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Original Investigation |

Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

George Molina, MD, MPH1,2; Thomas G. Weiser, MD, MPH3; Stuart R. Lipsitz, ScD1,4; Micaela M. Esquivel, MD3; Tarsicio Uribe-Leitz, MD, MPH3; Tej Azad, BA5; Neel Shah, MD, MPP1,6; Katherine Semrau, PhD, MPH1; William R. Berry, MD, MPA, MPH1; Atul A. Gawande, MD, MPH1; Alex B. Haynes, MD, MPH1,2
[+] Author Affiliations
1Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
2Massachusetts General Hospital, Department of Surgery, Boston
3Stanford University, Department of Surgery, Stanford, California
4Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
5Stanford University School of Medicine, Stanford, California
6Beth Israel Deaconess Medical Center, Department of Obstetrics and Gynecology, Boston, Massachusetts
JAMA. 2015;314(21):2263-2270. doi:10.1001/jama.2015.15553.
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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 < .001), respectively (adjusted for total health expenditure per capita, population, percent of urban population, fertility rate, and region). Higher cesarean delivery rates were not correlated with maternal or neonatal mortality at a country level. A sensitivity analysis including only 76 countries with the highest-quality cesarean delivery rate information had a similar result: cesarean delivery rates greater than 6.9 to 20.1 per 100 live births were inversely correlated with the maternal mortality ratio (slope coefficient, −21.3; 95% CI, −32.2 to −10.5, P < .001). Cesarean delivery rates of 12.6 to 24.0 per 100 live births were inversely correlated with neonatal mortality (slope coefficient, −1.4; 95% CI, −2.3 to −0.4; P = .004).

Conclusions and Relevance  National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

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Figure 1.
Relation Between Maternal Mortality Ratio in 2013 and Cesarean Delivery Rate (per 100 Live Births) in 2012 for 181 Countries

Thirteen countries did not have maternal mortality ratio data for 2013. The maternal mortality ratio was derived from death from pregnancy-related causes while pregnant or up to 42 days postpartum per 100 000 live births. Change points correspond with the following cesarean delivery rates: 7.2, 19.1, and 27.3. The blue shade indicates 95% CIs. The curve was fit to the data by spline regression models using the maximum cross-validation–adjusted R2 to choose the number of change points.

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Figure 2.
Relation Between Neonatal Mortality Rate (per 100 Live Births in 2012) and Cesarean Delivery Rate (per 100 Live Births) in 2012 for 191 Countries

Three countries did not have neonatal mortality rate data for 2012. The change point corresponds with a cesarean delivery rate of 19.4. The blue shade indicates 95% CIs. The curve was fit to the data by spline regression models using the maximum cross-validation–adjusted R2 to choose the number of change points.

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