Caesarean section (cs) rates in developed countries have grown rapidly over the past few decades, leading to concern among some experts that cs rates of 25-35% might be causing more harm than good to women and driving unnecessary health care expenditures (the US rate is roughly 30%). While it has been known for some time that rates are also high in some Latin American countries, there is a general perception that rates are still low in most developing countries – perhaps even too low. At least that is my perception based on the data I have seen from Sub-Saharan African countries.

I guess that is why it was so shocking for me to learn that rates in many Asian countries are high, potentially as high, as rates seen in Latin America and most developed countries. The results of a multi-country facility-based study of delivery and pregnancy outcomes in Asia has shown that at least a quarter of births delivered in facilities in 9 Asian countries were delivered by Caesarean section – in China nearly one half of births ended in a Caesarean section.

The study was only conducted in facilities, so these should not be taken as national rates. The authors also explored whether or not more intensive births were associated with better or worse outcomes for the mother and baby and found evidence that suggest that if anything these procedures are causing more harm than good (again, these findings should be interpreted cautiously given selection effects due to the facility-based nature of these surveys). But taken together, the overall levels and potential consequences do raise the question of whether cs rates are too high in some developing countries as well?

There are at least three potential explanations as to why rates are so high. First, it might be that women want caesarean sections and are increasingly electing these procedures. The Asia study did not seem to suggest this to be the case as most of the surgeries were done during the intrapartum period with indications. Second, it might be that there has been increased need for the service or new indications for which it is recommended – this again seems a bit unlikely as it is hard to imagine what could possibly explain the rapid increases. Finally, it could be that the physician has a high level of discretionary power over the decision to operate and that due to a number of factors have become more likely to intervene. This seems – at least to me – to be the most likely candidate but of course, I have not seen any good
evidence to support this view.

I really think that studies of this nature point to the urgent need for a better understanding of how women are accessing pre-natal, delivery, and post-natal care – not just in the developing world but everywhere. I am almost 7 months pregnant and am currently trying to develop a plan for my own delivery but end up finding myself frustrated with the lack of evidence that seems to be available to inform my decisions. It is amazing how little we know about a process that has been happening for at least as long as human have been on this earth…

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6 Responses to “Are caesarean section rates in developing countries too high?”

  1. Ryan says:

    California is experiences increases in maternal mortality, rates higher than Bosnia and Kuwait. I'm curious to know how the elective use of ceasarian has influenced that statistic.

  2. Karen Grepin says:

    Ryan, do you have a cite on that statistic? I am also curious about these questions and suspect that places like California are likely to be among the best places to study this question.

  3. Ryan says:

    While some epidemiologists hold that it is not a matter of increased risk of death but simply a function of more comprehensive reporting, I'm not sure that anybody know whether or not that is true. Here is a citation with more citations…

  4. Michael Keizer says:

    I live in one of the countries with the highest CS rates in the world: Australia. It turns out that CS incidence is actually fairly closely correlated with ethnicity and cultural background in first generation immigrants, but that second and later generations have relative incidences that are much closer to the average (when controlled for age).

    Which obviously opens some really interesting avenues for speculation about sociological influences.

  5. Caesarean section says:

    The number of C-sections performed in the United States has been “growing steadily,” with approximately 30 percent of women having the procedure. Other insurance companies that don’t necessarily reject women with C-sections often do charge them higher premiums or “factor in chronic or recurring problems that might have led to the Caesarean.” What’s even worse is that once you’re denied by one company, it’s harder to get coverage somewhere else because you’ve been red-flagged.

  6. Anonymous says:

    But the reason is that governments are actually covering up the safety of caesarean sections. The World Health Organisation prdoduced an absurd study showing that caesareans were riskier to mother and baby but the evidence showed nothing of the sort. There is a UK site that deals with governments distortion of statistics – it picked this up – I checked the data and he is absolutely right. Here is the link

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