Birth 2014 Sep 11;41(3):237-44. Epub 2014 Apr 11.

Ministry of Education -Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.

Background: Over the past three decades, the World Health Organization expert panel proposed cesarean delivery rate of 10-15 percent was used as a doctrine for an optimal rate of cesarean delivery despite the lack of concrete evidence. We set out to compile cesarean delivery rates, socioeconomic indicators, and health outcomes by countries in the last three decades to explore the optimal rates for medically necessary cesarean delivery.

Methods: We selected 19 countries which have readily accessible cesarean delivery and low maternal and infant mortality, including countries in North and West Europe, North America, Australia, New Zealand, and Japan. Information on cesarean delivery rate, human development index (HDI), gross domestic products (GDP), maternal, neonatal, and infant mortality rates of each country in the past 30 years was collected from published reports. A two-level fractional polynomial model was used to model the association between cesarean rate and mortality rates.

Results: Most of the countries have experienced sharp increases in cesarean delivery rates. Once cesarean delivery rate reached 10 percent, with adjustment for HDI and GDP, further increase in cesarean delivery rate had no impact on maternal, neonatal, and infant mortality rates.

Conclusions: Our findings corroborate the statement that a population-level cesarean section rate above 10-15 percent is hardly justified from the medical perspective.

JAMA 2015 Dec;314(21):2263-70

Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts2Massachusetts General Hospital, Department of Surgery, Boston.

Importance: Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes.

Objectives: To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality.

Design, Setting, And Participants: Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. Read More

Birth 2006 Dec;33(4):270-7

Perinatal Research Unit, Hospital de Clinicas, Montevideo, Uruguay.

Background: Cesarean section rates show a wide variation among countries in the world, ranging from 0.4 to 40 percent, and a continuous rise in the trend has been observed in the past 30 years. Our aim was to explore the association of cesarean section rates of different countries with their maternal and neonatal mortality and to test the hypothesis that in low-income countries, increasing cesarean section rates were associated with reductions in both outcomes, whereas in high-income countries, such association did not exist. Read More

Birth 2015 Mar 17;42(1):62-9. Epub 2015 Jan 17.

Department of Nursing at the Hunan University of Medicine, Huaihua, China; McLaughlin Centre for Population Health Risk Assessment, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada.

Background: Recent data indicate that more than half of high-income industrialized countries have a cesarean delivery rate of  > 25 percent, which is higher than the appropriate level considered by most health professionals worldwide.

Methods: Data for 31 high-income industrialized countries in 2010 (or the nearest year) obtained from the World Health Organization, Organization for Economic Cooperation and Development, World Bank, and individual countries were analyzed in this study. We examined the correlation between cesarean delivery rate and infant mortality rate with Pearson correlation coefficient analysis, and examined the independent effect of cesarean delivery on infant mortality with multiple linear regression analyses. Read More

Rev Panam Salud Publica 2011 May;29(5):303-8

Research Management, Hospital Foundation of Minas Gerais (FHEMIG), Belo Horizonte, Minas Gerais, Brazil.

Objective: To correlate international official data on Cesarean delivery rates to infant and maternal mortality rates and low weight-at-birth rates; and to test the hypothesis that Cesarean rates greater than 15% correlate to higher maternal and infant mortality rates.

Methods: Analyses were based on the most recent official data (2000-2009) available for 193 countries. Exponential models were compared to quadratic models to regress infant mortality rates, neonatal mortality rates, maternal mortality rates, and low weight-at-birth rates to Cesarean rates. Read More