Introduction
Caesarean section (CS) is a life-saving intervention for women and newborns when complications occur, such as antepartum haemorrhage, fetal distress, abnormal fetal presentation, and hypertensive disease. CS is the most common major surgical intervention in many countries.1 CS use has increased during the past 30 years to a frequency in excess of the proportion of 10–15% of births that is thought to be optimal.2, 3, 4 This increase in use has been driven by major increases in non-medically indicated CS in many middle-income and high-income countries.2, 3, 4 However, use of CS in more than 20% of births has not been shown to improve perinatal or neonatal outcomes in a population.4, 5, 6 By contrast, many low-income and middle-income countries still use CS for less than 10% of births in the overall population, which is considered to be indicative of inadequate access to medically indicated CS.3, 5, 6 Additionally, large differences in CS use have been observed between births in the poorest and the richest wealth quintiles within many low-income and middle-income countries.7
Key messages
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Caesarean section (CS) can save women's and infants' lives and should be universally accessible. However, the large increase in CS use, often for non-medical indications, is of concern given the risks for both women and children.
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CS use is increasing in all regions and, in 2015, more than one in five live births were by CS. In most countries, CS use has reached a frequency well above what is expected on the basis of obstetric indications. Within-country CS use is often particularly high among wealthier women and in private facilities.
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By contrast, inadequate access to CS is still a major issue in most low-income and several middle-income countries, especially in sub-Saharan Africa and among the poorest women. The low use of CS implies that women and babies are at much higher risks of dying because they cannot access lifesaving surgery during childbirth.
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Optimisation of CS use is needed, underpinned by a better understanding of demand and supply factors that drive the overuse of CS and by greater efforts to ensure universal access to CS for all women.
This is the first in a three-part Series on Optimising Caesarean Section Use that focuses on the high frequency of CS use globally and regionally, while acknowledging the concurrent problem of low use in some regions. The two other Series papers8, 9 summarise the evidence of health effects of CS on women and children and provide an overview of potential interventions to reduce high CS use. We aimed to describe the frequency of, trends in, determinants of, and inequalities in CS use, globally, regionally, and in selected countries. We update the global and regional estimates of the frequency of and trends in CS per 100 livebirths during 2000–15, including the relative contributions of changes in the number of births in health institutions and in intra-institutional use of CS to the overall use of CS in the population. We assess the extent to which country-level CS use is associated with socioeconomic development, women's education, urbanisation, fertility, and availability of physicians. We analyse within-country socioeconomic and geographic disparities in CS use in the population and the differences in CS use between public and private health facilities. Finally, we use the Robson classification10 to obtain further insights into the need for and use of CS as well as inequalities by women's education in Brazil and China.