Historically the introduction of caesarean section surgery w
Historically, the introduction of caesarean section surgery was associated with an improvement in maternal and perinatal health outcomes. WHO has stated that no empirical evidence exists for an ideal caesarean rate, but “what matters most is that all women who need caesarean sections actually receive them”. In areas with very high mortality rates, such as Africa, inadequate availability of caesarean section contributes to substantial maternal and perinatal morbidity and mortality. Conversely, in many developed countries, concerns exist about high rates of caesarean section, since increasing rates of this procedure show little evidence of leading to further improvement in perinatal outcomes. Caesarean section carries its own risks for maternal and infant morbidity and for subsequent pregnancies. At some point, these risks will outweigh the potential benefits associated with lowering the threshold at which the procedure becomes indicated. The skill needed to make a balanced clinical decision for an individual woman might well be greater than the skill required to actually undertake the procedure. Joshua Vogel and colleagues\' study in provides much-needed data to inform the debate about the global rise in caesarean section rates. Vogel and colleagues analysed data from 287 facilities in 21 countries that were included in both the WHO Global Survey of Maternal and Perinatal Health (2004–08) and the WHO Multi-Country Survey of Maternal and Newborn Health (2010–11). The results show not only the large increase in the caesarean section rate as countries move from lower to higher Human Development Index (HDI) categories, but also that rates are consistently rising even within these categories. As acknowledged by Vogel and colleagues, the data are not necessarily representative of the caesarean section rates in the overall populations of the included countries. The sample populations are drawn from large hospitals (>1000 deliveries per year), almost 70% of which were located urban areas. However, 54% of the world\'s 2-NBDG Supplier lived in urban areas in 2014, and this percentage is expected to rise to 66% by 2050. The study\'s results are a signpost for the future of maternity care as country incomes and urbanisation increase, unless changes to birth management can be achieved that will safely reduce the propensity to resort to caesarean delivery. Vogel and colleagues\' study adds depth to the comparison of international caesarean section rates through the use of the Robson classification. The Robson classification is a widely accepted, risk-based, ten-group classification system developed specifically to assess caesarean section rates. It allows comparison of clinically meaningful maternity population subgroups and the associated caesarean section rates across institutions, countries, development groups, and time. This system helps to account for some of the population variations that can occur (eg, populations with lower fertility rates will have comparatively more nulliparous births than will more fertile populations). In most countries and HDI categories, the rates of obstetric interventions (both caesarean sections and labour inductions) increased. Overall, the caesarean section rate increased over time in all countries except Japan, from 26·4% in the WHO Global Survey to 31·2% in the WHO Multi-Country Survey (p=0·003). Japan\'s small decrease in caesarean section rates, including a decline in caesarean section rates for nulliparous women at term in spontaneous or induced labour, was a notable exception and warrants further exploration for lessons to be learnt. The substantial variation in caesarean section rates within HDI categories is also notable, and probably indicates some underuse of appropriate caesarean sections as well as likely overuse of the procedure. This study raises as many questions as it answers. To what extent the caesarean section rate increases are caused by changes in pregnancy management, the availability of maternity services, and patient or provider expectations is not clear. Efforts to explain variation in Australian caesarean section rates within Robson groups showed that patient factors explain most of the variation in prelabour caesarean section rates but not after labour inductions, and that adjustment for private obstetric care, labour, and delivery practices actually increased the amount of unexplained variation in intrapartum caesarean section rates. Concerns about high rates of caesarean section in private obstetric care settings also exist in low HDI nations, with countries such as Bangladesh reporting caesarean section rates as high as 73% in private facilities. Another important question is whether or not the different rates of caesarean section are associated with variation in maternal and infant morbidity. In particular, it would be useful to know whether or not improvements in perinatal mortality have occurred that correspond to each country\'s change in caesarean section rate.