Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

• Published in: JAMA : the journal of the American Medical Association 2015-12, Vol.314 (21), p.2263-2270
• Main Authors: Molina, George, Weiser, Thomas G, Lipsitz, Stuart R, Esquivel, Micaela M, Uribe-Leitz, Tarsicio, Azad, Tej, Shah, Neel, Semrau, Katherine, Berry, William R, Gawande, Atul A, Haynes, Alex B
• Format: Article
• Language: English
• Subjects: Adult; Cesarean section; Cesarean Section - statistics & numerical data; Cross-Sectional Studies; Female; Gestational Age; Global Health; Humans; Infant; Infant Mortality - trends; Infant, Newborn; Maternal Mortality - trends; Mortality; Postpartum Period; Pregnancy; Sensitivity analysis
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2015.15553

IMPORTANCE: Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes. OBJECTIVES: To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. The year of analysis was 2012. Cesarean delivery rates were available for 54 countries for 2012. For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years. For the 22 countries for which no cesarean rate data were available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percent of urban population, and geographic region. EXPOSURES: Cesarean delivery rate. MAIN OUTCOMES AND MEASURES: The relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100 000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births). RESULTS: The estimated number of cesarean deliveries in 2012 was 22.9 million (95% CI, 22.5 million to 23.2 million). At a country-level, cesarean delivery rate estimates up to 19.1 per 100 live births (95% CI, 16.3 to 21.9) and 19.4 per 100 live births (95% CI, 18.6 to 20.3) were inversely correlated with maternal mortality ratio (adjusted slope coefficient, −10.1; 95% CI, −16.8 to −3.4; P = .003) and neonatal mortality rate (adjusted slope coefficient, −0.8; 95% CI, −1.1 to −0.5; P