Target rates for caesarean section may be too low, say researchers

The optimal rate of caesarean delivery in relation to maternal and neonatal mortality is about 19 caesarean deliveries in every 100 live births, claims a study published in JAMA that gathered data from 194 World Health Organization member states.1

In 1985 WHO stated that there was no justification for any region to have caesarean rates higher than 10-15%. However, caesarean rates in many countries are much higher than this and continue to increase worldwide.

US researchers gathered data on caesarean rates from 2012, as well as on health expenditure per capita, fertility rate, life expectancy, and regional information. Caesarean delivery rates in 2012 were available from 54 countries, and the most current rate was used for the 118 countries for which 2012 data were not available. For the 22 countries with no published caesarean delivery rate a predictive model was constructed.

The authors estimated that 22.9 million caesarean deliveries took place in 2012, giving a global estimate of 19.4 per 100 live births. South Sudan had the lowest caesarean rate (0.6%), and Brazil had the highest (55.6%).

The analysis found that, with increasing caesarean delivery rates, maternal mortality decreased up to the point of 7.2 caesareans in 100 live births (adjusted slope coefficient –68.1 (95% confidence interval –89.2 to –46.9)): this relationship was maintained but attenuated between 7.2 and 19.1 caesareans in 100 live births (–10.1 (–16.8 to –3.4); P=0.003). Higher caesarean delivery rates were not correlated with maternal or neonatal mortality at a country level.

Neonatal mortality was lower in countries with an increasing caesarean rate up to the point of 19.4 in 100 live births (–0.8 (–11.1 to –0.5); P<0.001). Neonatal mortality was not associated with caesarean delivery rates greater than 19.4 in 100 live births. A sensitivity analysis carried out including only the 76 countries with the highest quality data produced a similar result.

The authors concluded, “Previously recommended national target rates for caesarean deliveries may be too low.”

In an accompanying editorial Mary D’Alton and Mark Hehir, of Columbia University College of Physicians and Surgeons in New York City, said, “The optimal level of caesarean delivery cannot be as simple as a one-fits-all figure to be applied to all institutions and health care systems, and the obstetrical community must accept the fact that the appropriate caesarean delivery rate remains unknown.

“However, it is not whether the caesarean delivery rate is high or low that really matters, but rather whether appropriate performance of caesarean delivery is part of a system that delivers optimal maternal and neonatal care after consideration of all relevant patient and health system information.”2

In another study, also published in JAMA, researchers studied 321 287 babies born in Scotland to examine the relationship between a planned caesarean delivery and health problems or death in childhood.3 Compared with children born vaginally, those born by planned caesarean delivery were at increased risk of asthma requiring hospital admission (3.73% v 3.41%), salbutamol inhaler prescription at age 5 (10.3% v 9.6%), and death (0.40% v 0.32%). No significant differences were seen in the risk of obesity at age 5, inflammatory bowel disease, type 1 diabetes, or cancer. The researchers said the findings showed that avoidance of vaginal birth may be an important early life factor in the growing global burden of asthma, although the absolute increase in risk to individuals was low.

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