Caesarean birth as a component of surgical services in low- and middle-income countries.

We were very pleased to see further attention drawn to the issue of surgery as a global public health issue in lowand middle-income countries by Ozgediz et al. in the August 2008 edition of the Bulletin.1 We write to draw attention to one component of surgical services, Caesarean birth, which has been well documented relative to other types of surgery. Nationally representative data on Caesarean birth are available for approximately 90% of births in developing countries. Similar results from two separate compilation exercises have been published2,3 for the years around 2000 and efforts are underway to compile data for 2005. Many but not all of these data come from Demographic and Health Surveys, which also allow disaggregation by socioeconomic status.4 Moreover, substantial efforts have gone into determining the unmet need for Caesarean birth by defining indications for Caesarean that are “absolutely” life-threatening.5 Women who experience these problems are unlikely to survive if they do not receive a Caesarean. Absolute maternal indications include severe antepartum haemorrhage due to placenta praevia or abruptio placentae, major cephalopelvic disproportion, transverse lie and brow presentation. Several studies have now