What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies
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Open Access
- 21 June 2015
- journal article
- review article
- Published by Springer Science and Business Media LLC in Reproductive Health
- Vol. 12 (1), 1-10
- https://doi.org/10.1186/s12978-015-0043-6
Abstract
In 1985, WHO stated that there was no justification for caesarean section (CS) rates higher than 10–15 % at population-level. While the CS rates worldwide have continued to increase in an unprecedented manner over the subsequent three decades, concern has been raised about the validity of the 1985 landmark statement. We conducted a systematic review to identify, critically appraise and synthesize the analyses of the ecologic association between CS rates and maternal, neonatal and infant outcomes. Four electronic databases were searched for ecologic studies published between 2000 and 2014 that analysed the possible association between CS rates and maternal, neonatal or infant mortality or morbidity. Two reviewers performed study selection, data extraction and quality assessment independently. We identified 11,832 unique citations and eight studies were included in the review. Seven studies correlated CS rates with maternal mortality, five with neonatal mortality, four with infant mortality, two with LBW and one with stillbirths. Except for one, all studies were cross-sectional in design and five were global analyses of national-level CS rates versus mortality outcomes. Although the overall quality of the studies was acceptable; only two studies controlled for socio-economic factors and none controlled for clinical or demographic characteristics of the population. In unadjusted analyses, authors found a strong inverse relationship between CS rates and the mortality outcomes so that maternal, neonatal and infant mortality decrease as CS rates increase up to a certain threshold. In the eight studies included in this review, this threshold was at CS rates between 9 and 16 %. However, in the two studies that adjusted for socio-economic factors, this relationship was either weakened or disappeared after controlling for these confounders. CS rates above the threshold of 9–16 % were not associated with decreases in mortality outcomes regardless of adjustments. Our findings could be interpreted to mean that at CS rates below this threshold, socio-economic development may be driving the ecologic association between CS rates and mortality. On the other hand, at rates higher than this threshold, there is no association between CS and mortality outcomes regardless of adjustment. The ecological association between CS rates and relevant morbidity outcomes needs to be evaluated before drawing more definite conclusions at population level.Keywords
This publication has 28 references indexed in Scilit:
- Methods of achieving and maintaining an appropriate caesarean section rateBest Practice & Research Clinical Obstetrics & Gynaecology, 2013
- Inequities in the use of cesarean section deliveries in the worldAmerican Journal of Obstetrics and Gynecology, 2012
- The Quality of Modern Cross-Sectional Ecologic Studies: A Bibliometric ReviewAmerican Journal of Epidemiology, 2011
- Classifications for Cesarean Section: A Systematic ReviewPLOS ONE, 2011
- Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal HealthBMC Medicine, 2010
- Rates of caesarean section: analysis of global, regional and national estimatesPaediatric and Perinatal Epidemiology, 2007
- Maternal mortality, stillbirth and measures of obstetric care in developing and developed countriesInternational Journal of Gynecology & Obstetrics, 2007
- Cesarean Section Rates and Maternal and Neonatal Mortality in Low‐, Medium‐, and High‐Income Countries: An Ecological StudyBirth, 2006
- Meta-analysis of Observational Studies in EpidemiologyA Proposal for ReportingJAMA, 2000
- APPROPRIATE TECHNOLOGY FOR BIRTHThe Lancet, 1985