Academic Journal
Inequality atop excess: a nonlinear decomposition of wealth-related inequality in caesarean section delivery in Punjab, Pakistan.
| Τίτλος: | Inequality atop excess: a nonlinear decomposition of wealth-related inequality in caesarean section delivery in Punjab, Pakistan. |
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| Συγγραφείς: | Nadeem M; Department of Economics, Division of Management and Administrative Sciences, University of Education, Lahore, Pakistan., Adil S; Punjab Resource Improvement and Digital Effectiveness (PRIDE) Project, Planning and Development Board, Government of the Punjab, Lahore, Pakistan., Bashatah A; Department of Nursing Administration and Education, College of Nursing, King Saud University, Riyadh, Saudi Arabia., Arifi MNA; Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia., Syed W; Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia., Iqbal A; Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, United Kingdom.; Office of Lifelong Learning and the Physician Learning Program, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. |
| Πηγή: | Frontiers in public health [Front Public Health] 2026 Sep 30; Vol. 14, pp. 1930664. Date of Electronic Publication: 2026 Sep 30 (Print Publication: 2026). |
| Τύπος έκδοσης: | Journal Article |
| Γλώσσα: | English |
| Στοιχεία περιοδικού: | Publisher: Frontiers Editorial Office Country of Publication: Switzerland NLM ID: 101616579 Publication Model: eCollection Cited Medium: Internet ISSN: 2296-2565 (Electronic) Linking ISSN: 22962565 NLM ISO Abbreviation: Front Public Health Subsets: MEDLINE |
| Imprint Name(s): | Original Publication: Lausanne : Frontiers Editorial Office |
| Ιατρικοί όροι (MeSH): | Cesarean Section*/statistics & numerical data , Healthcare Disparities*/statistics & numerical data, Female ; Pakistan ; Humans ; Cross-Sectional Studies ; Pregnancy ; Adult ; Socioeconomic Disparities in Health ; Socioeconomic Factors ; Young Adult |
| Περίληψη: | Background: Caesarean section (CS) rates are rising rapidly across South Asia, and Pakistan combines over-use among advantaged groups with historically limited access among the poor. Quantifying and decomposing wealth-related inequality in CS delivery is essential for equitable obstetric policy. Decomposed by the Wagstaff-van Doorslaer method; the rich-poor gap was decomposed using a two-fold nonlinear (Yun) Oaxaca-Blinder decomposition. All estimates applied survey weights with PSU-cluster-robust inference; analyses used Python 3.12 (statsmodels 0.14). Because service-use variables lie on the causal pathway between wealth and CS, hierarchical models are reported and all decomposition results are descriptive, not causal. Methods: A cross-sectional analysis of 6,832 ever-married women with recorded last pregnancy delivery from the Punjab Health and Population Survey (PHPS) 2024-25 was done. The aim was to measure inequality by wealth in the rates of cesarean section (CS) delivery and identify the channels responsible for the inequality. The dependent variable CS delivery was binary, with the primary explanatory variable being a principal-component analysis (PCA) based household wealth index, with maternal, service use and clinical covariates. Inequality was measured using concentration curves, standard concentration index, Wagstaff-normalised concentration index, Erreygers concentration index and decomposed by Wagstaff-van Doorslaer method. The rich-poor gap was decomposed by a two-fold nonlinear (Yun) Oaxaca-Blinder decomposition. Survey weights were employed in all estimates, which were derived using PSU-cluster-robust inference; analyses were conducted in Python 3.12 (statsmodels 0.14). Because service-use variables lie on the causal pathway between wealth and CS, hierarchical models are reported and all decomposition results are descriptive, not causal. Results: The weighted CS rate was 43.3% (21.0% poorest to 64.6% richest quintile). CS delivery was concentrated among the wealthy (standard CI = 0.195, 95% CI 0.173-0.215; Erreygers = 0.337, 95% CI 0.301-0.373). In the fully adjusted model the richest quintile (OR 2.07, 95% CI 1.50-2.85), private-facility delivery (OR 3.50, 2.90-4.23) and lady-doctor attendance (OR 13.10, 9.65-17.80) showed the strongest associations. There was no multicollinearity (all VIF < 2.45) and model discrimination was good (AUC 0.824). Excluding proximate service-use variables, observed characteristics accounted for 66.9% of the 28.4-percentage-point rich-poor gap; adding service use raised this to 87.3%, with lady-doctor attendance (44.7%) and private-facility delivery (20.9%) the largest components. Conclusion: Wealth-related inequality in caesarean delivery in Punjab is predominantly associated with differential access to private, physician-led obstetric care. These associations are descriptive and cannot establish causation. Policy should pair clinical audit of elective CS indications in the private sector with financial protection for medically necessary CS among poorer women. (Copyright © 2026 Nadeem, Adil, Bashatah, Arifi, Syed and Iqbal.) |
| Competing Interests: | The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. |
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| Contributed Indexing: | Keywords: Oaxaca– Blinder decomposition; Pakistan; caesarean section; concentration index; maternal health services; socioeconomic inequality |
| Entry Date(s): | Date Created: 20261015 Date Completed: 20261015 Latest Revision: 20261016 |
| Update Code: | 20261016 |
| PubMed Central ID: | PMC13661399 |
| DOI: | 10.3389/fpubh.2026.1930664 |
| PMID: | 42876537 |
| Βάση Δεδομένων: | MEDLINE |
| ISSN: | 2296-2565 |
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| DOI: | 10.3389/fpubh.2026.1930664 |