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Experts see international increase in rates of caesarean sections

Potentially unnecessary caesarean section rates are increasing worldwide, particularly in lesser-developed countries, according to recently published data in The Lancet.

“The greatest increases in caesarean section rates were generally recorded in the least developed countries where — compared with the high-income countries — the cesarean section rates of the first survey were lower, and a higher unmet need for cesarean section probably exists,” Joshua P. Vogel, MBBS, School of Population Health, University of Western Australia, in Crawley, and colleagues wrote.

Researchers evaluated data from both the WHO Global Survey of Maternal and Perinatal Health (WHOGS; 2004-2008) and the WHO Multi-Country Survey of Maternal and Newborn Health (WHOMCS; 2010-2011), which analyzed deliveries from 287 facilities across 21 countries. To analyze the change in caesarean section rates, Vogel and colleagues then stratified countries according to Human Development Index (HDI) group and the Robson criteria was applied to both sets of data.

Between the two surveys, the overall rate of caesarean section increased in all countries from 26.4% in 2008 in the WHOGS to 31.2% in 2011 in the WHOMCS (P = .003), with the exception of Japan. The use of obstetric interventions, such as induction, pre-labor caesarean section and overall caesarean section increased over time as well. Across most Robson groups in all HDI categories, rates of caesarean section increased.

Among very high/high and low HDI countries, the use of induction and pre-labor caesarean section rates increased. After induction, cesarean section rates in multiparous women increased significantly in all HDI groups.

The number of women who previously had a caesarean section increased among moderate and low HDI countries along with the caesarean section rate among the same women.

“Women who have previously had a caesarean section are at an increasingly important determinant of overall caesarean rates. Therefore, implementation of evidence based strategies to avoid medically unnecessary primary caesarean section, and to encourage the safe and appropriate use of vaginal birth after caesarean section, is needed,” Vogel and colleagues wrote.

In an accompanying editorial, Christine L. Roberts, MBBS, FAFPHM, DrPH, and Tanya A Nippita, BSc, MBBS, both of the Clinical and Population Perinatal Health Research, The Kolling Institute, University of Sydney, Australia, note that eventually, caesarean section risks will outweigh the benefits that the procedure offers, and that the variation among countries, and even within countries, raises many questions.

 “Vogel and colleagues' study represents an important step in exploring and understanding how obstetric intervention rates are both increasing and also vary widely between countries and levels of development,” they wrote. “The substantial variation in caesarean section rates within HDI categories is also notable, and probably indicates some underuse of appropriate caesarean sections as well as likely overuse of the procedure.” – by Casey Hower

Disclosure: The researchers report no relevant financial disclosures.