A Chinese woman living in the United States reported that "My sister in law back home [in the Peoples Republic of China] went to the doctor early and scheduled a cesarean section. They didn't even consider giving birth vaginally because they were afraid of complications. I think because you're allowed to have only one child, the whole family was especially anxious and pay special attention. She chose to have a cesarean section because it is less risky and there is a lot less pain involved."
Elective primary cesarean births-both by maternal request and by physician choice-seem to be increasing globally. Reasons postulated to contribute to this include avoidance of what some women think is an increased risk of incontinence and sexual dysfunction after vaginal births, the perceived safety and convenience of elective cesareans, avoidance of the pain and fatigue associated with labor, potential liability issues in vaginal births, provider preference, and the convenience of giving birth on schedule.
Global Comparison of Rates
Country or regional comparisons of cesarean birth rates are challenging because of varying types of data available, but overall rates are estimated to vary from 2.9% in Sub-Saharan Africa to 26.3% in Southeast Asia (Stanton & Holtz, 2006). Elective primary cesarean birth rates are among the highest in the world in Latin America, with a reported rate of 80% to 90% in white, insured women who give birth in private hospitals. Differences in rates have been found in Greek public and private hospitals and in South Korea, where a study reported that providers and the healthcare system contribute to high cesarean birth rates rather than maternal demand. These high rates are significantly higher than the 15% cesarean birth rate recommended by the World Health Organization, and thousands of elective cesarean births are performed each year.
The rates of cesarean births in Brazil are high. In Sao Paulo, Brazil, 59 private hospitals have cesarean birth rates over 80%, and women at 38 weeks' gestation are scheduled for a collective cesarean "surgical day." The terms "the cut above" and "the cut below" are used in reference to the high prevalence of cesarean births and episiotomies in Brazil.
Can This Trend Be Reversed?
Strategies for reversing this trend for higher cesarean birth rates include hospital second opinion policies, better education of women of childbearing age regarding potential risks and benefits, and informed consent. Increased understanding of women's motivation, values, cultural factors, and fears related to requesting elective cesarean births through qualitative inquiry is essential. We know that there are no reductions in maternal and neonatal mortality when the cesarean birth rate is above 15%, yet globally these rates are escalating and birthing units are becoming surgical suites for more than one-third of women giving birth.
The Paradox of Low Rates of Cesarean Births
On the other hand, in developing countries (especially in rural areas and among poor, uninsured women), the recommended lower limit for cesarean births is 5% to 10% in order to avoid high rates of maternal and neonatal mortality and morbidity from obstetrical complications of vaginal births, because many of these areas do not have the resources to manage high-risk pregnancies. In Sub-Saharan Africa and Southeast Asia, it is estimated that the low cesarean birth rate among women living in poverty contributes to 80,000 maternal deaths each year.
Safe Motherhood Initiative
The year 2008 marks the 20th anniversary of the Safe Motherhood Initiative, and we are at the midpoint in the timeline to achieve Millennium Development Goal Five, which targets outcomes from childbirth. Meeting this goal depends on the reduction of cesarean births worldwide. The Women Deliver Conference, which was held in the United Kingdom in October 2007, was a landmark acknowledgment of how vital women are to society. Global development efforts, such as the United Nations Population Fund, should include a focus on achieving an appropriate level of cesarean births throughout the world. The dialogue needs to continue on the balance between meeting the needs of women for choice regarding the mode of birth and the appropriate use of interventions that support safe delivery of healthcare.