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The plateauing of cesarean rates in industrialized countries

Published:November 24, 2016DOI:https://doi.org/10.1016/j.ajog.2016.11.1038

      Objective

      There has been growing concern with the increase in cesarean rates in industrialized, transition, and developing countries,
      • Gibbons L.
      • Belizán J.
      • Lauer J.
      • Betrán A.
      • Merialdi M.
      • Althabe F.
      The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage.
      a concern reflected in the recent consensus statement on “Safe prevention of the primary cesarean delivery.”

      American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine; Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. 2014;210:179-93.

      This letter updates an earlier paper
      • Declercq E.
      • Young R.
      • Cabral H.
      • Ecker J.
      Is a rising cesarean delivery rate inevitable? Trends in industrialized countries, 1987 to 2007.
      that examined trends in cesarean rates in industrialized countries through 2007.

      Methods

      To enhance comparability we included only the 21 countries that met 3 criteria: (1) ≥50,000 births annually; (2) per capita gross domestic product of at least $20,000 in 2013; and (3) consistent reporting of national cesarean rates from 1988 through 2013 (Table). Data were drawn from 3 public use sources: (1) the Organization for Economic Co-operation and Development; (2) the World Health Organization (WHO) European Health for All database; and (3) country reports where available. The analysis compared 5-year intervals to examine if the annual change in cesarean rates in a given interval differed from the annual change in the next period. The slope of each country’s trend line for a 5-year interval was compared by calculating an exponentiated change in rate (multiplicative scale), which measures the ratio of annual rate of change during 1 period (eg, 2008 through 2013) compared to a prior period (eg, 2003 through 2008). We had complete data for all countries from 2000 through 2013. From 1988 through 1999 we had complete data on 13 countries. In the case of some countries, data reporting did not begin until after 1990 (Israel 1998; Austria 1995) or there was a period of missing data (eg, Switzerland 1992 through 1997). The Table presents data back to 1988 for descriptive purposes, but analysis focuses on the period from 1993 through 2013 where data were relatively complete. Since the United States had almost half of all births, weighted averages are presented with and without the United States. The methods are described in more detail elsewhere.
      • Declercq E.
      • Young R.
      • Cabral H.
      • Ecker J.
      Is a rising cesarean delivery rate inevitable? Trends in industrialized countries, 1987 to 2007.
      TableCesarean rates (per 1000 live births) in industrialized countries, 1988 through 2013
      Country198819931998200320082013Change 1993 through 2003Change 2003 through 2013Exponentiated change in rate 2003 through 2008 vs 1998 through 2003Exponentiated change in rate 2008 through 2013 vs 2003 through 2008
      Australia16718821328730532752.3%14.2%0.94
      P < .01
      1.00
      Austria
      Data not available for that year.
      Data not available for that year.
      146207271288
      Data not available for that year.
      39.1%0.98
      P < .01
      0.96
      P < .01
      Belgium10212914417619620736.0%17.8%0.98
      P < .01
      0.99
      Canada
      Data not available for that year.
      17518824826427341.5%10.2%0.95
      P < .01
      0.99
      Czech Republic759112315320524968.0%62.7%1.02
      P < .01
      0.97
      P < .01
      Denmark12912513719220922153.1%15.2%0.94
      P < .01
      0.98
      Finland13814615316216515810.8%–2.3%0.99
      P < .01
      1.00
      France12915516919320620824.6%7.8%0.99
      P < .01
      0.99
      P < .01
      Germany
      Data not available for that year.
      16619124829430649.7%23.4%0.98
      P < .01
      0.97
      P < .01
      Ireland97116
      Data not available for that year.
      234256285101.7%21.7%0.97
      P < .01
      1.00
      Israel
      Data not available for that year.
      Data not available for that year.
      134156169158
      Data not available for that year.
      1.3%1.000.97
      P < .01
      Italy18824129137838636156.9%–4.4%0.95
      P < .01
      0.98
      P < .01
      Netherlands
      Data not available for that year.
      8411113514316460.3%21.2%0.97
      P < .01
      1.03
      New Zealand11213818222323025661.6%14.8%0.96
      P < .01
      1.02
      Norway12812513715516916424.1%5.7%0.990.98
      P < .01
      Portugal14822527631935635041.4%9.9%0.980.97
      P < .01
      Slovak Republic
      Data not available for that year.
      10613318123330771.2%69.4%0.97
      P < .01
      1.02
      Spain12917320523824725237.2%5.8%0.97
      P < .01
      0.99
      Sweden11211613816516716442.2%–0.7%0.96
      P < .01
      0.99
      Switzerland171
      Data not available for that year.
      229268325330
      Data not available for that year.
      23.2%1.020.96
      P < .01
      United Kingdom
      Data not available for that year.
      15017921823125145.6%14.9%0.98
      P < .01
      1.00
      United States24721621029232232535.5%11.3%0.96
      P < .01
      0.97
      P < .01
      Weighted average20218619926128528940.1%10.8%0.97
      P < .01
      0.98
      Weighted average without United States14116319023625526244.5%11.1%0.970.99
      Declercq et al. Plateauing of cesarean rates in industrialized countries. Am J Obstet Gynecol 2017.
      a P < .01
      b Data not available for that year.

      Results

      There was a marked increase in cesarean rates in the decade from 1993 through 2003 with countries reporting an average increase of 40% (45% without the United States) in their cesarean rate, whereas the average increase from 2003 through 2013, with or without the United States, was 11%. Every country reported a smaller percent increase from 2003 through 2013 than from 1993 through 2003. In the most recent 5-year period, 2008 through 2013, the average increase was only 1.5% (data not shown), with 6 of the countries reporting declines in their cesarean rates. The exponentiated rates show none of the 21 countries experienced a significant increase from 2008 through 2013 compared to the prior period, while 10 experienced a significant decrease.
      Of the 5 countries with rates >30% in 2008, Italy reported a decline, 3 (Portugal, United States, and Switzerland) remained essentially unchanged, and only Australia increased by more than a single percentage point. Only the Czech Republic and Slovak Republic reported recent rapid increases.

      Discussion

      Cesarean rates in industrialized countries have generally plateaued, but at rates that are higher than recommended by WHO.

      World Health Organization. WHO statement on cesarean section rates. Available at: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/. Accessed Aug. 12, 2016.

      Industrialized countries’ efforts to control their cesarean rates can serve as a model for rapidly industrializing countries, such as Brazil and China, with high current cesarean rates.
      • Domingues R.M.S.M.
      • Dias M.A.B.
      • Nakamura-Pereira M.
      • et al.
      Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final.

      References

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        • Belizán J.
        • Lauer J.
        • Betrán A.
        • Merialdi M.
        • Althabe F.
        The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage.
        World Health Report. 2010; 30
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        • Declercq E.
        • Young R.
        • Cabral H.
        • Ecker J.
        Is a rising cesarean delivery rate inevitable? Trends in industrialized countries, 1987 to 2007.
        Birth. 2011; 38: 99-104
      2. World Health Organization. WHO statement on cesarean section rates. Available at: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/. Accessed Aug. 12, 2016.

        • Domingues R.M.S.M.
        • Dias M.A.B.
        • Nakamura-Pereira M.
        • et al.
        Processo de decisão pelo tipo de parto no Brasil: da preferência inicial das mulheres à via de parto final.
        Cad Saude Publica. 2014; 30: S101-S116