Cesarean sections as a percent of all births

The number of C-sections performed in a defined population during a reference period; total number of live births in the same reference period.

Numerator: clinical registries for data in a given geographical area on the number of C-sections performed; estimates of the number of births in that area; and population- based surveys for self-reported C-sections only.

Denominator: all live births during the reference period. Where data on the numbers of live births are absent, evaluators can calculate total estimated live births using census data for the total population and crude birth rates in a specified area. Total expected births = population x crude birth rate.

Household demographic surveys often produce national and disaggregated estimates of the self-reported C-section rate.

This indicator demonstrates the extent to which a particular life-saving obstetric service is being performed in emergency obstetric care facilities. It reflects the accessibility and utilization of services as well as the functioning of the health service system. The appropriate use of a C-section leads to a decrease in maternal mortality and morbidity, as well as a decrease in perinatal morbidity and mortality. While cesarean sections may be performed solely for the health of the fetus or newborn, in developing countries the vast majority relate to maternal indications.

Many of the major pre- and intrapartum causes of maternal mortality and morbidity require the use of this procedure to save the woman's life or to prevent serious morbidity.

Of all the procedures used to treat the major obstetric complications, C-sections may be the easiest to study because record-keeping for C-sections is more reliable than that for other procedures or obstetric complications (MotherCare, 2000b; UNICEF, WHO, UNFPA, 1997). However, it is critical that evaluators include information for all facilities performing C-sections in the area under study in the numerator.

Changes in the ability of the health care system to provide C-sections can have an impact within six to nine months.

UNICEF/WHO/UNFPA recommend a C-section rate between 5 and 15 percent of all births, based on estimates from a variety of sources. Rates less than 5 percent may indicate inadequate availability and/or access to emergency obstetric care. Rates above 15 percent suggest overuse of the procedure for non-emergency reasons. Excessive use unnecessarily exposes women to anesthesia and surgery with their concomitant risks. Moreover, it drains scarce health-care resources. Most of the countries with excessively high C-section rates are also highly litigious societies such as the United States, where nearly one in three babies is delivered by C-section (NY Times, 2010). However, some private clinics in Brazil have a c-section rate of over 90% (Ribeiro et al., 2007).

Disaggregation of the rate allows one to evaluate access to the procedure. Rates are often inconsistent between urban and rural environments, public or private sectors, different payment schemes, or across regions. Thus, sub-national estimates are encouraged (Maine, McCarthy, and Ward, 1992).

Crude birth rates produce estimates of live births only, whereas some C-sections are performed on pregnancies that result in stillbirths. If the number of C-sections performed for stillbirths is low, the use of live births should be acceptable as the denominator.

An alternative indicator, the proportion of facility deliveries that are C-sections, will vary by the case mix of patients and will be biased by referral patterns of women with complications requiring the procedure. Specifying an appropriate range of target percentages within a facility is impractical.

The procedure of C-section usually occurs at the end of a complex series of events, possibly including pre-existing and pregnancy-specific medical factors, identification of complications, transportation to health care facilities and availability of necessary technology. When using this indicator, managers and evaluators may also want to employ more in-depth techniques, such as case audits, to investigate what clinical indicators are being used for C-section and if the appropriate women are receiving this service. By itself, the indicator reveals nothing about the appropriateness of the procedure.

"Caesarean Births Are at a High in U.S.".  The New York Times.  March 23, 2010.

Ribeiro V., Figueiredo F., Silva A., Bettiol H., Batista R., Coimbra L., Lamy Z., and Barbieri M. Why are the rates of cesarian section in Brazil higher in more developed cities than in less developed ones?  Brazilian Journal of Medical and Biological Research (2007) 40: 1211-1220.