Higher Cesarean Delivery Rates May Be OK

Lara C. Pullen, PhD

December 02, 2015

An analysis of data from World Health Organization (WHO) member states suggests that national cesarean delivery rates of approximately 19 per 100 live births are associated with lower maternal or neonatal mortality. This number stands in contrast to the current WHO recommendation that population-level cesarean delivery rates not exceed 10% to 15%.

"A better understanding is needed for how health systems can most efficiently develop comprehensive maternal and neonatal health care infrastructure. This includes supporting safe and appropriate provision of cesarean delivery and other obstetric surgical services with the intent of reducing maternal and neonatal mortality without causing overuse of procedures," George Molina, MD, MPH, from Brigham and Women's Hospital in Boston, Massachusetts, and colleagues write.

The researchers published the results of their cross-sectional, ecological study in the December 1 issue of JAMA.

They collected data from 194 WHO member states from 2005 to 2012, including cesarean section rates, health expenditure per capita, fertility rate, and life expectancy. The cesarean delivery rate data were obtained from multiple sources, and the findings are based on large, population-level databases.

The researchers found a huge variability in the international cesarean delivery rate between countries (12.6 - 24.0 per 100 live births). Their analysis revealed that a cesarean delivery rate of approximately 19% was associated with optimal levels of maternal and neonatal mortality. The results suggest that the current recommended target rates for cesarean deliveries (10% - 15%) may be too low.

The authors explain that their study was designed to document associations and their data should not be interpreted as evidence of causality. Moreover, they acknowledge that cesarean delivery rates, viewed in isolation, provide inadequate information about a healthcare system.

Global Rates of Cesarean Delivery

Cesarean delivery rates continue to increase worldwide. As an example, approximately one third of deliveries that took place in the United States in 2013 were cesarean deliveries.

The increase is the result of an almost complete elimination of vaginal breech delivery, as well as a significant decrease in operative vaginal deliveries and vaginal birth after cesarean. Many women also specifically request cesarean delivery.

A great deal of effort, however, has been invested in reducing the cesarean delivery rate. One strategy that has demonstrated efficacy is a uniform approach to interpreting fetal heart monitoring data. In addition, the WHO has recommended systems that facilitate the auditing, analyzing, and comparison of a cesarean section rates across different settings.

The current study suggests, however, that efforts to reduce cesarean section rates may not improve patient outcomes. The authors explain that previous studies on the subject may be incomplete because they were focused on outcomes from a limited set of wealthier countries.

"The optimal level of cesarean 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' cesarean delivery rate remains unknown. However, it is not whether the cesarean delivery rate is high or low that really matters, but rather whether appropriate performance of cesarean delivery is part of a system that delivers optimal maternal and neonatal care after consideration of all relevant patient and health system information," write Mary E. D'Alton, MD, and Mark P. Hehir, MD, from Columbia University College of Physicians and Surgeons in New York City, in an accompanying editorial.

The authors and editorialists have disclosed no relevant financial relationships.

JAMA. 2015;314:2263-2270. Article full text, Editorial full text

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