Increasing global rates of caesarean section are debated because of evidence that medically unnecessary caesarean sections are associated with worse outcomes for mothers and their children. There is consensus that caesarean sections are overused in some countries and underused in others. As Ties Boerma and colleagues report in this Lancet Series on optimizing caesarean section use, there are unacceptable disparities: caesarean section rates of 44% in Latin America and the Caribbean compared with 4·1% in western and central Africa. Challenges have arisen as low-income and middle-income countries attempt to rectify insufficient access to caesarean sections. The investment in workforce training and facilities to increase access to caesarean sections can bring with it a culture of surgical intervention that leads to variation within countries between the urban wealthy giving birth in private facilities where there are high rates of caesarean section and the rural poor without access to the procedure. This situation calls for country and regional specific strategies to address these inequalities.