Reflections on

Cesarean Section

Rates

Dr. Allen Cherer

Cesarean section delivery is among the

most common surgical procedures. It is

estimated that in 2012 alone, over 22

million cesarean deliveries were

performed worldwide. Data from the

National Vital Statistics show that the

total cesarean section rate in the U.S.

in 1996 was approximately 21%.

Since that time, there has been a rapid

increase in the rate, such that in 2011,

close to 1 in 3 mothers delivered by

cesarean. Although the rate has leveled

since then, there remains no evidence

that such a significant increase has

been accompanied by a concomitant

decrease in maternal or neonatal

mortality.

Although cesarean delivery can be life-

saving for the fetus, the mother, or both in

certain cases, the concern exists that

cesarean delivery is overused. Hence, the

matter is a global health issue.

Since one of the main driving forces for

the increased total cesarean rate has been

a marked shift to repeat cesarean delivery

following a previous primary cesarean

section, a concerted effort over the past

several years has been to examine closely

the factors related to the safe

management of the nulliparous

pregnancy.

As early as 1985, the World Health

Organization (WHO) stated there was no

justification for any region to have a

cesarean delivery rate greater than 10-15

/100 live births. Nevertheless, the rates

continued to increase worldwide with no

scientific evidence indicative of

substantial maternal or perinatal benefit.

In fact, a number of studies have

associated higher rates of cesarean

deliveries with negative consequences,

including increased maternal and neonatal

morbidity and mortality as well as

increased consumption of limited health

resources by procedures without medical

indications.

In March 2014, a consensus report was issued

by the American College of Obstetrics and

Gynecology and the Society for Maternal-Fetal

Medicine on the safe prevention of the primary

cesarean section. Among other points, it

addressed management guidelines for the most

frequent indications for primary cesarean

deliveries, namely, labor dystocia, abnormal or

indeterminate fetal heart rate tracing, fetal

malpresentation, multiple gestation, and

suspected macrosomia.

The report encouraged obstetricians to

allow more time to progress through a

vaginal delivery without intervention,

recommended improved and standardized

fetal heart rate interpretation and

management, and advocated access to

non-medical interventionsduring labor,

such as continuous labor and delivery

support.

A study by researchers at Harvard Medical School and the

Stanford University School of Medicine published

December 2015 in The Journal of the American Medical

Association suggested that based on analyses of cesarean

section rates and maternal and neonatal outcomes,

among 194 WHO member countries the ideal rate of

childbirth by cesarean section approximates 19% of all

births as opposed to the previously considered optimal

rate of 10-15%. Although the finding is higher than the

former target, it remains significantly lower than the

current rate in U.S. hospitals.

In its April 2015 position statement on

cesarean delivery, the WHO moved away

from any target rate. Rather, it

emphasized that every effort should be

made to ensure cesarean sections are

provided to the women in need and only

be performed when medically necessary.

It is gratifying that the concept of “target

rate” is no longer tied to the delivery of

quality medical care. Primarily due to the

lack of a consistent classification system to

monitor and compare different obstetric

profiles, meaningful data relative to

cesarean section rates is missing.

It is only when such systems as the Robson

Ten Group Classification System are widely

adopted by institutions that valid “risk-

adjusted”cesarean section rates can

potentially be developed and comparisons

be made between institutions, regions, and

countries.