{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T05:05:43Z","timestamp":1790744743787,"version":"4.1.0"},"reference-count":39,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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\u2013van Doorslaer method; the rich\u2013poor gap was decomposed using a two-fold nonlinear (Yun) Oaxaca\u2013Blinder 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A cross-sectional analysis of 6,832 ever-married women with recorded last pregnancy delivery from the Punjab Health and Population Survey (PHPS) 2024\u201325 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\u2013van Doorslaer method. The rich\u2013poor gap was decomposed by a two-fold nonlinear (Yun) Oaxaca\u2013Blinder 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The weighted CS rate was 43.3% (21.0% poorest to 64.6% richest quintile). CS delivery was concentrated among the wealthy (standard CI\u202f=\u202f0.195, 95% CI 0.173\u20130.215; Erreygers\u202f=\u202f0.337, 95% CI 0.301\u20130.373). In the fully adjusted model the richest quintile (OR 2.07, 95% CI 1.50\u20132.85), private-facility delivery (OR 3.50, 2.90\u20134.23) and lady-doctor attendance (OR 13.10, 9.65\u201317.80) showed the strongest associations. There was no multicollinearity (all VIF\u202f&amp;lt;\u202f2.45) 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\u2013poor gap; adding service use raised this to 87.3%, with lady-doctor attendance (44.7%) and private-facility delivery (20.9%) the largest components.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1930664","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T04:52:48Z","timestamp":1790743968000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Inequality atop excess: a nonlinear decomposition of wealth-related inequality in caesarean section delivery in Punjab, Pakistan"],"prefix":"10.3389","volume":"14","author":[{"given":"Muhammad","family":"Nadeem","sequence":"first","affiliation":[{"name":"Department of Economics, Division of Management and Administrative Sciences, University of Education","place":["Lahore, Pakistan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shahid","family":"Adil","sequence":"additional","affiliation":[{"name":"Punjab Resource Improvement and Digital Effectiveness (PRIDE) Project, Planning and Development Board, Government of the Punjab","place":["Lahore, Pakistan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adel","family":"Bashatah","sequence":"additional","affiliation":[{"name":"Department of Nursing Administration and Education, College of Nursing, King Saud University","place":["Riyadh, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed N. Al","family":"Arifi","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, College of Pharmacy, King Saud University","place":["Riyadh, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wajid","family":"Syed","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, College of Pharmacy, King Saud University","place":["Riyadh, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayesha","family":"Iqbal","sequence":"additional","affiliation":[{"name":"Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham","place":["Nottingham, United Kingdom"]},{"name":"Office of Lifelong Learning and the Physician Learning Program, Faculty of Medicine and Dentistry, University of Alberta","place":["Edmonton, AB, Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"ref1","volume-title":"Transforming Our World: The 2030 Agenda for Sustainable Development","year":"2015"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"462","DOI":"10.1016\/S0140-6736(15)00838-7","article-title":"United Nations Maternal Mortality Estimation Inter-Agency Group collaborators and technical advisory group. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group","volume":"387","author":"Alkema","year":"2016","journal-title":"Lancet"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"e005671","DOI":"10.1136\/bmjgh-2021-005671","article-title":"Trends and projections of caesarean section rates: global and regional estimates","volume":"6","author":"Betr\u00e1n","year":"2021","journal-title":"BMJ Glob Health"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1111\/1471-0528.13526","article-title":"WHO statement on caesarean section rates","volume":"123","author":"Betr\u00e1n","year":"2016","journal-title":"BJOG"},{"key":"ref5","volume-title":"WHO Statement on Caesarean Section Rates","year":"2015"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1341","DOI":"10.1016\/S0140-6736(18)31928-7","article-title":"Global epidemiology of use of and disparities in caesarean sections","volume":"392","author":"Boerma","year":"2018","journal-title":"Lancet"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1349","DOI":"10.1016\/S0140-6736(18)31930-5","article-title":"Short-term and long-term effects of caesarean section on the health of women and children","volume":"392","author":"Sandall","year":"2018","journal-title":"Lancet"},{"key":"ref8","volume-title":"The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report Background Paper No. 30","author":"Gibbons","year":"2010"},{"key":"ref9","first-page":"941","article-title":"Uncertainty and the welfare economics of medical care","volume":"53","author":"Arrow","year":"1963","journal-title":"Am Econ Rev"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"223","DOI":"10.1086\/259880","article-title":"On the concept of health capital and the demand for health","volume":"80","author":"Grossman","year":"1972","journal-title":"J Polit Econ"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"99","DOI":"10.2307\/2555794","article-title":"Physician financial incentives and cesarean section delivery","volume":"27","author":"Gruber","year":"1996","journal-title":"Rand J Econ"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"473","DOI":"10.1016\/S0167-6296(99)00009-0","article-title":"Physician fees and procedure intensity: the case of cesarean delivery","volume":"18","author":"Gruber","year":"1999","journal-title":"J Health Econ"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1257\/pol.20140160","article-title":"Physicians treating physicians: information and incentives in childbirth","volume":"8","author":"Johnson","year":"2016","journal-title":"Am Econ J Econ Policy"},{"key":"ref14","first-page":"461","volume-title":"Handbook of Health Economics","author":"McGuire","year":"2000"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"k55","DOI":"10.1136\/bmj.k55","article-title":"Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries","volume":"360","author":"Boatin","year":"2018","journal-title":"BMJ"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"914","DOI":"10.2471\/BLT.13.117598","article-title":"Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa","volume":"91","author":"Cavallaro","year":"2013","journal-title":"Bull World Health Organ"},{"key":"ref17","volume-title":"7th Population and Housing Census 2023: National Results","year":"2023"},{"key":"ref18","volume-title":"Pakistan Maternal Mortality Survey 2019","year":"2020"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1186\/s12884-018-1743-z","article-title":"Factors associated with caesarean deliveries among child-bearing women in Pakistan: secondary analysis of data from the demographic and health survey, 2012\u201313","volume":"18","author":"Amjad","year":"2018","journal-title":"BMC Pregnancy Childbirth"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"e0186563","DOI":"10.1371\/journal.pone.0186563","article-title":"Rising trends and inequalities in cesarean section rates in Pakistan: evidence from Pakistan demographic and health surveys, 1990\u20132013","volume":"12","author":"Mumtaz","year":"2017","journal-title":"PLoS One"},{"key":"ref21","volume-title":"Pakistan Demographic and Health Survey 2017\u201318","year":"2019"},{"key":"ref22","volume-title":"Global Health Expenditure Database: Pakistan Country Profile","year":"2023"},{"key":"ref23","volume-title":"Sehat Sahulat Programme: Programme Documentation","year":"2022"},{"key":"ref24","volume-title":"Advancing Universal Health Coverage and Population Outcomes in Punjab: Baseline Findings of the Punjab Health and Population Survey (PHPS) 2024\u201325. Policy Brief","year":"2026"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"e005982","DOI":"10.1136\/bmjopen-2014-005982","article-title":"Prevalence and determinants of caesarean section in private and public health facilities in underserved south Asian communities","volume":"4","author":"Neuman","year":"2014","journal-title":"BMJ Open"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"207","DOI":"10.1016\/S0304-4076(02)00161-6","article-title":"On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam","volume":"112","author":"Wagstaff","year":"2003","journal-title":"J Econ"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"436","DOI":"10.2307\/144855","article-title":"Wage discrimination: reduced form and structural estimates","volume":"8","author":"Blinder","year":"1973","journal-title":"J Hum Resour"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"279","DOI":"10.2307\/145830","article-title":"Employers\u2019 discriminatory behavior and the estimation of wage discrimination","volume":"23","author":"Neumark","year":"1988","journal-title":"J Hum Resour"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"693","DOI":"10.2307\/2525981","article-title":"Male\u2013female wage differentials in urban labor markets","volume":"14","author":"Oaxaca","year":"1973","journal-title":"Int Econ Rev"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"25","DOI":"10.2307\/2807954","article-title":"An analytical framework for the study of child survival in developing countries","volume":"10","author":"Mosley","year":"1984","journal-title":"Popul Dev Rev"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"504","DOI":"10.1016\/j.jhealeco.2008.02.003","article-title":"Correcting the concentration index","volume":"28","author":"Erreygers","year":"2009","journal-title":"J Health Econ"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"429","DOI":"10.1002\/hec.953","article-title":"The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality","volume":"14","author":"Wagstaff","year":"2005","journal-title":"Health Econ"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"197","DOI":"10.1007\/s10182-008-0056-3","article-title":"An extension of the Blinder\u2013Oaxaca decomposition to nonlinear models","volume":"92","author":"Bauer","year":"2008","journal-title":"AStA Adv Stat Anal"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"275","DOI":"10.1016\/j.econlet.2003.09.008","article-title":"Decomposing differences in the first moment","volume":"82","author":"Yun","year":"2004","journal-title":"Econ Lett"},{"key":"ref35","volume-title":"Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and their Implementation","author":"O\u2019Donnell","year":"2008"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"1358","DOI":"10.1016\/S0140-6736(18)31927-5","article-title":"Interventions to reduce unnecessary caesarean sections in healthy women and babies","volume":"392","author":"Betr\u00e1n","year":"2018","journal-title":"Lancet"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1017\/S0965539501000122","article-title":"Classification of caesarean sections","volume":"12","author":"Robson","year":"2001","journal-title":"Fetal Matern Med Rev"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"CD004667","DOI":"10.1002\/14651858.CD004667.pub5","article-title":"Midwife-led continuity models versus other models of care for childbearing women","volume":"2016","author":"Sandall","year":"2016","journal-title":"Cochrane Database Syst Rev"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1353\/dem.2001.0003","article-title":"Estimating wealth effects without expenditure data\u2014or tears: an application to educational enrollments in states of India","volume":"38","author":"Filmer","year":"2001","journal-title":"Demography"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1930664\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T04:53:11Z","timestamp":1790743991000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1930664\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":39,"alternative-id":["10.3389\/fpubh.2026.1930664"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1930664","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]},"article-number":"1930664"}}