Epidemiology of cesarean delivery: frequency, indications, related morbidity, and evidence-based strategies for optimal use

Cesarean delivery is a complex issue, involving medical, social, economic, and ethical dimensions. Cesarean delivery rates have steadily increased worldwide since 1990. Yet, important disparities exist between and within countries, with cesarean delivery rates ranging from less than 3% to more than 55% between 2000 and 2015. These differences often reflect inequities in access to obstetric care-particularly in rural or low-resource settings-and socioeconomic divides. In many low-income areas, underuse is driven by limited access to surgical services and geographical and financial barriers. In contrast, overuse is driven by cesarean delivery without clear medical indication, particularly among wealthier women in urban area, who have easier access to the private sector. Evidence shows that population-level cesarean delivery rates between 9% and 19% are associated with reductions in maternal and neonatal mortality. Beyond this threshold, however, no further benefit has been observed. Accordingly, in 2015, the World Health Organization stated that efforts should be made to achieve a cesarean delivery threshold of at least 10% in clinical settings that have the capacity to properly conduct safe surgery. In many low- and middle-income countries, underuse and overuse of cesarean deliveries may coexist within different subgroups of the population (rural vs urban, poorer vs wealthier). Meanwhile, in high-income countries, where obstetric care is widely available and safe, an overuse of cesarean delivery without medical indications, with potential for increased negative outcomes, remains a concern. Finding the right balance and optimize cesarean delivery use remains a pressing challenge for each country to minimize both mortality and morbidity. The optimal cesarean delivery rate to balance the advantages and disadvantages of this obstetrical intervention is context-specific and varies according to countries, region, and settings. As such, in 2015, the World Health Organization emphasized that every effort should be made to provide cesarean delivery to women in need rather than striving to achieve a specific rate. A complex interplay of maternal, health professional, and institutional factors contributes to explain both underuse and overuse of cesarean deliveries, as well as inequities between or within countries. Interventions to address the underuse of cesarean deliveries should ensure a high access to safe obstetric care in both urban and rural areas and ensure a high level of quality of care through quality improvement programs. Interventions to address the overuse of cesarean deliveries should target unnecessary primary cesarean deliveries, through multifaceted strategies at clinical and nonclinical level, to encourage a shared decision-making culture, provide a supportive care environment, and promote best practices and interdisciplinary collaboration.