Two Decades of Change in Childbirth Care in Cambodia (2000-2021): Disparities in Ceasarean Section Utilization Between Public and Private Facilities.

Abstract

Background: Cambodia, a lower-middle-income country, confronts challenges related to childbirth safety. This study investigated the utilization of childbirth care across public and private health facilities, with a particular focus on the use of caesarean section (C-section). It also examined disparities in service utilization across urban and rural areas and among different socioeconomic statuses.

Methods: This study used cross-sectional data from the Demographic and Health Surveys conducted in Cambodia in 2000, 2005, 2010, 2014 and 2021-22. Descriptive analyses were performed to elucidate changes in place of delivery and C-section rates by public and private health facilities. Logistic regressions were applied using data from 2010 to 2021 to identify factors associated with C-section.

Results: The facility-based delivery rate significantly increased to 96.5% by 2021, while the overall C-section rate rose to 15.5%. Within public facilities, the C-section rate grew from 5.1% in 2010 to 9.7% in 2021, consistently higher in urban areas compared to rural ones. Notably, C-section utilization in public facilities did not significantly vary among different wealth index groups. From 2010 to 2021, the C-section rates in private facilities surged from 11.0% to 48.1%, with urban and rural rates reaching 50.5% and 45.7%, respectively. In 2021, the richest and richer groups accounted for most C-section deliveries in private facilities, constituting 38.5% and 28.8%, respectively. C-section use was significantly higher in 2021 compared to 2010 (Adjusted OR 3.32, 95% CI [2.72, 4.07]). Women over 20 years old, living in Central Plain, from richer or richest households, had secondary and higher education level, with female household head and had only one child were more likely to undergo a C-section than other women.

Conclusions: The private facilities have significantly driven the increase in C-sections, particularly among wealthier economic groups. Strengthening health system governance and promoting public-private partnerships are vital to curb C-section overuse and ensure equitable and effective childbirth care coverage.