What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies

Abstract

In 1985, WHO stated that there was no justification for caesarean section (CS) rates higher than 10–15 % at population-level. While the CS rates worldwide have continued to increase in an unprecedented manner over the subsequent three decades, concern has been raised about the validity of the 1985 landmark statement. We conducted a systematic review to identify, critically appraise and synthesize the analyses of the ecologic association between CS rates and maternal, neonatal and infant outcomes. Four electronic databases were searched for ecologic studies published between 2000 and 2014 that analysed the possible association between CS rates and maternal, neonatal or infant mortality or morbidity. Two reviewers performed study selection, data extraction and quality assessment independently. We identified 11,832 unique citations and eight studies were included in the review. Seven studies correlated CS rates with maternal mortality, five with neonatal mortality, four with infant mortality, two with LBW and one with stillbirths. Except for one, all studies were cross-sectional in design and five were global analyses of national-level CS rates versus mortality outcomes. Although the overall quality of the studies was acceptable; only two studies controlled for socio-economic factors and none controlled for clinical or demographic characteristics of the population. In unadjusted analyses, authors found a strong inverse relationship between CS rates and the mortality outcomes so that maternal, neonatal and infant mortality decrease as CS rates increase up to a certain threshold. In the eight studies included in this review, this threshold was at CS rates between 9 and 16 %. However, in the two studies that adjusted for socio-economic factors, this relationship was either weakened or disappeared after controlling for these confounders. CS rates above the threshold of 9–16 % were not associated with decreases in mortality outcomes regardless of adjustments. Our findings could be interpreted to mean that at CS rates below this threshold, socio-economic development may be driving the ecologic association between CS rates and mortality. On the other hand, at rates higher than this threshold, there is no association between CS and mortality outcomes regardless of adjustment. The ecological association between CS rates and relevant morbidity outcomes needs to be evaluated before drawing more definite conclusions at population level.Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-015-0043-6) contains supplementary material, which is available to authorized users.

Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population‐based ecological study with longitudinal data

“…Several ecological studies have analysed the association between the mode of delivery and maternal, neonatal, and infant mortality, and identified an inflection point below which there was a strong association between caesarean section rates and mortality outcomes 2, 4, 12, 13, 14, 15, 16, 17, 18. A systematic review of ecological studies concluded that this point ranged from 9 to 16%, and at caesarean section rates above this threshold, there was no longer an association between caesarean section rates and maternal or infant mortality 30. Among the eight studies found, only two previous ecological studies controlled for socio‐economic conditions.…”

Nesa Days 2015, Conference Report

“…It reflects especially on the rate of vaginal birth after previous cesarean section where very few obstetricians can take decision for vaginal delivery. They have overviewed the main problems associated with increased rate of cesarean section [8][9][10]. It seems the main reason of repeat cesarean sections is the uterine scar dehiscence after previous cesarean section, which can produce rupture of the uterus through dehiscence scar during pregnancy [43] or delivery in about 70% of cases.…”

“…In the US, maternal mortality has increased from 10 (1998) to 14/ 100.000 (2004) due to placenta percreta, scars or emergency hysterectomy after a complication induced by a (previous) Cesarean [10]. Confidential inquiries about the specified complications as the direct or indirect cause of combined mortality or severe morbidity are rare.…”

The Closure Non Closure of the Parietal Peritoneum in the Caeserean Section

“…Since 1985, a C-section rate of 10-15 % has been deemed optimum by international health-care community [6]. When C-section rates rise towards 10% across a population, maternal and newborn deaths decrease; when they are higher than 15% , there is no evidence of reduced morbidity [6]. Even though, the C-section rates rise up 70% in some countries, the standard evidence-based quidelines are not established [3,2].…”

“…Although the aim of caesarean section is the decreasing of newborn and mother and morbidity rates, the complications of the caesarean section can be result in disability or death of the baby and mother [3][4][5]. Since 1985, a C-section rate of 10-15 % has been deemed optimum by international health-care community [6]. When C-section rates rise towards 10% across a population, maternal and newborn deaths decrease; when they are higher than 15% , there is no evidence of reduced morbidity [6].…”