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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.