Background The Arab region has some of the highest caesarean section rates globally; however, trends and inequalities have not been explored regionally. This study aimed to examine the trends of caesarean section and describe variations in caesarean section by economic status and type of healthcare facility (private/public sector).

Methods This was a secondary data analysis of the two most recent(2006–2018) demographic and health surveys(DHS) or multiple indicator cluster surveys(MICS) for eight countries in the Arab region (Algeria, Egypt, Iraq, Jordan, Qatar, Tunisia, State of Palestine and Yemen). DHS/MICS are nationally representative household surveys; the sampling frame includes area units across the entire country, and employs a multi-stage stratified cluster sampling procedure, to provide a sample population of women aged 15–49 years who had a live birth in the preceding two years. The outcome was caesarean section at last birth. Temporal trends were calculated using generalised linear models and presented as risk differences(RD) with 95% confidence intervals(95%CI). Caesarean section was disaggregated against household wealth index and type of healthcare facility (private/public sector) and presented using equiplots. Analyses accounted for the complex sampling design and were conducted using STATA(v.15).

Results In the most recent survey, use of caesarean section ranged from 57.3% of births (95%CI:55.6–59.1%) in Egypt to 5.7% of births (95%CI:5.0–6.6%) in Yemen. Overall, the use of caesarean section has increased across the Arab region with the exception of Jordan, which had no statistically significant change during 2012–2018 shown by an RD of -3.0% (95%CI:-7.4–1.4%). Within all Arab countries, caesarean section use was highest in the richest quintile compared to the poorest quintile, for example in Iraq: 47.6% (95%CI:41.4–54.0%) vs. 27.7% (95%CI:24.5–31.1%), respectively. Caesarean section use was higher in private sector facilities compared to public sector: 70.2% (95%CI:68.2–72.1%) vs. 50.8% (95%CI:47.6–54.1%) in Egypt, and 21.9% (95%CI:18.1–26.1%) vs. 15.7% (95%CI:13.3–18.4%) in Yemen, respectively. Excluding Egypt, there was a larger absolute number of births in public sector facilities compared to private sector facilities.

Conclusion Variations in the use of caesarean section exist within and between Arab countries, and it was unequally distributed amongst the richest quintiles and private healthcare facilities. The self-reported nature of the data is a notable limitation. The private sector has a prominent role in the observed trends; however, moderate increases in the use of caesarean section within the public sector will result in a larger absolute increase nationally. Urgent policies and interventions are required to address non-medically indicated caesarean sections.