This Lancet Series paper, one of three on the high rate of Caesarean Section (CS), describes the global, regional and selected country levels, trends, determinants and inequalities in CS. Based on data from 169 countries representing 98.4% of the world's births, we estimate that 21.1% (95% uncertainty range 19.9-22.4%) or 29.7 million births occurred through CS in 2015, representing almost a doubling since 2000 (12.1%; 10.9-13.3%). The differences in CS rates between regions in 2015 were tenfold, with a high of 44.3% (41.3-47.4%) in the Latin America and the Caribbean region and a low of 4.1% (3.6-4.6%) in the West and Central African region. The global and regional increases were driven both by increasing coverage of births by health facilities (66.5% of the global increase) and higher CS rates within health facilities (33.5%), with considerable variation between regions. Based on the most recent data, population-based CS rates exceeded 15% of births in 63% of 169 countries, while 28% countries had CS rates below 10%. National CS rates varied from 0.6% in South Sudan to 58.1% in the Dominican Republic. Within-country disparities in CS rates were also very large, with a sixfold difference in CS rates between births in the richest and poorest quintiles in low-and middle-income countries, markedly high CS rates among low obstetric risk births among especially more educated women in Brazil and China and 1.6 times higher CS rates in private facilities compared to public facilities.

This Lancet Series paper, one of three on the high rate of Caesarean Section (CS), describes the global, regional and selected country levels, trends, determinants and inequalities in CS. Based on data from 169 countries representing 98.4% of the world's births, we estimate that 21.1% (95% uncertainty range 19.9-22.4%) or 29.7 million births occurred through CS in 2015, representing almost a doubling since 2000 (12.1%; 10.9-13.3%). The differences in CS rates between regions in 2015 were tenfold, with a high of 44. 3% (41.3-47.4%) in the Latin America and the Caribbean region and a low of 4.1% (3.6-4.6%) in the West and Central African region. The global and regional increases were driven both by increasing coverage of births by health facilities (66.5% of the global increase) and higher CS rates within health facilities (33.5%), with considerable variation between regions.Based on the most recent data, population-based CS rates exceeded 15% of births in 63% of 169 countries, while 28% countries had CS rates below 10%. National CS rates varied from 0.6% in South Sudan to 58.1% in the Dominican Republic. Within-country disparities in CS rates were also very large, with a sixfold difference in CS rates between births in the richest and poorest quintiles in low-and middle-income countries, markedly high CS rates among low obstetric risk births among especially more educated women in Brazil and China and 1.6 times higher CS rates in private facilities compared to public facilities. Manuscript Key messages Global CS rates are high and increasing. In 2015, an estimated 21.1% or 29.7 million births occurred through CS, which represented almost a doubling since 2000. The differences in population CS rates between regions were very large, with a high of 44.3% in the Latin America and the Caribbean region and a low of 4.1% in West and Central African region. There are large persistent disparities in the CS rate between and within countries. Population CS rates are increasing in all regions but are still well below 10% in sub-Saharan Africa. Many poor women in low-and middle-income countries still do not have adequate access to CS. In several countries, poor women have CS rates close to 0%, implying that women and babies die because they cannot access life-saving surgery during labour. At the other end, there is strong evidence of massive over-use of CS in many countries. CS rates are still increasing in most regions with rates well over 15% by 2015, driven by extremely high CS rates among wealthier women, high rates in private facilities and by high proportions of women at low risk of obstetric complications giving birth by CS. AbstractThis Lancet Series paper, one of three on the high rate of Caesarean Section (CS), describes the global, regional and selected country levels, trends, determinants and inequalities in CS. Based on data from 169 countries representing 98.4% of the world's births, we estimate that 21.1% (95% uncertainty range 19.9-22.4%) or 29.7 million births occurred through CS in 2015, representing almos...