Rates of caesarean section are of concern in both developed and developing countries. We set out to estimate the proportion of births by caesarean section (CS) at national, regional and global levels, describe regional and subregional patterns and correlate rates with other reproductive health indicators. We analysed nationally representative data available from surveys or vital registration systems on the proportion of births by CS. We used local non-parametric regression techniques to correlate CS with maternal mortality ratio, infant and neonatal mortality rates, and the proportion of births attended by skilled health personnel. Although very unevenly distributed, 15% of births worldwide occur by CS. Latin America and the Caribbean show the highest rate (29.2%), and Africa shows the lowest (3.5%). In developed countries, the proportion of caesarean births is 21.1% whereas in least developed countries only 2% of deliveries are by CS. The analysis suggests a strong inverse association between CS rates and maternal, infant and neonatal mortality in countries with high mortality levels. There is some suggestion of a direct positive association at lower levels of mortality. CS levels may respond primarily to economic determinants.

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Objective To examine the association between decision to delivery interval and maternal and baby outcomes. Design National cross sectional survey. Setting Maternity units in England and Wales. Subjects reviewed 17 780 singleton births (99% of all births) delivered by emergency caesarean section in England and Wales between 1 May 2000 and 31 July 2000. Main outcome measures Association between decision to delivery interval and baby outcomes (Apgar scores of < 7 and < 4 at five minutes and stillbirth) and maternal outcomes (requirement for special care additional to routine care after caesarean section and where care was provided). Results Compared with babies delivered within 15 minutes, there was no difference in maternal or baby outcome for decision to delivery interval between 16 and 75 minutes. After 75 minutes, however, there was a significantly higher odds of a five minute Apgar score of < 7 (odds ratio 1.7, 95% confidence interval 1.2 to 2.4), and 50% increase in odds of special care additional to routine care for mothers. Conclusion A decision to delivery interval of 30 minutes is not an absolute threshold for influencing baby outcome. Decision to delivery intervals of more than 75 minutes are associated with poorer maternal and baby outcomes and should be avoided.

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This review indicates that many different interventions have efficacy in preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section. There is little evidence that combinations of treatment are better than single agents.

Case mix adjustment is important to enable understanding of the factors that influence the CS rate. These include organisational and staffing levels as well as women's preferences for childbirth and clinician's attitudes. An understanding of how these factors influence the CS rate is essential for evaluation of quality and appropriateness of obstetric care provided to women.

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