Caesarean Births Doubled Around the World Amid Signs of Both Overuse and Underuse

The number of infants born through caesarean section (C-section) almost doubled between 2000 and 2015—from 12% to 21% of all births—according to The Lancet. The surgery is still unavailable for many women giving birth in low-income countries and regions, yet is overused in many middle- and high-income settings, said the journal, which published a series of papers on the topic Thursday.

The research tracked trends in C-section use globally and in 9 regions based on data from 169 countries from World Health Organization and UNICEF databases.¹

In the United States, the lowest use of C-sections was in New Mexico (nearly 18%); rates rose to 33.1% in New Jersey. Previous estimates for New Jersey c-section rates were 28%, according to data from the Leapfrog Group in 2015.

C-sections can be life-saving interventions for women and newborns when complications occur, such as bleeding, fetal distress, hypertensive disease, and infants in abnormal positions. But the surgery is associated with complications in future births and is not without risk.

It is estimated that 10% to 15% of births medically require a C-section due to such complications, implying that average C-section use would fall in the range.

However, the research found that:

• Most countries used C-section above the recommended level (63%, 106/169 countries).
• In 15 countries, C-section use exceeded 40%. The Dominican Republic had the highest rate, at 58.1%.
• More than 1 in 4 countries in 2015 had levels below expectations (28%, 47/169 countries).

Within countries, large differences in use of C-sections exist between socioeconomic levels, between public and private sectors, and between regions, where the pace of change varied widely, with rapid increases seen in South Asia and much slower rises in Africa.

Disparities were found between low- and middle-income countries, where the wealthiest women were 6 times more likely to have a C-section compared with the poorest women, and where C-section was 1.6 times more common in private facilities than public facilities. Researchers suggested that this could be explained by persistent issues with shortages in health facilities and staff in vulnerable and rural populations.

However, the pace of change varied substantially between regions. In the 10 countries with the highest number of births in 2010 to 2015, there were large differences in C-section use between regions—for example, differences between provinces in China ranged from 4% to 62%, and interstate differences in India ranged from 7% to 49%.

The South Asia region has seen the most rapid increase in use (6.1% per year), with C-section being underused in 2000 but being overused by 2015 (increasing from 7.2% of births via C-section to 18.1%).

C-section continues to be overused in North America, Western Europe and Latin America and the Caribbean, where rates increased by around 2% per year between 2000 to 2015. C-section use increased from 24.3% to 32% in North America, from 19.6% to 26.9% in Western Europe, and from 32.3% to 44.3% in Latin America and the Caribbean.

The global increases in C-section use are attributed both to more births taking place in health institutions (about two-thirds of the increase) and to greater frequency of intervention through C-section (about one-third of the increase). C-sections are underused across sub-Saharan Africa (around 2% per year), where C-section use has remained low.

C-section harms

There are no benefits of C-section in cases without a medical indication, and there are short and long-term risks associated with C-sections for both mothers and children.² Harm and even death can occur, especially when there are not sufficient facilities, skills, and health care available, the researchers noted.

For mothers, maternal death and disability is higher after C-section than vaginal birth. C-sections have a more complicated recovery, and lead to scarring of the womb, which is associated with bleeding, abnormal development of the placenta, ectopic pregnancy, stillbirth, and preterm birth in subsequent pregnancies.

For infants, there is emerging evidence that C-section births can lead to different hormonal, physical, bacterial, and medical exposures during birth, which can subtly alter their health. While the long-term risks of this are not well-researched, the short-term effects include changes in immune development, which can increase the risk of allergies and asthma and alter the microbiome.

Talking about C-section overuse with patients

According to the series, some women request C-sections because of past negative experiences of vaginal birth, fear of labor pain or of the effects of labor such as pelvic floor damage or urinary incontinence.³ To address this, the authors recommend further research to study relaxation training, childbirth training workshops, educational outreach, and meeting with healthcare professionals.

For healthcare professionals, improved education, guidelines and communication, and second-opinion policies may also be helpful to address influences such as women’s requests, convenience, financial incentives, and fear of litigation. In particular, in some regions C-sections are seen as protective, and physicians are less likely to be sued if complications occur, than during vaginal delivery.

The authors warn that young physicians are becoming experts in C-section, while losing confidence in their skills to assist in vaginal birth.

References

1. Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. The Lancet 2018; 392:1341-48

2. Sandall J, Tribe RM, Avery L, et al. Short-term and long-term effects of caesarean section on the health of women and children. The Lancet. 2018;392: 1349-57

3. Betrán AP, Temmerman M, Kingdon C, et al. Interventions to reduce unnecessary caesarean sections in healthy women and babies. The Lancet. 2018;392:1349-57