Caesarean sections

Rates of caesarean delivery have increased over time in nearly all OECD countries, although in a few countries this trend has reversed, at least slightly, in the past few years. Reasons for the increase include the rise in first births among older women and in multiple births resulting from assisted reproduction, malpractice liability concerns, scheduling convenience for both physicians and patients, and the increasing preference of some women to have a caesarean delivery. Nonetheless, caesarean delivery continues to result in increased maternal mortality, maternal and infant morbidity, and increased complications for subsequent deliveries, raising questions about the appropriateness of caesarean deliveries that may not be medically required.

In 2015, much as in previous years, caesarean section rates were lowest in Nordic countries (Iceland, Finland, Sweden and Norway), Israel and the Netherlands, with rates ranging from 15% to 17% of all live births (Figure 9.20). They were highest in Turkey, Mexico and Chile, with around one out of two live births delivered by caesarean section.

9.20. Caesarean section rates, 2015 (or nearest year)
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Source: OECD Health Statistics 2017.

 http://dx.doi.org/10.1787/888933605312

Caesarean rates have increased since 2000 in most OECD countries, with the average rising from 20% in 2000 to 28% in 2015, although the rate of growth seems to have slowed over the past 5 years (Figure 9.21). Growth rates have been particularly rapid in Poland, the Slovak Republic and the Czech Republic which have historically had relatively low rates, as well as some of the countries with the highest rates today (Turkey, Korea). In other countries, the growth rate has shown a notable slowing since the mid-2000s, such as in Israel, Finland and Sweden. In Italy, caesarean rates have come down significantly in recent years, although they remain among the highest in Europe.

9.21. Caesarian section trends in selected OECD countries, 2000 to 2015 (or nearest year)
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Source: OECD Health Statistics 2017.

 http://dx.doi.org/10.1787/888933605331

There can be substantial variations in caesarean rates across regions and hospitals within the same country. In Italy, there continue to be huge variations in caesarean rates, mainly driven by the southern regions of the country. Spain shows similar large variations across its regions (OECD, 2014).

In several countries, there is evidence that private hospitals tend to perform more caesarean sections than public hospitals. In France, private for-profit hospitals authorised to provide maternity care for pregnancies without complications have caesarean rates as high as public hospitals which have to deal with more complicated cases (FHF, 2008). In Switzerland, caesarean sections have been found to be substantially higher in private clinics (41%) than in public hospitals (30.5%) (OFSP, 2013).

A number of countries have taken different measures to reduce unnecessary caesarean sections. Public reporting, provider feedback, the development of clearer clinical guidelines, and adjustments to financial incentives have been used to try to reduce the inappropriate use of caesareans. In Australia, where caesarean section rates are high relative to most OECD countries, a number of States have developed clinical guidelines and required reporting of hospital caesarean section rates, including investigation of performance against the guidelines. These measures have discouraged variations in practice and contributed to slowing down the rise in caesarean sections. Other countries have reduced the gap in hospital payment rates between a caesarean section and a normal delivery, with the aim to discourage the inappropriate use of caesareans (OECD, 2014).

Definition and comparability

The caesarean section rate is the number of total caesarean deliveries performed per 100 live births.

In Ireland, Mexico, New Zealand and the United Kingdom, the data only include activities in publicly-funded hospitals (though for Ireland all of maternity units are located in publicly-funded hospitals). This may lead to an underestimate of caesarean section rates in these countries, since there is some evidence that private hospitals tend to perform more caesarean sections than public hospitals.

References

FHF – Fédération hospitalière de France (2008), Étude sur les césariennes [Study on caesareans], Paris.

OECD (2014), Geographic Variations in Health Care: What Do We Know and What Can Be Done to Improve Health System Performance?, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264216594-en.

OFSP – Office fédéral de la santé publique (2013), Accouchements par césarienne en Suisse [Births by caesareans in Switzerland], Bern.