BackgroundThe caesarean section (CS) rate continues to increase across high-income, middle-income and low-income countries. We present current global and regional CS rates, trends since 1990 and projections for 2030.MethodsWe obtained nationally representative data on the CS rate from countries worldwide from 1990 to 2018. We used routine health information systems reports and population-based household surveys. Using the latest available data, we calculated current regional and subregional weighted averages. We estimated trends by a piecewise analysis of CS rates at the national, regional and global levels from 1990 to 2018. We projected the CS rate and the number of CS expected in 2030 using autoregressive integrated moving-average models.ResultsLatest available data (2010–2018) from 154 countries covering 94.5% of world live births shows that 21.1% of women gave birth by caesarean worldwide, averages ranging from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean. CS has risen in all regions since 1990. Subregions with the greatest increases were Eastern Asia, Western Asia and Northern Africa (44.9, 34.7 and 31.5 percentage point increase, respectively) while sub-Saharan Africa and Northern America (3.6 and 9.5 percentage point increase, respectively) had the lowest rise. Projections showed that by 2030, 28.5% of women worldwide will give birth by CS (38 million caesareans of which 33.5 million in LMIC annually) ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia .ConclusionThe use of CS has steadily increased worldwide and will continue increasing over the current decade where both unmet need and overuse are expected to coexist. In the absence of global effective interventions to revert the trend, Southern Asia and sub-Saharan Africa will face a complex scenario with morbidity and mortality associated with the unmet need, the unsafe provision of CS and with the concomitant overuse of the surgical procedure which drains resources and adds avoidable morbidity and mortality. If the Sustainable Development Goals are to be achieved, comprehensively addressing the CS issue is a global priority.

ObjectiveCaesarean section was initially performed to save the lives of the mother and/or her baby. Caesarean section rates have risen substantially worldwide over the past decades. In this study, we set out to compile all available caesarean section rates worldwide at the country level, and to identify the appropriate caesarean section rate at the population level associated with the minimal maternal and neonatal mortality.DesignEcological study using longitudinal data.SettingWorldwide country‐level data.PopulationA total of 159 countries were included in the analyses, representing 98.0% of global live births (2005).MethodsNationally representative caesarean section rates from 2000 to 2012 were compiled. We assessed the relationship between caesarean section rates and mortality outcomes, adjusting for socio‐economic development by means of human development index (HDI) using fractional polynomial regression models.Main outcome measuresMaternal mortality ratio and neonatal mortality rate.ResultsMost countries have experienced increases in caesarean section rate during the study period. In the unadjusted analysis, there was a negative association between caesarean section rates and mortality outcomes for low caesarean section rates, especially among the least developed countries. After adjusting for HDI, this effect was much smaller and was only observed below a caesarean section rate of 5–10%. No important association between the caesarean section rate and maternal and neonatal mortality was observed when the caesarean section rate exceeded 10%.ConclusionsAlthough caesarean section is an effective intervention to save maternal and infant lives, based on the available ecological evidence, caesarean section rates higher than around 10% at the population level are not associated with decreases in maternal and neonatal mortality rates, and thus may not be necessary to achieve the lowest maternal and neonatal mortality.Tweetable abstractThe caesarean section rate of around 10% may be the optimal rate to achieve the lowest mortality.

ObjectiveTo generate a global reference for caesarean section (CS) rates at health facilities.DesignCross‐sectional study.SettingHealth facilities from 43 countries.Population/SampleThirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.MethodsWe hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.Main outcome measuresArea under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.ResultsAccording to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).ConclusionsThis article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.Tweetable abstractThe C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Objective To examine the quality and completeness of information on caesarean section in web pages used by laypersons in Brazil, a country with very high rates of caesarean delivery.Design Cross-sectional study.Setting Brazil.Sample A total of 176 Internet websites.Methods The term 'caesarean delivery' and 25 synonyms were entered into the most popular search engines in Brazil. The first three pages of hits were downloaded and assessed by two independent investigators using the DISCERN instrument and a content checklist.Main outcome measures Quality and completeness of information on caesarean section.Results A total of 3900 web pages were retrieved and 176 fulfilled the selection criteria. The overall average DISCERN score was 43.6 (AE8.9 SD), of a maximum score of 75; 30% of the pages were of poor or very poor quality and 47% were of moderate quality. Most pages scored low, especially in questions related to reliability of the information. The most frequently covered topics were: indications for caesarean section (80% of websites), which did not reflect clinical practice; short-term maternal risks (80%); and potential benefits of caesarean section (56%), including maternal and doctor convenience. Less than half of the websites mentioned perinatal risks and less than one-third mentioned long-term maternal risks associated with caesarean section, such as uterine rupture (17%) or placenta praevia/accreta (12%) in future pregnancies.Conclusions The quality and completeness of web-based resources in Portuguese about caesarean section were poor to moderate. Pending improvement of these resources, obstetricians should warn pregnant women about these facts and encourage them to discuss what they have read on the Internet about caesarean section.Keywords Caesarean section, doctor-patient relationships, health literacy, Internet, patient education, prenatal education.Tweetable abstract The quality and completeness of information about caesareans is poor in 176 websites used by Brazilians.Keywords Caesarean section, doctor-patient relationships, health literacy, Internet, patient education, prenatal education. IntroductionIn 1985, the World Health Organization (WHO) stated that there were no justifications for caesarean section rates higher than 10-15% anywhere in the world, 1 and yet rates are steadily increasing worldwide.2 Brazil has been the world champion of delivery by caesarean section since the early 1990s, 3 and numbers continue to rise. In 2010 over 50% of all deliveries in Brazil were by caesarean section, representing a 20% increase in just 4 years. 4,5 In the private sector, caesarean section rates are over 80%. 6,7 Reasons for increasing caesarean section rates are under investigation. Several contributing factors from both the health provider and user sides have been identified, including fear of labour pain, misconceptions about vaginal delivery, previous traumatic births, social values, personal preferences, fear of litigation, economic reasons, and convenience for both patients and doctors. [8][9][10][...

BackgroundIn most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates.ObjectivesTo identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates.Search strategyMedline, Embase, CINAHL and LILACS were searched from 2001 to 2016.Selection criteriaStudies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates.Data collectionData on study design, interventions used, CS rates, and perinatal outcomes were extracted.ResultsOf 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias.ConclusionWe identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates.Tweetable abstractUse of the Robson classification in clinical audit cycles to reduce caesarean rates.