The Global Epidemic of Unnecessary Cesarean Section Births

Извор: WUNRN – 06.01.2018

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

January 24, 2017 - Cesarean section surgery, when medically indicated and performed by trained staff with the necessary equipment and supplies, can be a life-saving procedure for the mother and baby. However, compared to vaginal delivery, cesareans are associated with a higher risk of maternal and neonatal death; numerous maternal morbidities including infection, uterine rupture and amniotic fluid embolism; neonatal morbidities often related to iatrogenic prematurity; and potential complications in subsequent pregnancies. Studies have also observed that children born via cesarean are more likely to develop respiratory problems, diabetes and obesity later in life.

Therefore, cesareans should be considered a major surgical intervention and only be performed when clinically necessary. Furthermore, to minimize the risks associated with cesarean section, the surgery should only be performed by skilled health workers in high quality facilities.

For many years, researchers have debated the optimal cesarean rate for maximizing maternal and infant health outcomes. Since 1985, the World Health Organization has estimated the ideal population-level cesarean rate at 10-15%, although some scientists have suggested a higher figure. Further investigation of an optimal rate is certainly warranted. Theoretically, the optimal population-level cesarean rate should be calculated based on the proportion of laboring women who have a medical indication for cesarean delivery. But, unfortunately, the high and increasing levels of cesarean delivery rates around the world illustrate that the procedure is not always medically indicated.

Clinicians sometimes disagree about what constitutes a medical indication, and in some cases lack the necessary tools to identify a complication. For example, fetal distress is a commonly reported reason for performing a cesarean—but how exactly does one measure fetal distress? How long should a provider wait for an abnormal fetal heartbeat to return to normal before deciding to perform a cesarean? How can clinicians in low-resource settings without access to fetal monitoring technology accurately assess these situations?

Before developing consensus on the optimal population-level rate, the global maternal health community must agree upon the medical indications for cesarean delivery and ensure that clinicians around the world are adhering to standardized, evidence-based guidelines.


The Global Epidemic of Unnecessary Cesarean Sections (Part 2)he Global Epidemic of Uecessary Cesarean Sections (Part 2)

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health - Posted on January 25, 2017

Trends over time

In 1990, roughly one in 15 babies on the planet was born via cesarean section surgery. In 2014, one in five babies was born via cesarean. The rates have increased dramatically over the past few decades in most regions, with the fastest growth taking place in North Africa and Latin America and the Caribbean. There is substantial variation within regions, with certain countries experiencing more rapid increases than others.


Previous Cesarean Rate (Year)

Current Cesarean Rate (Year)


4.4% (1990)

36.2% (2011)


16% (1990)

43.4% (2012)

Dominican Republic

20% (1991)

56.4% (2013)


4.6% (1992)

51.8% (2014)


3.8% (1990)

36.7% (2012)


12.4% (1987)

45.2% (2012)


2% (1992)

16% (2011)


7.2% (1992)

36.3% (2011)


8% (1993)

47.5% (2011)

Considering data and measurement limitations is important when interpreting trends. Currently, there is no standard, internationally-accepted classification system to measure and monitor cesarean rates, which presents challenges when attempting to make comparisons between locations or time periods. Despite this limitation, though, available data illustrate a clear upward trend in most parts of the world.

Wide geographic variation

The highest cesarean rates are mostly found in middle-income countries in Latin America and the Caribbean, North America, Europe, Australia and Southeast Asia, while the lowest rates are found in sub-Saharan Africa. National cesarean section rates vary widely, ranging from less than 2% of births in Burkina Faso, Chad, Ethiopia, Madagascar, Niger and Timor-Leste—where many women do not have access to safe cesareans when they need them—to greater than 40% in Brazil, Colombia, Dominican Republic, Egypt, Iran, Maldives, Mexico and Turkey.

Highest National Cesarean Rates

Lowest National Cesarean Rates

1. Dominican Republic: 56.4% (2013)

1. Niger: 1.4% (2012)

2. Brazil: 55.6% (2012)

2. Chad: 1.5% (2010)

3. Egypt: 51.8% (2014)

3. Ethiopia: 1.5% (2011)

4. Iran: 47.9% (2009)

4. Timor-Leste: 1.7% (2009)

5. Turkey: 47.5% (2011)

5. Burkina Faso: 1.9% (2010)

6. Mexico: 45.2% (2012)

6. Madagascar: 1.9% (2013)

7. Colombia: 43.4% (2012)

7. Nigeria: 2% (2013)

8. Maldives: 41.1% (2011)

8. Guinea-Bissau: 2.3% (2010)

9. Uruguay: 39.9% (2012)

9. Guinea: 2.4% (2012)

10. Italy: 38.1% (2011)

10. Gambia: 2.5% (2010)


There is also wide variation within countries depending on location. For example, in the United States, facility-level cesarean rates ranged from 7.1% to 69.9% in 2009. Similarly, cesarean rates in China ranged from 4% to 62.5% in 2014 across provinces.

The Global Epidemic of Unnecessary Cesarean Sections (Part 3)cesarean-sections-part-3ctions (Part 3)

By: Sarah Hodin, Project Coordinator II, Women and Health Initiative, Harvard T.H. Chan School of Public Health

Possible explanations

January 26, 2017 - In addition to geographic variability, researchers have proposed several theories to explain the rise in cesarean deliveries: Some have claimed that today’s women are simply at higher risk of developing childbirth-related complications than women were 30 years ago—perhaps partially due to older childbearing age. However, variation in hospital-level primary cesarean rates among low-risk women illustrates that a woman’s health status alone cannot account for the trend.

Others have suggested that, in some contexts, convenience factors and the threat of medical malpractice lawsuits create incentives for providers to choose cesareans over vaginal delivery. Social determinants such as a woman’s socioeconomic status, type of payment and race/ethnicity have been identified as contributing factors in different countries.

In the United Kingdom and the United States, in particular, emphasis on the “too posh to push” phenomenon in the media has reinforced the notion that many women are choosing to schedule cesarean deliveries, when in reality, available evidence reveals that elective cesarean deliveries are relatively uncommon. Hospital-level factors including whether a facility is public or private can also affect a woman’s likelihood of undergoing cesarean section surgery.

Overall, there does not seem to be a consensus on an explanation for the cesarean epidemic. Several interconnected factors influence cesarean rates, and those factors differ depending on the particular sociocultural, political and economic context.

Finding a balance

The global maternal health community is struggling to strike a balance—providing adequate, high quality care without falling into the trap of unnecessary intervention. A very low cesarean rate can indicate a lack of access to life-saving resources and is generally associated with higher maternal and newborn mortality. A very high cesarean rate, on the other hand, can be a sign of over-intervention and a trend of medicalized birth. Importantly, higher cesarean rates are not associated with improved maternal or infant outcomes. In fact, evidence suggests that higher cesarean rates can be associated with worse outcomes.

The global cesarean epidemic is not only a threat to the health of mothers and children around the world, but also to health systems. Swift action from clinicians, researchers, programmers and policymakers is needed.



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