Trends in caesarean births and socioeconomic and geographic inequalities in Pakistan: a comparative analysis of South Asia

Caesarean section (CS) is a life-saving procedure when medically indicated; however, its increasing use has raised concerns about potential overuse and inequitable access across socioeconomic and geographic groups, particularly in low- and middle-income countries. This study examined trends in CS prevalence and associated socioeconomic and geographic inequalities in Pakistan, with comparisons across South Asian countries. Demographic and Health Survey data from Pakistan (2006, 2012, and 2017) and selected South Asian countries were analysed using the World Health Organization’s Health Equity Assessment Toolkit (HEAT). Inequalities were assessed by wealth quintile, educational attainment, place of residence, and subnational region using four summary measures: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF). Estimates were reported with 95% confidence intervals (CIs). In Pakistan, CS prevalence increased from 8.70% in 2006 to 24.40% in 2017. In 2017, prevalence was substantially higher among women in the richest wealth quintile (46.10%) than among those in the poorest quintile (10.00%), and among women with higher education (51.10%) than among those with no education (12.50%). Urban women had a higher prevalence than rural women (34.90% vs. 19.40%). Punjab recorded the highest provincial prevalence (31.80%), whereas Balochistan recorded the lowest (4.20%). Absolute inequalities increased over time, although relative inequalities declined for wealth, education, and place of residence. Cross-country comparisons showed that Bangladesh had the highest CS prevalence among women in the richest wealth quintile (61.30%), urban women (43.70%), and women with higher education (59.40%), while prevalence and inequality patterns varied across the countries examined. CS prevalence increased substantially in Pakistan between 2006 and 2017, with persistent socioeconomic and geographic inequalities. Policies should promote equitable access to medically indicated CS while strengthening clinical oversight to identify and reduce potentially unnecessary procedures. Addressing both underuse and potential overuse is essential to improving maternal healthcare equity.