. Women’s decision making defines the responsible person who makes 

decisions on a woman’s personal health care. These variables and the statistical examination of this 

conceptual framework are explained below. 

Figure 1 Conceptual framework 

The sociodemographic variables:

1. Mother’s age at birth

2. Place of residence

3. Region of residence

4. Education

5. Employment status

6. Wealth status

7. Birth order

8. Nationality

The health system-related

variables included the following:

1. Health insurance coverage

2. Place of delivery

The women’s decision making

variable:

Decision on own health care

C-section

5 

2 DATA AND METHODS 

2.1 Data 

This study is based on data from the 2017-18 Jordan Population and Family Health Survey, which is the 

seventh to be conducted in Jordan (Department of Statistics Jordan and ICF 2019). The sampling frame 

was based on Jordan’s Population and Housing Census frame for 2015. The JPFHS is representative of 

Jordan with data from Jordan’s 12 governorates distributed over three regions (South, Central, and North). 

The data is also representative of urban and rural areas separately, and of three national groups: 

Jordanians, Syrians, and a group of other nationalities. A total of 14,689 eligible women age 15-49 were 

successfully interviewed for the survey. 

Our study population included women age 15-49 who had a live birth in the 5 years before the survey and 

who delivered their most recent birth in a health facility. Women who did not deliver in the 5 years before 

the survey (n=7,389) and women who reported a noninstitutional delivery (n=106) were excluded. Since 

we are using decision making as a variable that is only asked of currently married women, we restricted 

our population to currently married women and excluded unmarried women (n=124). After weighting and 

excluding women with missing responses, the sample size for our study was 6,525 women. 

2.2 Variables 

2.2.1 Dependent variables 

The dependent variable is C-section delivery among currently married women age 15–49 for their most 

recent birth in the 5 years before the survey. The variable used the responses to one question in the 

JPFHS: “Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out?” 

with a binary outcome of “yes” or “no” categories. 

2.2.2 Independent variables 

With our conceptual model, three sets of variables that are associated with C-section delivery were 

identified from empirical evidence. These are sociodemographic variables, health system-related 

variables, and variables of decision making. 

The sociodemographic variables included the following: 

1. Mother’s age at birth defined as the age of the mother at the time of the birth and calculated by 

subtracting the date of birth of the individual woman respondent from the date of the child’s birth. 

This was recoded into four categories of 10-year intervals: <20, 20-29, 30-39, and 40+. 

2. Place of residence defined as either urban or rural. 

3. Region of residence defined as the first administrative level within the country, as reflected in 

Jordan’s 12 governorates. 
6 

4. Respondent’s educational attainment defined in four categories: no education, primary, secondary, 

and higher. 

5. Employment status recoded into two categories of employed and non-employed. 

6. Wealth status index defined as the wealth status of the household, captured in five quintiles: poorest, 

poorer, middle, richer, and richest. 

7. Birth order defined as the order number of the births from first to last and recoded into three groups: 

first birth, second to third birth, and fourth birth or more. 

8. Nationality recoded into three categories of Jordanian, Syrian, and other. The other category includes 

Egyptian, Iraqi, other Arab nationalities, and non-Arab nationalities. 

The health system variables included the following: 

1. Health insurance coverage defined as the woman having any type of health insurance or not. 

2. The place of delivery recoded into two groups of either private or public health facility. 

The women’s decision-making variable is defined as the person who usually makes decisions about the 

respondent’s own health care. The variable is measured by asking the question: “Who usually makes 

decisions about health care for yourself: you, your husband, you and your husband jointly, or someone 

else?” This is recoded into four categories: respondent alone, respondent and her husband, husband alone, 

and others. 

2.3 Statistical analysis 

Data analyses were performed with Stata version 16.0 software. The data were weighted to account for 

disproportionate sampling and nonresponse. The analysis also adjusted for the effect of the complex 

survey design. The data analyses included descriptive and inferential statistics. The baseline 

socioeconomic, demographic, and other characteristics of respondents were computed with summary 

statistics and percentages. Bivariate analysis was performed to assess the relationship between the 

independent variables and the dependent variable using the chi-square test. The association between the 

independent variables and C-section among women was investigated with logistic regression. The results 

were presented with adjusted odds ratios (OR) with 95% confidence intervals (CI). A p-value of less than 

0.05 was set for statistical significance. 
7 

3 RESULTS 

3.1 Descriptive statistics of the respondents 

A total of 6,525 women were included in this study. Table 1 summarizes the sociodemographic 

characteristics of currently married women age 15-49 who delivered their most recent live birth in a 

health facility in the 5 years before the survey. The percentage of women who delivered by C-section was 

27%. Half of the sample (51%) were women age 20-29, 39% were between 30-39, 5% were age 40 or 

above, and 5% were younger than age 20. The majority of women (89%) reside in urban areas. 

Approximately 37% of the women live in Amman, the capital of Jordan, 19% in Irbid, the largest 

governorate of North Jordan, and 13% in Zarqa, a governorate of the Central Region of Jordan, while the 

rest were distributed across the remaining nine governorates. The majority of women were Jordanian 

(86%), while 11% were Syrian and 4% were other nationalities. The proportion with education beyond 

the secondary level was relatively high with more than half (53%) of the women having completed 

secondary education and 39% higher education. The great majority of the women were unemployed at the 

time of the survey (87%). 

The results of the household wealth index show that 48% of women were in the poorer and poorest 

quintiles compared to 30% in the richer and richest quintiles. More than one-third of women (38%) had 

four or more births, while 42% had two or three births. Nearly 65% of the women delivered in public 

hospitals. The percentage of women with health insurance was 62%, while the remaining did not have any 

type of health insurance. 

Regarding decision making, it was found that the decision is shared between a woman and her husband in 

most of the cases (69%), while only 23% of women make this decision by themselves. 

 
8 

Table 1 Percent distribution of women age 15-49 by selected sociodemographic characteristics 

(N=6,525) weighted, Jordan PFHS 2017-18 

% N 

Delivery by cesarean section 

C-section 27.2 1,772 

Other 72.8 4,753 

Mother’s age at birth 

<20 5.2 336 

20-29 50.7 3,309 

30-39 39.0 2,545 

>=40 5.1 334 

 

Type of place of residence 

Urban 88.6 5,780 

Rural 11.4 746 

Region by governorate 

Amman 37.2 2,425 

Balqa 5.1 330 

Zarqa 13.2 860 

Madaba 2.6 167 

Irbid 19.3 1,259 

Mafraq 7.3 474 

Jerash 3.3 217 

Aljoun 2.5 165 

Karak 3.6 235 

Tafilah 1.7 109 

Maan 1.7 112 

Aqaba 2.6 170 

 

Educational level 

No education 1.3 88 

Primary 6.2 406 

Secondary 53.0 3,457 

Higher 39.4 2,574 

Employment 

Not employed 87.1 5,687 

Employed 12.9 839 

Wealth 

Poorest 24.2 1,581 

Poorer 23.6 1,540 

Middle 21.9 1,427 

Richer 19.1 1,243 

Richest 11.2 734 

Birth order number 

First 19.4 1,265 

2-3 42.3 2,760 

4 and more 38.3 2,500 

 

Nationality

Jordanian 85.5 5,578 

Syrian 10.6 692 

Other 3.9 255 

Person responsible for decision making 

on respondent’s health care 

Respondent alone 22.5 1,469 

Respondent and husband 69.2 4,514 

Husband alone 8.1 529 

Others 0.2 13 

 

Place of delivery

Public 64.6 4,216 

Private 35.4 2,309 

Health insurance coverage 

No 38.1 2,485 

Yes 61.9 4,041 

Total 100.0 6,525 

Note: The women who had no births in the 5 years before the 

survey, women who did not have their delivery at a health institution, 

and women who are not currently married are excluded. 
9 

3.2 Cesarean section by characteristics of the respondents 

Table 2 shows C-section by characteristics of the women. C-section deliveries were significantly different 

between age groups. Women below age 20 had the lowest rates of C-section compared to the other older 

groups. C-section rates did not differ according to birth order among women. 

No significant differences in C-section use were found between women who reside in urban areas 

compared to the rural areas. However, a significant difference in C-section use was found among the 

different regions in Jordan. Madaba (a Central Region governorate) had the highest rate of C-section 

(35%), while Aqaba had the lowest rate (13%). The results also show no relationship between 

employment status and C-section. Comparisons of women with different levels of education show that 

although women with no education undergo C-section slightly more often (31%) than women of primary 

(28.5%), secondary (26%), or more highly (29%) educated groups, the results were not statistically 

significant. The use of C-section did not differ between Jordanian women and women of other 

nationalities. 

3.3 Cesarean section use by health system and decision making 

As shown in Table 2, C-section was found to be more common in private facilities (31%) than in public 

facilities (25%). However, there was no significant difference between insured women and uninsured 

women in the use of C-section. Our findings show that 49% of women had a C-section if the decision was 

made by others compared to 23-28% if the decision was made by the respondent alone, or by her husband 

or jointly. However, these differences were not statistically significant. 

 
10 

Table 2 Cesarean section use by characteristics of the respondents, Jordan PFHS 2017-18 

% CI p-value 

Mother’s age at birth <0.001 

<20 19.0 [14.1,25.1] 

20-29 25.0 [22.9,27.2] 

30-39 30.5 [27.9,33.2] 

>=40 31.6 [25.6,38.3] 

Type of place of residence 0.911 

Urban 27.2 [25.5,28.9] 

Rural 27.0 [24.0,30.2] 

 

Region by governorate 0.003 

Amman 27.0 [23.9,30.3] 

Balqa 29.5 [25.3,34.0] 

Zarqa 27.4 [23.5,31.6] 

Madaba 35.3 [30.7,40.2] 

Irbid 28.7 [25.1,32.7] 

Mafraq 27.5 [24.7,30.6] 

Jerash 26.6 [22.6,31.0] 

Aljoun 28.1 [24.2,32.4] 

Karak 22.8 [18.4,27.9] 

Tafilah 29.5 [25.5,33.9] 

Maan 19.4 [15.2,24.4] 

Aqaba 13.0 [10.3,16.3] 

Educational level 0.237 

No education 31.3 [21.1,43.7] 

Primary 28.5 [22.8,35.0] 

Secondary 25.7 [23.7,27.8] 

Higher 28.7 [26.1,31.5] 

Employment 0.651 

Not employed 27.0 [25.4,28.7] 

Employed 28.2 [23.6,33.3] 

Wealth 0.599 

Poorest 26.3 [23.4,29.3] 

Poorer 28.5 [25.5,31.6] 

Middle 25.4 [22.4,28.7] 

Richer 29.2 [24.8,34.1] 

Richest 26.3 [20.8,32.6] 

 

Birth order number 0.221 

First 29.2 [25.6,33.1] 

2-3 27.7 [25.3,30.2] 

4 and more 25.5 [23.1,28.1] 

Nationality 0.662 

Jordanian 27.4 [25.7,29.2] 

Syrian 26.3 [22.2,30.9] 

Other 24.1 [17.4,32.4] 

Person responsible for decision 

making on respondent’s health care 0.183 

Respondent alone 28.3 [25.3,31.6] 

Respondent and husband 27.3 [25.4,29.2] 

Husband alone 22.5 [18.0,27.7] 

Others 49.0 [15.1,83.8] 

Place of delivery 0.005 

Public 25.3 [23.5,27.2] 

Private 30.6 [27.6,33.7] 

 

Health insurance coverage 0.530 

No 26.5 [23.9,29.3] 

Yes 27.6 [25.7,29.5] 

Total 27.2 [25.6,28.7] 
11 

3.4 Factors associated with cesarean section use 

Table 3 summarizes the results of the logistic regression analyses for C-section among the women in this 

study. We found that region, mother’s age at birth, birth order, and facility type were significantly 

associated with C-section delivery. 

Our analysis shows that the mother’s age is significantly associated with C-section. Mothers who gave 

birth at age 30-39 and 40 and over had almost three times the odds of C-section delivery compared to 

mothers who were younger than age 20. The region where a woman resides was also significantly 

associated with C-section. The odds of C-section use are 60% lower for women in Aqaba compared to 

women in Amman (CI 0.3-0.6, p<0.001) and are 60% higher for women in Madaba compared to women 

in Amman (CI 1.2- 2.1, p<0.01). No other regions showed a significant difference in C-section compared 

to Amman. The study also found that the odds ratio of C-section for women with a 4th or higher birth 

order were 50% lower compared to women with a first-order birth (CI 0.4-0.7, p<0.001). No significant 

associations were found with C-section in relation to the women’s place of residence, education, 

employment, wealth status, or nationality. 

With the health system variables, facility type was a significant factor in relation to C-section. The odds 

of having a C-section were 40% higher for women who delivered in private hospital compared to women 

who delivered in a public hospital (CI 1.2-1.8, p<0.001). Health insurance coverage and women’s 

decision making about her own health were not significantly associated with C-section. 

 
12 

Table 3 Adjusted logistic regression for various factors on C-section among women age 15-49 

who had a live birth in the 5 years before the survey, for the most recent birth, Jordan 

PFHS 2017-18 

C-section 

Variable AOR 95% CI 

Mother’s age at birth (Ref. <20) 

20-29 1.7** 1.1 - 2.7 

30-39 2.9*** 1.9 - 4.5 

>=40 3.3*** 2.0 - 5.5 

Type of place of residence 

(Ref. Urban) 

Rural 1.0 0.8 - 1.2 

 

Region by governorate (Ref. Amman) 

Balqa 1.3 1.0 - 1.7 

Zarqa 1.1 0.9 - 1.5 

Madaba 1.6** 1.2 - 2.1 

Irbid 1.2 0.9 - 1.5 

Mafraq 1.2 0.9 - 1.6 

Jerash 1.1 0.8 - 1.5 

Aljoun 1.1 0.8 - 1.5 

Karak 0.8 0.6 - 1.2 

Tafilah 1.2 0.9 - 1.7 

Maan 0.8 0.5 - 1.1 

Aqaba 0.4*** 0.3 - 0.6 

Education (Ref. None) 

Primary 0.9 0.5 - 1.7 

Secondary 0.7 0.4 - 1.3 

Higher 0.8 0.4 - 1.4 

Employment (Ref. Employed) 

Not employed 0.9 0.7 - 1.3 

Wealth (Ref. Poorest) 

Poorer 1.1 0.9 - 1.4 

Middle 0.9 0.7 - 1.2 

Richer 1.0 0.7 - 1.4 

Richest 0.8 0.5 - 1.2 

 

Birth order number (Ref. First) 

2-3 0.8 0.6 - 1.0 

4 and more 0.5*** 0.4 - 0.7 

Nationality (Ref. Jordanian) 

Syrian 1.0 0.8 - 1.4 

Others 0.8 0.5 - 1.3 

 

Person responsible for decision 

making on respondent’s health care 

(Ref. Respondent alone) 

Respondent and husband 1.0 0.8 - 1.2 

Husband alone 0.8 0.5 - 1.1 

Others 2.9 0.6 - 14.5 

Place of delivery (Ref. Public) 

Private 1.4*** 1.2 - 1.8 

 

Health insurance coverage (Ref. No) 

Yes 1.1 0.9 - 1.3 

AOR: adjusted odds ratio 

*** p<0.001, ** p<0.01, * p<0.05 
13 

4 DISCUSSION 

This study assessed the use of C-section in Jordan and examined the sociodemographic disparities of the 

rate of C-section delivery among Jordanian women age 15-49. The study was a secondary analysis of the 

JPFHS 2017-18. The data showed that 27% of currently married women age 15 to 49 reported C-section 

as the mode of delivery of their last birth within 5 years before the survey. 

Our study showed that C-section deliveries were significantly different among age groups, with 

C-sections more common among older mothers than the younger mothers. This finding is consistent with 

previous JPFHS surveys from 2007 and 2012, when the rates of C-section increased with older mothers. 

Similar findings were reported in Egypt by Al Rifai in 2017. This might be related to a previous history of 

having a C-section in the older maternal age groups. Studies in Jordan report previous C-section to be a 

primary indicator for repeated C-section (Akasheh and Amarin 2000; Omar and Qudah 2007). Increased 

C-sections among older mothers are also commonly perceived as clinically driven because pregnancies at 

an older age are associated with medical complications (Dulitzki et al. 1998). Herstad et al. (2016) 

reported increased C-sections in Norway among women who were older than 35 who had low-risk 

pregnancies with their first baby. Similarly, an older study by Peipert and Bracken (1993) found that 

C-section rates increased with maternal age among groups of women with and without complications of 

pregnancy or labor. Another study reported that older primiparous women were at significantly increased 

risk of C-section delivery even when no complication were present (Gordon et al. 1991). Evidence from 

Jordan about the underlying factors for higher C-section among older mothers is needed. 

Our analysis found a significant difference in C-section rates between different regions. Among the 12 

governorates of Jordan, women living in Madaba reported the highest rate of C-section, while women 

living in Aqaba had the lowest rate. Previous JPFHS data from 2007 and 2012 reported Madaba to have 

the highest rates of births by C-section, 22.6% and 33.9% respectively. The lowest rates of C-section 

among births that varied across the years were in Mafraq (13.3%) in 2007 and Maan (19.7%) in 2012. 

These findings are difficult to explain given the lack of evidence on differences in obstetric health-care 

practice specific to each governorate. This would be an important topic for future research. 

This study shows that place of delivery is an important determinant for C-sections in Jordan. We found a 

significantly higher number of women having C-sections for their last birth in private care facilities 

compared to the public facilities. This is consistent with other studies in Jordan (Batieha et al. 2017; 

HamdAllah 2018; Khawaja and Al-Nsour 2007). The high number of C-sections in the private sector 

might be explained by women’s preferences to utilize private services. A qualitative study conducted in 

Jordan found that women tend to perceive private health-care services to be of higher quality compared to 

public health-care services and that women choose private health care over the public services, 

particularly for the antenatal care, although the higher costs of delivery in private hospitals can affect their 

choice of delivery in these hospitals (Alyahya et al. 2019). The private sector in Jordan is very active and 

is one of the main health-care providers, with 66 of the 116 total number of all sector hospitals (The 

Hashemite Kingdom of Jordan High Health Council 2016). Other reasons reported were the preference of 

women to choose C-section delivery due to fear of pain or the belief that C-section is safer (Al Rowaily, 

Alsalem, and Abolfotouh 2014; Kamal 2013; McCourt et al. 2007). These preferences might be 
14 

considered in the private sector, which in turn might result in more C-sections (Mehedi, Al-Diwan, and 

Al-Hadithi 2018). 

The present study focused on disparities in the use of C-section among women in Jordan. In our study, 

there were no significant differences between mothers in relation to wealth status, place of residence, 

educational level, employment, or nationality. This is inconsistent with evidence from other studies (Al 

Rifai 2017; Cavallaro et al. 2013). Explanations might be found in context-specific analysis of the 

socioeconomic factors in Jordan. Nevertheless, reports show that Jordan’s socioeconomic inequality 

levels are low compared to international standards (UNDP 2015). 

This study has a number of strengths. First, the study used recent data from a nationally representative 

demographic and health survey in Jordan, which allows for generalizability of the study’s results in the 

Jordanian context. Second, the study adds to the limited pool of evidence on the factors related to 

C-section in Jordan. However, since the JPFHS is a cross-sectional survey, we are unable to determine 

causality of the associations between the variables of interest. Another limitation is that we were unable to 

determine where and when women are not receiving necessary C-sections or where and when women are 

having C-sections that are unnecessary. 
15 

5 CONCLUSIONS 

Overall, this study found the strongest predictor of C-section to be older maternal age at birth. C-sections 

are more prevalent in Madaba and are less prevalent in Aqaba. Higher numbers of C-section deliveries 

occurred in the private sector, which might reflect variation in practice between public and private 

providers. No significant differences in C-section were found by wealth status, place of residence, 

educational level, employment, nationality, decision making on health, or health insurance, which reflect 

low disparities in C-section performance among women in Jordan. This study highlights a need to identify 

where C-section is overused in Jordan and then to formulate strategies capable of controlling or regulating 

the performance of C-sections and reducing any unnecessary C-sections. 

17 

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