Elsevier

The Lancet

Volume 392, Issue 10155, 13–19 October 2018, Pages 1341-1348
The Lancet

Series
Global epidemiology of use of and disparities in caesarean sections

https://doi.org/10.1016/S0140-6736(18)31928-7Get rights and content

Summary

In this Series paper, we describe the frequency of, trends in, determinants of, and inequalities in caesarean section (CS) use, globally, regionally, and in selected countries. On the basis of data from 169 countries that include 98·4% of the world's births, we estimate that 29·7 million (21·1%, 95% uncertainty interval 19·9–22·4) births occurred through CS in 2015, which was almost double the number of births by this method in 2000 (16·0 million [12·1%, 10·9–13·3] births). CS use in 2015 was up to ten times more frequent in the Latin America and Caribbean region, where it was used in 44·3% (41·3–47·4) of births, than in the west and central Africa region, where it was used in 4·1% (3·6–4·6) of births. The global and regional increases in CS use were driven both by an increasing proportion of births occurring in health facilities (accounting for 66·5% of the global increase) and increases in CS use within health facilities (33·5%), with considerable variation between regions. Based on the most recent data available for each country, 15% of births in 106 (63%) of 169 countries were by CS, whereas 47 (28%) countries showed CS use in less than 10% of births. National CS use varied from 0·6% in South Sudan to 58·1% in the Dominican Republic. Within-country disparities in CS use were also very large: CS use was almost five times more frequent in births in the richest versus the poorest quintiles in low-income and middle-income countries; markedly high CS use was observed among low obstetric risk births, especially among more educated women in, for example, Brazil and China; and CS use was 1·6 times more frequent in private facilities than in public facilities.

Introduction

Caesarean section (CS) is a life-saving intervention for women and newborns when complications occur, such as antepartum haemorrhage, fetal distress, abnormal fetal presentation, and hypertensive disease. CS is the most common major surgical intervention in many countries.1 CS use has increased during the past 30 years to a frequency in excess of the proportion of 10–15% of births that is thought to be optimal.2, 3, 4 This increase in use has been driven by major increases in non-medically indicated CS in many middle-income and high-income countries.2, 3, 4 However, use of CS in more than 20% of births has not been shown to improve perinatal or neonatal outcomes in a population.4, 5, 6 By contrast, many low-income and middle-income countries still use CS for less than 10% of births in the overall population, which is considered to be indicative of inadequate access to medically indicated CS.3, 5, 6 Additionally, large differences in CS use have been observed between births in the poorest and the richest wealth quintiles within many low-income and middle-income countries.7

Key messages

  • Caesarean section (CS) can save women's and infants' lives and should be universally accessible. However, the large increase in CS use, often for non-medical indications, is of concern given the risks for both women and children.

  • CS use is increasing in all regions and, in 2015, more than one in five live births were by CS. In most countries, CS use has reached a frequency well above what is expected on the basis of obstetric indications. Within-country CS use is often particularly high among wealthier women and in private facilities.

  • By contrast, inadequate access to CS is still a major issue in most low-income and several middle-income countries, especially in sub-Saharan Africa and among the poorest women. The low use of CS implies that women and babies are at much higher risks of dying because they cannot access lifesaving surgery during childbirth.

  • Optimisation of CS use is needed, underpinned by a better understanding of demand and supply factors that drive the overuse of CS and by greater efforts to ensure universal access to CS for all women.

This is the first in a three-part Series on Optimising Caesarean Section Use that focuses on the high frequency of CS use globally and regionally, while acknowledging the concurrent problem of low use in some regions. The two other Series papers8, 9 summarise the evidence of health effects of CS on women and children and provide an overview of potential interventions to reduce high CS use. We aimed to describe the frequency of, trends in, determinants of, and inequalities in CS use, globally, regionally, and in selected countries. We update the global and regional estimates of the frequency of and trends in CS per 100 livebirths during 2000–15, including the relative contributions of changes in the number of births in health institutions and in intra-institutional use of CS to the overall use of CS in the population. We assess the extent to which country-level CS use is associated with socioeconomic development, women's education, urbanisation, fertility, and availability of physicians. We analyse within-country socioeconomic and geographic disparities in CS use in the population and the differences in CS use between public and private health facilities. Finally, we use the Robson classification10 to obtain further insights into the need for and use of CS as well as inequalities by women's education in Brazil and China.

Section snippets

Global and regional frequency and trends

We updated the WHO and UNICEF databases on population CS use and institutional delivery (ie, within health institutions) with data published before Jan 1, 2018, which were derived from household surveys, annual vital statistics, and routine statistical surveillance. For household surveys, information is collected retrospectively and statistics are computed for reference periods, typically for the 3 or 5 years preceding the survey. We located all survey data points in the calendar year that was

Contributions of increasing institutional birth rates and intra-institutional CS rates

Population CS use, the proportion of all livebirths by CS, can also be expressed as the product of the proportion of all livebirths in the population that occurred in any health institution (institutional births) and the proportion of livebirths by CS within health institutions (intra-institutional CS use). The intra-institutional CS estimate provides additional insights into the epidemiology of CS in countries where a substantial proportion of births occur at home, since the proportion of

Disparities between countries

An analysis based on the most recent data point from each country showed that CS was used in more than 15% of births in 106 (63%) of the 169 countries assessed, whereas, in 48 (28%) countries, CS was used in less than 10% of births. There were large differences in intra-institutional CS use, even among countries with similar proportions of institutional births (figure 2). Among 85 countries with more than 95% of births occurring in health facilities, intra-institutional CS use varied from less

Disparities within countries

We updated data from a previous study7 with data from Demographic and Health Surveys or Multiple Indicator Cluster Surveys to examine the effects of household wealth on both population and intra-institutional CS use for 82 low-income and middle-income countries (table 2). There were large differences in population CS use between women in the poorest (median 4·1%, IQR 1·9–12·0) and the richest (19·1%, 10·6–33·8) wealth quintile in these countries. Two thirds (55 countries) of 82 low-income and

CS according to need

The Robson classification provides further information on the need for and use of CS by possible medical indication.10, 15 The Robson system classifies women giving birth in health facilities into ten groups on the basis of their obstetric characteristics (parity, previous CS, gestational age, onset of labour, fetal presentation, and number of fetuses). Groups 1 and 2 comprise nulliparous women who begin labour at or after 37 weeks with singleton, cephalic, fetuses; groups 3 and 4 comprise

Poor access versus overuse

In 2015, an estimated 29·7 million (21·1%) births globally were by CS, which represented almost a doubling in the proportion since 2000, when 16·0 million (12·1%) births were by CS. The differences in the frequency of CS use between regions were striking, with a high of 44·3% in the Latin America and Caribbean region and a low of 4·1% in the west and central Africa region. CS use more than doubled in frequency in the south Asia region and the eastern Europe and central Asia region during

Conclusions

There are several limitations to our analysis. First, we were unable to obtain recent data for all countries and, for a small proportion of countries (26 [15·4%] of 169 countries), we only had one data point during 2000–15, so we used additional data points in the 1990s to obtain better information on trends. We did, however, have data for mode of delivery that represented 98·4% of the world's births in 2015. Second, we relied heavily on survey data for low-income and middle-income countries.

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