Caesarean section rates continue to rise amid growing inequalities in access: WHO

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Rising rates suggest increasing numbers of medically unnecessary, potentially harmful procedures

According to new research from the World Health Organization (WHO), caesarean section use continues to rise globally, now accounting for more than one in five (21 per cent) of all childbirths. This number is set to continue increasing over the coming decade, with nearly a third (29 per cent) of all births likely to take place by caesarean section by 2030, the research found.

While a caesarean section can be an essential and life-saving surgery, it can put women and babies at unnecessary risk of short- and long-term health problems, if performed, when there is no medical need.

“Caesarean sections are absolutely critical to save lives in situations where vaginal deliveries would pose risks. So, all health systems must ensure timely access for all women when needed. However, not all the caesarean sections carried out at the moment are needed for medical reasons. Unnecessary surgical procedures can be harmful, both for a woman and her baby,” said Dr Ian Askew, Director, WHO’s Department of Sexual and Reproductive Health and Research and the UN joint programme.

Caesarean sections can be essential in situations such as prolonged or obstructed labour, foetal distress, or because the baby is presenting in an abnormal position. However, as with all surgeries, they can have risks. These include the potential for heavy bleeding or infection, slower recovery times after childbirth, delays in establishing breastfeeding and skin-to-skin contact, and increased likelihood of complications in future pregnancies.

There are significant discrepancies in a woman’s access to caesarean sections, depending on where in the world she lives. In the least developed countries, about eight per cent of women gave birth by caesarean section with only five per cent in sub-Saharan Africa, indicating a concerning lack of access to this life-saving surgery.

Conversely, in Latin America and the Caribbean, rates are as high as four in ten (43 per cent) of all births. In five countries (Dominican Republic, Brazil, Cyprus, Egypt and Turkey), caesarean sections now outnumber vaginal deliveries.

Worldwide, caesarean section rates have risen from around seven per cent in 1990 to 21 per cent today, and are projected to continue increasing over this current decade. If this trend continues, by 2030, the highest rates are likely to be in Eastern Asia (63 per cent), Latin America and the Caribbean (54 per cent), Western Asia (50 per cent), Northern Africa (48 per cent) Southern Europe (47 per cent) and Australia and New Zealand (45 per cent), the research suggested.

Further, causes of high caesarean section usage vary widely between and within countries. Drivers include health sector policies and financing, cultural norms, perceptions and practices, rates of pre-term births and quality of healthcare.

Rather than recommending specific target rates, WHO underscores the importance of focusing on each woman’s unique needs in pregnancy and childbirth.

“It’s important for all women to be able to talk to healthcare providers and be part of the decision-making on their birth, receiving adequate information including the risks and benefits. Emotional support is a critical aspect of quality care throughout pregnancy and childbirth,” said Dr Ana Pilar Betran, Medical Officer, WHO and HRP.

WHO recommends some non-clinical actions that can reduce medically unnecessary use of caesarean sections, within the overall context of high quality and respectful care:

  • Educational interventions that engage women actively in planning for their birth such as child-birth preparation workshops, relaxation programmes and psychosocial support where desired, for those with fear of pain or anxiety. Implementation of such initiatives should include ongoing monitoring and evaluation.
  • Use of evidence-based clinical guidelines, performing regular audits of caesarean section practices in health facilities, and providing timely feedback to health professionals about the findings.
  • Requirement for a second medical opinion for a caesarean section decision in settings where this is possible.
  • For the sole purpose of reducing caesarean sections, some interventions have been piloted by some countries but require more rigorous research:
    (a) A collaborative midwifery-obstetrician model of care, for which care is provided primarily by midwives, with 24-hour back-up from a dedicated obstetrician.
    (b) Financial strategies that equalise the fees charged for vaginal births and caesarean sections.
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