In addition to geographic variability, researchers have proposed several theories to explain the rise in cesarean deliveries: Some have claimed that today’s women are simply at higher risk of developing childbirth-related complications than women were 30 years ago—perhaps partially due to older childbearing age. However, variation in hospital-level primary cesarean rates among low-risk women illustrates that a woman’s health status alone cannot account for the trend.
Others have suggested that, in some contexts, convenience factors and the threat of medical malpractice lawsuits create incentives for providers to choose cesareans over vaginal delivery. Social determinants such as a woman’s socioeconomic status, type of payment and race/ethnicity have been identified as contributing factors in different countries.
In the United Kingdom and the United States, in particular, emphasis on the “too posh to push” phenomenon in the media has reinforced the notion that many women are choosing to schedule cesarean deliveries, when in reality, available evidence reveals that elective cesarean deliveries are relatively uncommon. Hospital-level factors including whether a facility is public or private can also affect a woman’s likelihood of undergoing cesarean section surgery.
Overall, there does not seem to be a consensus on an explanation for the cesarean epidemic. Several interconnected factors influence cesarean rates, and those factors differ depending on the particular sociocultural, political and economic context.
Finding a balance
The global maternal health community is struggling to strike a balance—providing adequate, high quality care without falling into the trap of unnecessary intervention. A very low cesarean rate can indicate a lack of access to life-saving resources and is generally associated with higher maternal and newborn mortality. A very high cesarean rate, on the other hand, can be a sign of over-intervention and a trend of medicalized birth. Importantly, higher cesarean rates are not associated with improved maternal or infant outcomes. In fact, evidence suggests that higher cesarean rates can be associated with worse outcomes.
The global cesarean epidemic is not only a threat to the health of mothers and children around the world, but also to health systems. Swift action from clinicians, researchers, programmers and policymakers is needed.
Read a statement about the prevention of primary cesareans from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.
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