title: Challenges affecting access to cesarean delivery and strategies to overcome them in low-income countries.
abstract: BACKGROUND
  Most maternal deaths occur in low-income countries where access to appropriate medical care is restricted.
  
  
  OBJECTIVE
  To evaluate rates of cesarean deliveries and identify barriers to this mode of delivery in low-income countries.
  
  
  METHODS
  A review of Medline and PubMed was performed to identify reports published in English or French using the keywords "cesarean section," "maternal mortality," and "developing countries."
  
  
  METHODS
  Studies investigating the obstacles to cesarean delivery and plans to overcome them in low-income countries were included.
  
  
  METHODS
  Data from included studies were extracted and analyzed.
  
  
  RESULTS
  Studies from 16 countries in Sub-Saharan Africa were included. The average rate of cesarean delivery was 3.6% (range 1.5%-7.1%). The rate was negatively correlated with the maternal mortality ratio (r=-0.63; P=0.005), neonatal mortality rate (r=-0.81; P<0.001), and infant mortality rate (r=-0.80; P<0.001). Major barriers to achieving higher rates of cesarean deliveries include poverty, limited access to healthcare services, and a shortage of skilled providers.
  
  
  CONCLUSIONS
  Maternal and infant mortality rates could be lowered by increasing access to cesarean delivery. Additional education of patients and providers, establishment of more heath facilities, and governmental support of obstetric care could help to reach this goal.
authors.affiliation: Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY, USA. Electronic address: mohamad.irani@hotmail.com.
authors.forename: Mohamad
authors.initials: M
authors.lastname: Irani
authors.affiliation: Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
authors.forename: Shad
authors.initials: S
authors.lastname: Deering
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data*; D003906:Developing Countries; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D063130:Maternal Death / Q000706:statistics & numerical data*; D008428:Maternal Mortality / Q000639:trends; D011203:Poverty; D011247:Pregnancy
keywords: Cesarean delivery; Low-income countries; Morbidity; Mortality; Simulation