Rates of caesarean delivery as a percentage of all live births have increased in
all OECD countries in recent decades, although in a few countries this trend has reversed at least slightly in the past few years. Reasons for the
increase include reductions in the risk of caesarean delivery, malpractice liability concerns, scheduling convenience for both physicians and
patients, and changes in the physician-patient relationship, among others. Nonetheless, caesarean delivery continues to result in increased maternal
mortality, maternal and infant morbidity, and increased complications for subsequent deliveries (Minkoff and Che-rvenak, 2003; Bewley and Cockburn,
2002; Villar et al., 2006). These concerns, combined with the greater financial cost (the average cost associated with a caesarean section is at least
two times greater than a normal delivery in many OECD countries; Koechlin et al., 2010), raise questions about the appropriateness of some caesarean
delivery that may not be medically required.
In 2011, caesarean section rates were lowest in Nordic countries (Iceland,
Finland, Sweden and Norway) and the Netherlands, with rates ranging from 15% to 17% of all live births (Figure 4.8.1). In the Netherlands, 16% of all
births occurred at home in 2010 (a much higher proportion than in other countries, although this proportion has come down), while 11% occurred in a
birth centre (a homelike setting) under care of the primary midwife (Euro-Peristat, 2013). Among OECD countries, caesarean section rates were highest
in Mexico and Turkey (over 45%), followed by Chile, Italy, Portugal and Korea (with rates ranging between 35% and 38%).
Caesarean rates have increased rapidly over the past decade in most OECD
countries, with the average rate across countries going up from 20% in 2000 to 27% in 2011 (Figure 4.8.2). Increases in first births among older women and the rise in multiple births
resulting from assisted reproduction have contributed to the overall rise in caesarean deliveries. The growth rate since 2000 has been particularly
rapid in Mexico and Turkey (which started with already high rates in 2000, thereby widening the gap with the OECD average) and in Slovenia, the
Czech Republic and the Slovak Republic (which started with low rates, but are moving rapidly towards the OECD average). In many countries, however,
the growth rate has slowed down since 2005. In some countries such as Finland and Sweden (which had low rates) and Italy and Korea (which had high
rates), the trend of rising rates has reversed and the rates have come down at least slightly since the mid-2000s.
There can be substantial variations in caesarean rates across regions and
hospitals within the same country. In Switzerland, where caesareans now account for one-third of all births, caesarean rates were less than 20% in
certain regions (cantons) while they exceeded 40% in others in 2010. Within the same region (canton), there are also important variations across
hospitals. Caesarean sections were substantially higher in private clinics (41%) than in public hospitals (30.5%) (OFSP, 2013). In France, a 2008
study by the French Hospital Federation also found higher caesarean rates in private for-profit facilities than in public facilities, even though the
latter are designed to deal with more complicated pregnancies (FHF, 2008).
While caesarean delivery is required in some circumstances, the benefits of
caesarean versus vaginal delivery for normal uncomplicated deliveries continue to be debated. Professional associations of obstetricians and
gynaecologists in countries such as Canada now encourage the promotion of normal childbirth without interventions such as caesarean sections (Society
of Obstetricians and Gynaecologists of Canada et al., 2008).
Definition and comparability
The caesarean section rate is the number of caesarean deliveries performed
per 100 live births.
In Mexico, the number of caesarean sections is estimated based on public
hospital reports and data obtained from National Health Surveys. Estimation is required to correct for under-reporting of caesarean deliveries
in private facilities. The combined number of caesarean deliveries is then divided by the total number of live births as estimated by the
National Population Council.