Cesarean section rates are increasing around the world, sparking concern for maternal and fetal health. New data from the World Health Organization (WHO) finds that 21 percent of all childbirths are by C-section and that C-section rates are anticipated to continue rising to 29 percent by 2030, with variability across countries.
These rates represent a drastic increase in just a few decades: In 1990, the worldwide C-section rate was estimated at about 7 percent. Many C-sections, particularly in wealthier nations, are by choice, suggesting a need for better education about the risks of this procedure.
Geographic Differences in C-Section Rates
The lowest rates of C-sections occur in sub-Saharan Africa, where only 5 percent of births are by C-section. The Dominican Republic, Brazil, Cyprus, Egypt and Turkey have the highest rates of C-sections, which outnumber vaginal births in those countries. The U.S. cesarean rate has increased from 22.7 percent in 1990 to 31.9 percent as of 2018.
The WHO estimates that by 2030, East Asia will have the highest regional C-section rates at 63 percent, followed by Latin America and the Caribbean. The organization also expects that the nations in those regions with the lowest wealth and least access to medical care will perform the largest number of these C-section deliveries, leading to concerns about worse health outcomes and higher maternal and fetal mortality rates.
Factors Driving the Increase in C-Sections
A mix of clinical indications and personal choice play into the increasing rates of non-vaginal birth. Research in the Lancet found that fear of labor pains, worries about pelvic floor damage and fear of negative effects on sexual relationships drove some people away from choosing a vaginal birth. A recurring theme across countries is a belief that C-section is safer than vaginal birth, despite the scientific evidence to the contrary. Some pregnant patients choose C-section to control their delivery date, have tubal ligation at the same time or due to a negative experience with vaginal delivery.
The Lancet researchers found that media coverage in some countries has presented an image of C-section delivery as being fashionable and convenient. Health coverage may also play a role. In Brazil, which has an overall C-section rate above 50 percent, a staggering 80 percent to 90 percent of babies born in the private sector are delivered by C-section, compared with 30 percent to 40 percent of babies born in the public sector. The researchers also cited findings from Chile that revealed some hospitals are incentivized to encourage C-sections because they are more profitable for the hospital than vaginal births.
Physician attitudes also play a role in the choices patients make. The Lancet researchers found that health providers often went along with a patient's request for an elective C-section in part because of fear of litigation. The United Kingdom had the highest rate of physician compliance with patient requests in the survey.
Clinical reasons for an increase in C-sections include rising rates of maternal obesity, multiple births and older maternal age, the WHO reports. COVID-19 may also be a medical reason for a C-section procedure, although its effect on rates isn't yet clear. One systematic review of several Chinese studies and another published in the European Journal of Midwifery found that women with COVID-19 were more likely to deliver by C-section, possibly because they were at higher risk of complications. Other research found the rate of premature delivery by C-section actually decreased during the pandemic. Whether the pandemic has an ongoing effect on the overall rates of C-sections remains to be seen.
Educating Patients on the Risks of C-Sections
The cesarean section procedure carries risks of infection, hemorrhage and anesthesia complications for the pregnant patient. Further, infants delivered via this method have higher rates of asthma or other respiratory problems. A C-section also entails higher risks of complications with future pregnancies, including uterine rupture and issues with implantation, including issues with embryo implantation, placenta accreta and uterine rupture. It also increases healthcare costs overall.
The WHO recommends certain interventions to reduce unnecessary cesarean sections, including educating patients about the potential risks, requiring a context-specific second opinion, providing childbirth training workshops and more. By offering education and support, physicians can help combat misinformation and take the first step in lowering the rates and risks of elective C-sections.
