Intended for healthcare professionals


Alarming global rise in caesarean births, figures show

BMJ 2018; 363 doi: (Published 12 October 2018) Cite this as: BMJ 2018;363:k4319
  1. Jacqui Wise
  1. London, UK

Caesarean section use is growing at an “alarming” rate, accounting for 21% of births globally in 2015—up from 12% in 2000—experts have warned.

A series of three papers published in the Lancet shows that 106 out of 169 countries have caesarean section rates above the 10% to 15% of births that is thought to be optimal.123 In at least 15 countries the caesarean rate exceeds 40%, including the Dominican Republic (58.1%), Brazil (55.5%), Egypt (55.5%), and Turkey (53.1%). In the UK, caesarean section deliveries have increased from 19.7% of births in 2000 to 26.2% in 2015.

A caesarean section can be a life saving intervention when medically indicated and should be universally available, the authors say. Access is still a major problem in most low income and several middle income countries, especially in sub-Saharan Africa and among the poorest women. For example, the caesarean rate in South Sudan is only 0.6%.

The researchers say the increases in caesarean deliveries were partly driven by an increasing proportion of births occurring in healthcare facilities.

Within countries there can be large differences in caesarean rates. For example, in China the rate ranged from 4% to 62% between provinces, and state differences in India ranged from 7% to 49%. The use of caesarean section is often particularly high among wealthier women and in private facilities.

The prevalence of maternal mortality and maternal morbidity is higher after caesarean section than after vaginal birth. Caesarean section is associated with an increased risk of uterine rupture, the placenta embedding in the wrong part of the uterus, ectopic pregnancy, stillbirth, and preterm birth. There is also emerging evidence that babies born by caesarean have different exposures to hormones and bacteria than those delivered vaginally and this can alter the development of the immune system.

Common reasons women ask for caesarean section include negative experiences of vaginal birth or fear of labour, pelvic floor damage, urinary incontinence, or reduced quality of sexual functioning. The authors of the third paper suggest more midwife led units, antenatal education, and offering continuous labour support may help reduce the rate of caesarean sections.

A position paper from the International Federation of Gynaecology and Obstetrics, also published in the Lancet, calls on governmental bodies, professional organisations, and other stakeholders to stop the caesarean epidemic.4 It recommends that delivery fees for physicians undertaking caesarean section and attending vaginal delivery should be the same in both private and public hospitals. It adds that hospitals should have to publish annual caesarean rates and women should be informed properly on the benefits and risks of caesarean section.

“Caesarean section is a type of major surgery, which carries risks that require careful consideration. The growing use of caesarean section for non-medical purposes could be introducing avoidable complications, and we advocate that caesarean section should only be used when it is medically required,” said Jane Sandall from King’s College London and a co-author of one of the studies.

The lead author of the series of papers, Marleen Temmerman, from Aga Khan University, Kenya and Ghent University, Belgium, said: “Pregnancy and labour are normal processes, which occur safely in most cases. The increases in caesarean section use—mostly in richer settings for non-medical purposes—are concerning because of the associated risks for women and children. Caesareans can create complications and side effects for mothers and babies, and we call on healthcare professionals, hospitals, funders, women, and families to only intervene in this way when it is medically required.”


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