Thursday, February 23, 2017

A C-section rate of approximately 19 percent seems to be ideal for the health of both women and newborns.

All generalization are false including the recent statement by India’s Union women and Child Development Minister about bringing down the C-section rate to 10%. The minister recently asked the health minister to issue a mandate to all the hospitals displaying the C-section rates. She took this action in response to a petition against hospitals and doctors profiteering by pushing women towards surgical deliveries instead of natural vaginal birth.

The petition has received 1.3 lakh signatures so far, a number that is not much looking at the total population of the country.

"We have entered into an area, very sorry to say, in the last 20 years, where doctors care more about money than about patients' health. We would like the hospitals to display data on how many cesarean section deliveries they have done," said the Minister.

"The normal Cesarean delivery rate in a country would not be more than 10 percent, because it is usually done as a last resort. In this country, it is extremely high because it brings the doctor more money," she further added.

Well, you cannot generalize and mandate a uniform C-section rate for all the hospitals in all the states across country. It all depends upon the healthcare infrastructure, geographical location, access to prenatal care and surgical expertise and the needs of individual woman.

Pointing a finger at the obstetrician and asking her to stop doing C-section is like treating a symptom instead of going into the root of problem. A hospital can have a C-section rate as high as 70% if it a tertiary care high risk hospital.

A review of trends around the world shows that currently about 18.6% of births take place by Cesarean section.  The rates vary from as low as 2% to as high as 50%. In U.S.A, about 1.3 million babies are delivered by Cesarean every year, which roughly equals to every 1 in every 3 children born in US(33%).

The WHO recommends that the ‘ideal’ rate of C-section for optimum maternal and fetal outcome should be around 10-15%.This was  based on the  observation that some countries with the lowest perinatal mortality rates had cesarean delivery rates that were less than 10 per 100 live births. The study also has insufficient data and relied upon average C-section rate from multiple previous year.

However, new study recently examined the relationship between C-section rates and maternal and neonatal mortality in 194 countries around the globe concluded that C-section rate up to 19 percent is associated with lower maternal and neonatal outcome. C-section delivery rates above 19 percent showed no further improvement in maternal and neonatal mortality rates.[1] Researchers used mathematical modeling to impute C-section rates for countries where data was missing and to account for other contributing factors such as health expenditure.

Latin America and the Caribbean region has the highest CS rates (40.5%) while some countries in Africa have the lowest (7%). Brazil occupies the top slot with a rate that exceeds 50% (55.6%).

The  study  found out that in countries with very low C-section rate, people did not have access to basic healthcare and surgical facilities resulting in high maternal and neonatal morbidity and mortality. In fact, a study by WHO concluded that in countries with C-section rate < 10%, there is an additional need for 0.8 – 3.2 million CS every year to improve maternal and neonatal mortality and morbidity. [2]

Dr. Thomas Weiser, an assistant professor of surgery at Stanford School of Medicine says “As countries increase the number of C-sections they provide, mortality goes down— but only to a point, when the C-section rate tops 19 percent, benefits for maternal and infant health plateau.

Increasing C-section rates in recent years are due to modern technology of continuous FHS monitoring in labor room which is a two-way sword, practicing defensive medicine, rise in on-demand C-sections beside other maternal and perinatal factors that come into play.

According to ACOG " Safe reduction of the rate of primary cesarean deliveries, is the only way to  lower  the repeat  cesarean section rate and total cesarean rate."

To conclude, it is impossible to form a policy regarding relationship between delivery methods and birth outcomes. Each case must be decided taking into consideration social, medical, obstetrical and healthcare factors.

Our goal as an obstetrician should be to see that every woman who needs a C-section should get one and every woman who does not need a C-section should not get one.



  1. Its a bilateral decision from the patients and the doctors to understand and give a full fledged consent for either CS or normal delivery accepting the outcome at the end. Yes , every woman has a right to deliver normally.

  2. Its a bilateral decision from the patients and the doctors to understand and give a full fledged consent for either CS or normal delivery accepting the outcome at the end. Yes , every woman has a right to deliver normally.