Title: Factors associated with cesarean delivery in Latin America and the Caribbean
Description: Cesarean delivery has notably increased around the world during the last three decades. Globally, the proportion of birth by cesarean delivery is higher in countries with higher levels of socioeconomic development, higher female enrollment in secondary education, higher levels of urbanization, greater density of physicians, and lower fertility. Additionally, cesarean rates are consistently higher in private than public health facilities in all regions of the world. Latin America and the Caribbean is the region with the highest cesarean rates globally and Dominican Republic is the country with one of the highest rates of cesareans worldwide. This research focuses on factors associated with cesarean delivery in Latin America and the Caribbean with an emphasis on Dominican Republic and is presented in three interconnected papers. The first paper, entitled “Determinants of cesarean delivery in Latin America and the Caribbean: a scoping review” identified factors associated with the escalating rates of cesareans in the region by mapping the literature on social determinants, women’s preferences, and healthcare providers’ attitudes and beliefs towards cesarean delivery.

Thirty studies conducted between 2009 and 2019 met the inclusion criteria for the scoping review. Cesarean delivery was positively associated with older maternal age, higher maternal education, higher household income or wealth, urban residency, and delivering at a private health facility. Other factors such as ethnicity and marital status were less consistently assessed in the studies. Many studies evaluated social determinants of cesarean as covariates in multivariate analysis but did not evaluate them as the primary association, hence the impact of those determinants in cesarean delivery remains understudied. Women’s beliefs and providers’ attitudes were found to influence cesarean rates; however, detailed evidence on individual incentives is still limited. The second paper entitle “Relationship between mode of delivery and type of health facility in Dominican Republic: an analysis of the Multiple Indicator Cluster Survey” is a secondary data analysis of a population-based survey that evaluates differences in the determinants of cesarean delivery in public and private healthcare facilities.

Among a sample of 4,398 women who delivered at a healthcare facility, cesarean rates were 48.1% and 86.5% in public and private hospitals respectively. In public hospitals, cesareans were associated with older maternal age, higher education, higher quintile of wealth, and Catholic religion. After adjusting for confounders, no associations were found between sociodemographic factors or maternal health characteristics and cesarean delivery in private hospitals. This study underscores the need to study other drivers of cesareans, particularly in private hospitals. The third paper entitle “Factors associated with cesarean delivery across maternal age groups in Dominica Republic” examines the differences in factors associated with cesarean delivery in adolescents, younger, and older women. Cesarean rates were 52.6%, 59.6%, and 71.0% in women aged <20, 20-34 or 35-39 years old respectively. Overall, there were no differences in the odds of cesarean delivery between adolescents and women aged 20-34.

Women aged 35 or older were more likely to have a cesarean delivery than women aged 20-34. In women 20-34 years old, education, Catholic religion, and wealth were associated with cesareans. In women >=35 years, education and wealth were associated with cesarean delivery. Delivering at a private hospital increased the odds of cesarean delivery across the three age groups. The objective of this dissertation is to contribute to the literature with evidence to inform programs, policies, and practice and to highlight opportunities for further research on determinants of cesarean delivery in Latin American and the Caribbean, and particularly in Dominican Republic.