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Copyright 2015 American Medical Association All rig hts reserved

RelationshipBetween CesareanDelivery Rate andMaternal

andNeonatalMortality

GeorgeMolinaMD MPH Thomas G Weiser MD MPH StuartR Lipsitz ScD Micaela M Esquivel MD

Tarsicio Uribe-Leitz MDMPH Tej AzadBA NeelShah MDMPP KatherineSemrauPhD MPH

William R Berry MD MPA MPH Atul A Gawande MD MPH Alex BHaynes MD MPH

IMPORTANCE Based on older analyses the World Health Organization (WHO)recommends

that cesarean delivery rates should not exceed 10 to 15 per 100live 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 studyestimating annual

cesarean delivery rates from data collectedduring 2005 to 2012 forall 194WHO member

states Theyear of analysis was 2012Cesareandelivery rates were available for54 countries

for 2012For the 118 countriesfor which 2012 data were not available the2012 cesareandelivery rate was imputed from other yearsFor the22 countries forwhichno cesarean rate

data were available therate wasimputed from total healthexpenditure per capita fertility

rate life expectancy percent of urban population and geographic region

EXPOSURES Cesarean delivery rate

MAINOUTCOMES ANDMEASURES The relationship between population-level cesarean

delivery rate and maternal mortality ratios (maternal deathfrom pregnancy related causes

duringpregnancy or up to 42 days postpartum per 100 000 live births) or neonatal mortality

rates (neonatal mortalitybefore age28 days per 1000 live births)

RESULTS The estimatednumber of cesarean deliveries in 2012 was 229million (95 CI225

million to 232 million)At a country-level cesarean delivery rate estimates up to 191 per 100

live births (95 CI163 to 219) and 194per 100 live births (95 CI186 to 203)were

inversely correlated with maternal mortality ratio (adjusted slope coefficient minus101 95 CI

minus168 to minus34 P = 003) and neonatal mortality rate (adjusted slope coefficient minus08 95 CI

minus11 to minus05 P lt 001)respectively (adjusted for total health expenditure per capita

population percent of urbanpopulation fertility rate and region) Higher cesarean delivery

rates were notcorrelated with maternal or neonatal mortality at a country level A sensitivity

analysis including only 76 countries with the highest-quality cesarean delivery rate

information hada similar result cesarean delivery rates greater than 69 to 201 per 100 live

births were inversely correlated with the maternal mortality ratio (slope coefficient minus213

95 CIminus322 to minus105 P lt 001)Cesareandelivery rates of 126 to 240per 100 live births

were inversely correlated with neonatal mortality (slope coefficient minus14 95 CI minus23 to

minus04 P = 004)

CONCLUSIONS AND RELEVANCE Nationalcesareandelivery ratesof up to approximately 19 per

100live 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

JAMA 2015314(21)2263-2270 doi101001jama201515553

Editorialpage2238

AuthorVideo Interview and

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Author Affiliations Author

affiliationsare listed atthe endof this

article

Corresponding Authors Alex B

Haynes MD MPH AriadneLabs401

Park Dr Third Floor EastBoston MA

02215 (abhaynesmghharvardedu)

andThomas GWeiserMDMPH

Departmentof SurgeryStanford

UniversityMedical Center300

Pasteur Dr S067 Stanford CA 94305

(tweiserstanfordedu)

Research

Original Investigation

(Reprinted) 2263


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Cesarean delivery is lifesaving for obstructed labor and

other emergency obstetrical conditions ensuring ac-

cess to cesarean delivery is an essential strategy for

meeting the Millennium Development Goals983089 and the forth-

coming Sustainable Development Goals983090 forreducingchild and

maternal mortality However as a surgical procedurethere are

risks of complications and overuse can be harmful to both

mothers and neonates Although the optimal population-

level cesarean delivery rate is difficult to know the World

Health Organization(WHO) recommended that national rates

notexceed983089983088 to 983089983093 cesarean deliveries per983089983088983088 live births983091 De-

spite this cesarean delivery rates in many countries are sub-

stantially higher983092983093

Studies of the relationship between cesarean delivery

rate and mortality have yielded inconsistent results983094-983096 In

Latin American hospitals increasing cesarean delivery rates

from 983089983088 to 983090983088 was associated with greater preterm deliv-

ery and neonatal mortality983096 In Asian hospitals there was a

higher risk of maternal mortality and morbidity from cesar-

ean deliveries983095 Conversely in Africa where the median

cesarean delivery rate was 983096983096 the risk of neonatal death

was lower in facilities having higher elective cesarean rates983094

Three studies of cesarean delivery reported that cesarean

rates of up to 983089983088 to 983089983093 cesarean deliveries per 983089983088983088 live births

were associated with optimal neonatal983093 and maternal mortal-

ity outcomes983093983097983089983088 These studies were limited by either hav-

ing incomplete data or relying on averaged cesarean delivery

rates from multiple years without accounting for year-to-year

variation in these estimates

Thepurposeof this study wasto provide betterestimates

for the relationship between cesareandelivery rates and neo-

natal and maternal mortality Optimal cesarean rates associ-

ated withminimal maternal andneonatal mortality rates were

estimated from the most recent data available and limited to

estimates for a single year 983090983088983089983090

Methods

PopulationandHealth Databases

Population and health data were obtained for all 983089983097983092 WHO

member states from the World Bank World Development

Indicators (WDI) database983089983089 These data included total popu-

lation life expectancy at birth percent urban population

gross domestic product (GDP) per capita total health expen-

diture per capita total fertility rate and the national birth

rate Fifteen countries did not have all of these variables in

the WDI database In these instances data were obtainedfrom other sources including the United Nations983089983090 WHO983089983091

and the Central Intelligence Agency983089983092 Information was col-

lected for 983090983088983089983090 and for the years 983090983088983088983093 through 983090983088983089983089 when

983090983088983089983090 data were not available When total health expenditure

per capita was not available for the year for which cesarean

delivery data were obtained either the subsequent or previ-

ous yearrsquos figure was used in that order of preference (see

Statistical Appendix in the Supplement for countries without

recent total health expenditure data) Since health expendi-

ture data were reported in US dollars by the World Bank all

expenditure figures were adjusted to 983090983088983089983090 US dollars using

the consumer price index to account for inflation983089983093

Additional data obtained from the WDI database in-

cluded 983090983088983089983090 neonatal mortality rate (neonates who die be-

fore reaching 983090983096daysof age per983089983088983088983088 live births) and the 983090983088983089983091

maternal mortality ratio(death from pregnancy-related causes

while pregnant or up to 983092983090 days postpartum per983089983088983088 983088983088983088 live

births)983089983089Maternal mortalityis typicallypresented as a ratio to

live birthssince other measures of pregnancynot resulting in

live births are usually not recorded by statistical agencies in

any standardized way983089983094

Of the 983089983097983092 WHO member states 983091 did not have neonatal

mortalityrate informationand 983089983091 didnot have maternal mor-

tality ratios These countries were not included in the analy-

sisevaluatingthe relationshipbetweencesarean delivery rate

and maternal and neonatal mortality Maternal mortality ra-

tio data were from 983090983088983089983091 since these ratios are only periodi-

cally reported and the closest year to 983090983088983089983090 for which data are

available was 983090983088983089983091 The reliability of the data sources is dis-

cussed in the Data Source Appendix in the Supplement

The institutional review board is not necessary for pub-

licly available population-level statistics because it does not

involve human subjects research

CesareanDeliveryDataSources

Country-level cesarean delivery rates for the most recent

year in the period ranging from 983090983088983088983093 to 983090983088983089983090 were obtained

from various sources as described below (eTable 983089 in the

Supplement) Only the most recent cesarean delivery rate

was used so that all countries only had one cesarean

delivery rate used in this analysis The Organization of Eco-

nomic Co-operation and Development (OECD) Health Statis-

tics Database983089983095983089983096 the European Health for All Database

(HFA-DB)983089983097 and the Demographic and Health Surveys (DHS)

program database983090983088

were consulted first due to their qualityassurance mechanisms and rigorous methods If cesarean

delivery rates differed by sources the most recent data from

the OECD DHS and HFA-DB were prioritized in that order

Other data sources included the WHO Global Health

Observatory Data Repository983090983089 The WHO World Health

Statistics 983090983088983089983088 report983090983090 the UNICEF Global Databases

983090983088983089983092983090983091 health-related databases and the peer-reviewed lit-

erature on PubMed (See the Statistical Appendix for more

details regarding sources of available data and see Data

Source Appendix for documentation for each of the primary

and secondary data sources in the Supplement) In particu-

lar the DHS program methods have been previously

described

983090983092983090983093

and have been shown to be reliable

983090983094

BuildingModels toEstimateCountry-Level

CesareanDeliveryRates

The goal of this study wasto relate 983090983088983089983090 population-level ce-

sarean delivery rate with maternal mortality ratios and neo-

natal mortality rates Cesarean delivery rate information for

983090983088983089983090 wasavailable for983093983092 countriesFor983089983089983096 countriesthe one

mostrecentcesarean delivery rate available wasfrom 983090983088983088983093to

983090983088983089983089 Twenty-twoof the 983089983097983092 countriesdid not have anycesar-

eandelivery rate informationfor any of theyears we studied

Research Original Investigation Cesarean Delivery Rateand Maternal and Neonatal Mortality

2264 JA MA December 1 2015 Volume 314 Number21 (Reprinted) jamacom



7232019 joi150140



Cesarean delivery rate was transformed with a base-983089983088

logarithm because of nonnormally distributed data when

performing multiple imputation Population and health vari-

ables were transformed with a base-983089983088 logarithm if they had

a right-skewed distribution Based on a previous study

showing that total health expenditure per capita was the

most strongly correlated variable with overall country-level

surgical volume and since cesarean delivery is a substantial

component of this volume983090983095 total health expenditure per

capita was chosen a priori to be included in the model to pre-

dict cesarean delivery rate for countries without any data

and for countries missing 983090983088983089983090 data but having data ranging

from 983090983088983088983093 to 983090983088983089983089 The Spearman correlation was used to

evaluate the relationship between observed cesarean deliv-

ery rate data and population and health variables The vari-

ables were total health expenditure per capita life expec-

tancy at birth GDP per capita total population size percent

urban population fertility rate annual number of births

and birth rate These were selected because the data were

readily available and because they are potentially related to

cesarean delivery rates For the variables that were signifi-

cantly correlated with cesarean delivery rate we performed

the Spearman correlation testing to assess if any of these

population and health variables were collinear Collinearity

between these variables was assumed to be present if the

correlation coefficient resulting from Spearman correlation

testing was greater than 983088983096983093 For collinear variables we

used the variable having a higher Spearman r for it and

cesarean delivery rate in the model to predict 983090983088983089983090 cesarean

delivery rate for 983090983090 countries with missing cesarean delivery

rate data and for 983089983089983096 countries with cesarean delivery rate

data available from 983090983088983088983093 to 983090983088983089983089 but not 983090983088983089983090 A nonpara-

metric rank-regression approach983090983096 was used to examine the

association between cesarean delivery rate and WHO region

(See the statistical appendix for results of the Spearman cor-relation testing in the Supplement)

Countrieswith available cesarean delivery rate datawere

compared with countries without any available cesarean de-

livery rate data by fitting exact bivariable logistic regression

models983090983097 to test whether the probability that missing cesar-

ean delivery ratedata was related to observed population and

healthdata (seeStatistical Appendix in the Supplement forfur-

ther details)

Spline regression models were used to examine the rela-

tionship betweenlog-transformed cesarean deliveryrates (the

outcomevariable) andpopulationand health variables(thepre-

dictors) These variables were selected for inclusion in the

spline regression models based on the results of the Spear-man correlation testing and the fitted exact bivariable logis-

tic regression models Cross-validation adjusted R 983090 was used

as a measure of model fit first each countryscesarean deliv-

ery rate was predicted by a regression without that country

and the cross-validation adjusted R 983090 was calculated as the

square of correlation between the observed and predicted ce-

sarean deliveryratesmultipliedby a degrees-of-freedom cor-

rection Splineregressionmodels weredistinguished fromone

another by the number of change-points (combinations of 983088

983089 983090 or 983091 change points) for each variable thatwas tested the

model with the maximum cross-validation adjusted R 983090 was

identified as the best fit

Imputationof CesareanDeliveryRates

For the 983090983090 countries with no cesarean deliveryrate data 983090983088983089983090

cesarean delivery rates were imputed using the best predic-

tive model that included total health expenditure per capita

fertilityrate life expectancy percent of urbanpopulation and

regioninformation(see Statistical Appendix in theSupplement

for more details) For the 983089983089983096 countries having a cesarean de-

livery rate from the years983090983088983088983093-983090983088983089983089 but not983090983088983089983090 regression

wasused to impute the983090983088983089983090 rate using a predictivemodel that

also included total healthexpenditure percapita fertility rate

life expectancy percent of urban population and region in-

formation Potential measurement error in the cesarean de-

livery rate dataare describedin theStatisticalAppendix in the

Supplement

Evaluationof theRelationship BetweenCesareanDelivery

RateandMortality

Afterimputing the missing cesareandeliveryrate data spline

regression models weresubsequently fitted to nonparametri-

cally explore the relationship between 983090983088983089983090 cesarean deliv-

ery rateestimates and983090983088983089983091 maternalmortality ratio for coun-

trieswith availablematernal mortalitydata For eachof the983091983088983088

multiplyimputeddata sets theregression models werefit be-

tween cesareandelivery rate andmaternal mortality ratio and

then the results were combined using the Rubin combining

rule983091983088 which estimates the multiple imputation variance by

combiningthe variance withinand acrossimputed data sets

Splineregressionmodels were testedwith983088 to983091 change points

usingthe maximum cross-validationadjusted R 983090 to choosethe

numberof changepoints A similaranalysis wasperformedfor

the relationship between 983090983088983089983090 cesarean delivery rate esti-

mates and983090983088983089983090 neonatalmortality ratefor countrieswith avail-ableneonatal mortalitydata Therelationshipbetweencesar-

eandeliveryrate estimatesfor 983090983088983089983090with maternaland neonatal

mortality wasadjusted fortotal health expenditure percapita

fertilityrate percentof urban population total population size

and WHO region A sensitivity analysis was performed using

countrieswith cesareandeliveryrate datafrom the OECDand

DHSonly (n = 983095983094)because these arerelatively high-qualityand

uniform data sourcesThe above methodswere usedto evalu-

ate the relationship between 983090983088983089983090 cesarean delivery rate es-

timates and maternal and neonatal mortality for these coun-

tries A secondsensitivityanalysiswas performedthatexcluded

983097 countries with cesarean delivery rate data that came from

the least reliable sources

AccountingforUncertainty in theCorrelations Between

CesareanDeliveryRateandMortality

Statistical inferencefor themultiplyimputed datasets wasper-

formed using the approach of Rubin983091983088 which estimates the

multipleimputationvarianceby combiningthe variancewithin

andacrossimputeddatasetsto make inferencesaboutthe re-

lationship between cesarean deliveryratesand maternal mor-

tality ratios and between cesarean delivery rates and neona-

talmortality rates For each of the 983091983088983088 datasetswith imputed

Cesarean Delivery Rateand Maternal and Neonatal Mortality Original Investigation Research

jamacom (Reprinted) JAMA December 1 2015 Volume 314 Number21 2265



7232019 joi150140



cesarean delivery rates the spline functions were fitted be-

tween cesareandelivery rates andmaternal mortalityratiosand

between cesareandelivery rates and neonatalmortalityrates

Themultiple imputation estimatewas the mean of the slopes

and change points over all 983091983088983088imputationsThe multiple im-

putation variance wascalculated as thesum of thewithin- and

between-imputation variances Using the multiply imputed

data sets and the Rubin approach for combining983091983088 estimates

of theoverall global cesareandelivery volumeandoverall global

cesareandelivery ratein 983090983088983089983090andtheircorresponding983097983093 con-

fidence intervals were generated (See statistical appendix in

the Supplement for further details)

Allstatistical testswere performed with983090-sided P valuesAll P values lt983088983093 wereconsideredstatistically significantSAS ver-

sion983097983090 (SAS InstituteInc) wasused for all statistical analyses

Results

The most recently available cesarean delivery data from the

years 983090983088983088983093 through 983090983088983089983090 were used in this analysis for 983089983095983090 of

the 983089983097983092 (983096983096983095) WHO member states (eTable 983089 in the Supple-

ment) whichrepresented 983097983095983094 of alllivebirthsin the world

Among the983089983095983090 countrieswith observed dataSouth Sudan had

thelowest cesarean delivery rate (983088983094) while Brazilhad the

highest (983093983093983094) The most recent cesarean delivery rate datawere available from the years983090983088983089983088through983090983088983089983090 for983089983090983094 WHO

member states 983090983088983088983095-983090983088983088983097 for 983091983095 WHO member states and

983090983088983088983093-983090983088983088983094 for 983097 WHO member states Only the most re-

cently availablecesarean delivery ratewas used for countries

with available data

Using exact bivariable logisticregressionmodels983090983097theonly

population and health variable that was significantly associ-

ated with whether cesarean delivery rate data was missing

amongthe 983089983097983092WHOmember stateswas WHO region( P = 983088983090)

(Table 983089) Because region wasassociated with whether cesar-

eandelivery rate wasmissingit wasincluded inthe finalmodel

that estimated cesareandelivery rate for countrieswith no ce-

sarean delivery rate data

The estimated global number of cesarean deliveries for

983090983088983089983090 was983090983090983097million (983097983093 CI983090983090983093 to 983090983091983090)yielding a global

cesarean deliveryrateestimate of 983089983097983092 per983089983088983088 live births(983097983093

CI 983089983096983093-983090983088983091) (Table 983090) eTable 983090 in the Supplement lists the

imputed (n = 983090983090) extrapolated (n = 983089983089983096) or observed (n = 983093983092)

estimatesof cesareandelivery rate and volumewith 983097983093 CIs

total annualbirthsand total health expenditureper capita for

all WHO member states in 983090983088983089983090

Forty-five countries accounting for 983089983090983097 of the global

population and 983090983093983095 of global live births in 983090983088983089983090 had esti-matedcesarean deliveryrates less thanor equalto 983095983090 per983089983088983088

livebirths(Table983090)Fifty-threecountries accounting for983090983090983092

of theglobalpopulationand 983089983093983097of global live births in 983090983088983089983090

hadestimatedcesareandelivery rates higher than 983090983095983091 per983089983088983088

live births The983092983096 countriesthatwerewithin therange of more

than 983095983090 to 983089983097983089 per 983089983088983088 live birthsaccounted for983091983096983088 of the

global live births in 983090983088983089983090

Figure983089 shows the relationship between estimatedcesar-

eandelivery ratesin 983090983088983089983090 andmaternalmortality ratiosin 983090983088983089983091

for the 983089983096983089 countries with available maternal mortality data

Thebest fittingadjustedsplineregression model had983091 change

points (cross-validation adjusted R 983090 = 983088983095983095983094983096)at cesareande-

liveryratesof 983095983090 (983097983093 CI983092983092 to983089983088983089)983089983097983089(983097983093CI 983089983094983091 to983090983089983097)and 983090983095983091 (983097983093 CI 983090983094983090 to 983090983096983091) per 983089983088983088 live births With in-

creasing cesarean delivery rates maternal mortality de-

creased upto 983095983090 per983089983088983088 live birthsor less (adjustedslopeco-

efficient minus983094983096983089 983097983093 CI minus983096983097983090 to minus983092983094983097 P lt 983088983088983089 mean

maternal mortality ratio 983092983094983091983091 983097983093 CI 983091983097983091983094 to 983093983091983091983089 per

983089983088983088 983088983088983088live births) Thisrelationship was maintained albeit

somewhat attenuated between 983095983090 to 983089983097983089 per 983089983088983088 live births

(adjusted slope coefficient minus983089983088983089 983097983093 CI minus983089983094983096 to minus983091983092

P = 983088983088983091 mean maternal mortality ratio 983089983091983095983088 983097983093CI 983089983088983088983092

to 983089983095983091983093 per 983089983088983088 983088983088983088 live births Estimated cesarean delivery

Table 1 ComparisonofCountriesWithandWithoutAvailable CesareanDeliveryData

Mean (95 CI)

P ValueaCountries With Data(n = 172)

Countries Without Data(n = 22)

Countries in sample by WHOregion No ()

African region 44 (26) 2 (9)

02

American region 28 (16) 7 (32)

Eastern Mediterranean region 19 (11) 3 (14)

European region 51 (30) 2 (9)

Southeast Asian region 10 (6) 1 (5)

Western Pacific region 20 (12) 7 (32)

Population size in 2012 millions 399 (183-615) 62 (07-117) 21

Life expectancy in 2012 y 701 (687-715) 723 (686-760) 29

Population l iving i n urban areas i n 2012 560 (525-595) 607 (507-707) 38

Totalfertility rate births perwomanin 2012b 29 (27-31) 25 (19-32) 29

Mean annual N oo f births i n 2012thousands 771 (403-1139) 147 (11-283) 15

Birth rate p er 1000 people i n 2012 223 (207-239) 190 (148-232) 17

GDPpercapitain2012incurrentUS$ 13754 (10252-17255) 16744 (9551-23937) 56

Total health expenditure per capita adjustedto2012 US$

1069 (788-1350) 898 (543-1253) 68

AbbreviationGDP grossdomestic

product

a P valuesare derived fromfrom

exactbivariablelogistic regression

models

b Fertilityratedata for2012was

available onlyfor 188 countries

(n = 168for countries with data

n = 19 forcountries without data)





7232019 joi150140



ratesmore than 983089983097983089 per983089983088983088livebirths were notcorrelatedwith

maternalmortalityratios forestimatedcesareandelivery rates

higherthan 983089983097983089 to 983090983095983091 per983089983088983088 live births theadjustedslope

coefficientwas 983090983088 (983097983093 CIminus983093983088 to 983097983089 P = 983093983095) andthe mean

maternal mortality ratio was 983091983093983097 (983097983093 CI 983090983089983094 to 983093983088983090) per

983089983088983088 983088983088983088livebirthsfor estimatedcesareandelivery rates higher

than 983090983095983091 per983089983088983088 live birthsthe adjusted slope coefficientwas

983088983088983089 (983097983093 CI minus983091983093983096to 983091983094983088 P = 983097983097983093) and the mean maternal

mortality ratio was 983091983094983095 (983097983093 CI 983090983095983095-983092983093983096) per 983089983088983088 983088983088983088 live

births The unadjusted analysis results were similar and are

shown in the Statistical Appendix

The best fitting spline regression model assessing the re-

lationship between estimatedcesarean delivery rate and neo-

natal mortality rate for 983089983097983089 countries with available neonatal

mortality data had 983089 change point (cross-validation adjusted

R 983090 983088983095983089983095983096 Figure 983090) Neonatal mortality was lower for coun-

tries with increasing cesarean rate up to 983089983097983092 (983097983093 CI 983089983096983094 to

983090983088983091) cesarean deliveriesper 983089983088983088livebirths(adjustedslopeco-

efficient minus983088983096 983097983093 CI minus983089983089 to minus983088983093 P lt 983088983088983089) Neonatal mor-

tality was not associatied with cesareandelivery rates greater

than983089983097983092 cesareandeliveries per983089983088983088live births(adjusted slope

coefficient 983088983088983088983094 983097983093 CI minus983088983089983090983094 to 983088983089983091983096 P = 983097983091) The un-

adjusted analysis results were similar and are shown in the

Statistical Appendix in the Supplement

Sensitivity analyseswere performed for 983095983094 countriesthat

havethe highest-quality cesareandelivery ratesavailablefrom

theOECD (n = 983090983093)and DHS(n = 983093983089) withfindingssimilar tothe

main analysis Similar results were found usinga data setthat

excluded the 983097 countries with the least reliable data Details

of these analyses and results can be found in the Statistical

Appendix in the Supplement

Discussion

Thisanalysissuggests that the optimal cesareandelivery rate

may be higher than that previously estimated by the WHO983091983089

Theoptimalcesarean deliveryrate in relationto maternaland

neonatal mortality was approximately 983089983097 cesarean deliveries

per983089983088983088 livebirths TheWHO recommendation that population-

level cesareandelivery ratesshould notexceed 983089983088to 983089983093was

a consensusopinion based on theobservation that some coun-

tries withthe lowest perinatalmortalityrateshad cesarean de-

livery rates that were less than 983089983088 per 983089983088983088 live births983091

Prior studies suggesting that lower cesarean delivery rate

thresholds were optimal for maternal983093983097983089983088 and neonatal

mortality983093were incomplete becausethey examineddata from

limited sets of countries and often examined outcomes inwealthier countries Moreover many studies used data from

varying years without accounting for heterogeneity across

years983097983089983088983090983093983091983090 No study hadcesarean delivery rate data forall

983089983097983092 WHOmember states983097983089983088983090983093983091983090 The strength of the current

study is the use of available data from 983089983095983090 countries and in-

clusion of data estimatedfor a singleyear 983090983088983089983090 and cesarean

delivery rates forall WHO memberstatesBy focusing thees-

timates to a single year we avoided possible bias caused by

usingcesareandeliveryrate data from varying years since ce-

sarean delivery rates and mortality change over time T a b l e 2 M

e a n N a t i o n a l E s t i m a t e s f o r

C o u n t r i e s A c c o r d i n g t o C e s a r e a n D e l i v e r y R a t e s

W i t h T o t a l V o l u m e o f C e s a r e a n D e l i v e r i e s f o r E a c h C a t e g o r y

C e s a r e a n D e l i v e r y

R a t e G r o u p s p e r

1 0 0 L i v e B i r t h s

M e a n ( 9 5

C I ) a

O v e r a

l l M e a n ( 9 5

C I )

le 7

2

gt 7

2 -

1 9

1

gt 1 9

1 -

2 7

3

gt 2 7

3

T o t a l G l o b a l C e s a r e a n

D e l i v e r

i e s

A v e r a g e G l o b a l C e s a r e a n

D e l i v e r y

R a t e

C o u n t r i e s

N o

4 5

4 8

4 8

5 3

S h a r e o f g l o b a l p o p u l a t i o n i n 2 0 1 2

1 2 9

3 4 1

3 0 6

2 2 4

S h a r e o f g l o b a l l i v e b i r t h s i n 2 0 1 2

2 5 7

3 8 0

2 0 4

1 5 9

E s t i m a t e d c e s a r e a n d e l i v e r y r a t e p e r 1 0 0

l i v e b i r t h s i n 2 0 1 2

4 4

( 3 8 - 5 1

)

1 3 3

( 1 2 3 - 1 4 4

)

2 3 7

( 2 2 3 - 2 5 1

)

3 5 3

( 3 3 1 - 3 7 5

)

1 9 4

( 1 8 5 - 2 0 3

)

E s t i m a t e d v o l u m e o f c e s a r e a n d e l i v e r i e s

i n m i l l i o n s i n 2 0 1 2

1 4

( 1 3 - 1 4

)

6 5

( 6 4 - 6 7

)

6 8

( 6 6 - 6 9

)

8 2

( 8 0 - 8 4

)

2 2 9

( 2 2 5 - 2 3 2

)

E s t i m a t e d o f t o t a l v o l u m e o f g l o b a l c e s a r e a n d e l i v e r i e s i n 2 0 1 2

6 0

( 5 7 - 6 4

)

2 8 6

( 2 7 6 - 2 9 7

)

2 9 6

( 2 8 4 - 3 0 8

)

3 5 7

( 3 4 3 - 3 7 2

)

M a t e r n a l m o r t a l i t y r a t i o p e r 1 0 0 0 0 0 l i v e b i r t h s i n 2 0 1 3 b

4 6 3 3

( 3 9 3 6 - 5 3 3 1 )

1 3 7 0

( 1 0 0 4 - 1 7 3 5

)

3 5 9

( 2 1 6 - 5 0 2

)

3 6 7

( 2 7 7 - 4 5 8

)

N e o n a t a l m o r t a l i t y r a t e p e r 1 0 0 0 l i v e b i r t h s i n 2 0 1 2 c

3 0 2

( 2 7 6 - 3 2 7

)

1 7 3

( 1 4 1 - 2 0 5

)

6 7

( 5 2 - 8 1

)

6 3

( 5 3 - 7 3

)

T o t a l h e a l t h e x p e n d i t u r e p e r c a p i t a i n 2 0

1 2

U S $

8 6 ( 3 6 - 1 3 6 )

7 2 2 ( 3 1 4 - 1 1 3 1 )

1 7 7 4 ( 1 0 7 0 - 2 4 7 8 )

1 5 0 9 ( 1 0 3 1 - 1 9 8 7 )

a

C e s a r e a n d e l i v e r y r a t e g r o u p s a r e c a t e g

o r i z e d b y c e s a r e a n d e l i v e r y r a t e p e r 1 0 0 l i v e b i r t h s T h e s e c a t e g o r i e s a r e

b a s e d o n t h e r e l a t i o n s h i p b e t w e e n c e s a r e a n d e l i v e r y r a t e s i n 2 0 1 2 a n d m a t e r n a l m o r t a l i t y r a t i o i n 2 0 1 3

b

T h e r e w e r e 1 3 W o r l d H e a l t h O r g a n i z a t i o n ( W H O ) m e m b e r s t a t e s w i t h m i s s i n g 2 0 1 3 m a t e r n a l m o r t a l i t y r a t i o d a t a

( 6 f o r gt 7 2 - 1 9 1

1 f o r t h e gt 1 9 1 -

2 7 3 a n d 6

gt 2 7 3 t h e c e s a r e a n d e l i v e r y r a t e g r o u p s )

c

T h r e e W H O m e m b e r s t a t e s w

e r e m i s s i n g 2 0 1 2 n e o n a t a l m o r t a l i t y r a t e d a t a ( 2 f o r t h e gt 7 2 - 1 9 1 a n d 1 f o r t h e

gt 1 9 1 -

2 7 3 c e s a r e a n d e l i v e r y r

a t e g r o u p s )





7232019 joi150140



A betterunderstanding is neededfor howhealth systems

canmostefficiently develop comprehensive maternaland neo-

natal health careinfrastructureThis includessupportingsafe

and appropriate provision of cesarean delivery and other ob-

stetric surgical services with the intent of reducing maternal

and neonatal mortality without causing overuse of proce-

dures The safe and appropriate provision of emergency ob-

stetricalcareis dependent ona healthcaresystem that canpro-

vide essential surgical care Increasing the proportion of

cesarean deliveries w ithout attention to safety and quality

within a functioning system of care may not result in im-proved health outcomesSimilarly there are countrieswhere

very low maternal and neonatal mortality are obtained with

relatively low cesarean rates suggesting a complex interplay

between overall maternal health resources emergency ob-

stetrical services and other factors Furthermore the opti-

malcesarean deliveryratederived fromthis study maynot ap-

plytoallcountries becausea certainlevel of nationallyavailable

resources may be required

Thisstudy had certain limitations Cesareandelivery rate

data were obtained from many differentsourcesMost of the

countries we studied had cesarean delivery rate information

from sources commonly used in policy decisions and re-

search studies Twenty-two countries did not have cesarean

delivery dataand their rates were estimated using regression

modelsCesareandelivery rates were notavailablefor theyear

983090983088983089983090 for 983089983089983091 countries Using regression models 983090983088983089983090 cesar-

ean delivery rates were estimated from rates available in the

years983090983088983088983093through983090983088983089983089Toour knowledgethisis thefirsttime

multiple imputation modeling has been used to generate ce-

sareandeliveryrate estimates forcountrieswith missingdata

Thismethodpermitsestimationof global cesareandeliveryvol-ume and cesarean delivery rate Some data that might have

been informative such as the percent of births attended by

skilled health personnel(physicians nursesor midwives)pro-

portionof deliveriesat facilitiesandcliniciandensity were not

included in thestatisticalmodels becausethesedatawereonly

available forsome of thecountries Anotherlimitationwas the

inabilityto fully assessthe effectof measurementerrorwhen

evaluating cesarean delivery rate as a covariate When cesar-

eandeliveryrate isused asa covariate to predictmaternal mor-

tality ratios and neonatal mortality rates measurement error

Figure 2 RelationBetween NeonatalMortality Rate(per 100Live Births in 2012) andCesareanDelivery Rate

(per 100LiveBirths) in2012for 191 Countries

50

40

30

20

10

20

0

0 40 5010 30 60

N e o n a t a l M o r t a l i t y R a t e i n 2 0 1 2

p e r 1 0 0 0 L i v e B i r t h s

Cesarean Delivery Rate in 2012 per 100 Live Births

Observed neonatal mortality rate for countriesImputed cesarean delivery rateExtrapolated cesarean delivery rateObserved cesarean delivery rate

Predicted neonatal mortality ratio

Threecountriesdid nothave

neonatal mortality ratedata for 2012

Thechange pointcorresponds

with a cesarean delivery rate of 194

Theblueshadeindicates 95CIs

The curvewas fitto the data byspline

regression modelsusing the

maximum cross-validationndashadjustedR 2 to choosethe numberof

change points

Figure 1 RelationBetweenMaternalMortality Ratioin 2013and CesareanDelivery Rate(per 100Live Births)

in2012for 181Countries

1000

1200

800

600

400

200

20

0

0 40 5010 30 60

M a t e r n a l M o r t a l i t y R a t i o i n 2 0 1 3


Observed maternal mortality ratio for countriesImputed cesarean delivery rateExtrapolated cesarean delivery rateObserved cesarean delivery rate

Predicted maternal mortality ratio

Thirteen countries did not have

maternal mortality ratiodata for

2013 Thematernal mortality ratiowasderived fromdeath from

pregnancy-related causeswhile

pregnantor up to 42days

postpartumper 100000live births

Change points correspond withthe

following cesarean delivery rates72

191 and 273 Theblue shade

indicates95 CIs The curvewas fit

to thedataby splineregression

modelsusing themaximum

cross-validationndashadjusted R 2 to

choosethe numberof changepoints





7232019 joi150140



couldyield biasedresultsusually attenuated to thenullThere

are no available data to adjust for the possible measurement

error (see Statistical Appendix in the Supplement) and thus

the high correlations reported betweencesareandelivery rates

and maternal mortality ratios (cross-validation adjusted R 983090

value of 983088983095983095983094983096 forthe best maternalmortality splinemodel)

and between cesarean delivery rates and neonatal mortality

rates (cross-validation adjusted R 983090 valueof 983088983095983089983095983096 forthe best

neonatal mortality spline model) are likely conservative

The findings herein were based on large population-

level databases from heterogeneous environments and have

theattendant limitations on quality However thedata thatun-

derlie themain findings of theanalysiswere fromsources with

rigorousmethods andquality assurancepracticesthese same

data are used by the majority of international policy and de-

velopment agencies to make recommendations and monitor

progress in maternal and child health Multiple sensitivity

analyses demonstrated that the findings were not driven by

any particular data set and persisted when only the most ro-

bust data sources were included

Due to the nature of ecologic analyses causality cannot

be inferred fortherelationship between cesareandelivery rates

andmaternal andneonatal mortality Furthermore thisstudy

did notaccountfor differencesin cesareandeliveryrateswithin

populations that were due to regional variation wealth dis-

parity or other factors In developing countries cesarean de-

livery rates in urban areas are upto 983091 times higher thanin ru-

ral districts983091983091There arelarge absolutedifferencesin cesarean

delivery rates based on wealth within countries surveyed by

DHS983091983092 In the United States the variation in cesareandeliver-

ies at the hospital level ranged from 983095983089 to 983094983097983097 per 983089983088983088 live

birthsin 983090983088983088983097983091983093some of whichmay be dueto differential risks

of obstructed labor malpresentation or otherindications for

cesarean delivery A countryrsquos rate most likely reflects varia-

tionin practicesand in patient risksbut howmuchof this vari-

ance is within a population is unknown The contribution of

patientfactors to thissignificant variation in theUnitedStates

was small as was exemplified by the wide variability of ce-

sarean delivery in lower-risk pregnancies983091983093 Nevertheless a

risk-adjusted cesarean deliveryrate maybe suitable whendis-

cussing theappropriate level of obstetricsurgical care In ad-

dition thisanalysisfocusesexclusivelyon mortalityas a health

outcome There may be additional benefits to increased ac-

cess to cesarean deliveryincluding reduction of morbidity due

to complicatedvaginaldelivery such as obstetrical fistulas or

abnormalconnectionbetween thevaginaand other neighbor-

ing structures (eg bladder or rectum) that occurs after pro-

longedand untreated obstructedlabor Conversely there may

be healthburdens associated with more frequentcesarean de-

livery including short-term perioperativemorbidity andlong-

term sequelae such as small bowel obstruction placenta ac-

creta and complications of subsequent pregnancies a

relationshipthat hasbeen describedintheUnitedStates983091983094This

relationshiphas notbeen exploredin settingswith lowerhealth

resources Despite these limitations the findings of the cur-

rent analysis highlight a significant correlation between ce-

sarean delivery rateand lower mortalitythat merits attention

in the development of policy to strengthen surgical compo-

nents of health systems

Conclusions

National cesareandelivery rates of up to approximately 983089983097 per

983089983088983088live births wereassociated with lower maternalor neona-

tal mortality among WHO member states Previously recom-

mended national target rates for cesarean deliveries may be

too low

ARTICLE INFORMATION

Author Affiliations AriadneLabsat Brighamand

WomenrsquosHospital and theHarvard TH Chan

Schoolof PublicHealth Boston Massachusetts

(Molina Lipsitz ShahSemrauBerry Gawande

Haynes) Massachusetts General Hospital

Departmentof SurgeryBoston (Molina Haynes)

Stanford University Departmentof Surgery

Stanford California (Weiser Esquivel Uribe-Leitz)

Centerfor Surgeryand PublicHealthBrigham and

WomenrsquosHospitalBoston Massachusetts (Lipsitz)

Stanford UniversitySchool of MedicineStanford

California (Azad) BethIsrael DeaconessMedical

CenterDepartment of Obstetricsand Gynecology

Boston Massachusetts (Shah)

Author Contributions DrsMolina andHaynes had

full accessto all ofthedatainthestudy and take

responsibility forthe integrityof thedataand the

accuracy of thedataanalysisDrs Weiser and

Molinacontributed equallyto the article

Study concept and design Molina WeiserLipsitz

ShahHaynes

Acquisition analysis or interpretation of data

Molina WeiserLipsitz Esquivel Uribe-Leitz Azad

Semrau Berry Gawande Haynes

Draftingof themanuscriptMolina Weiser Lipsitz

Haynes

Critical revision of themanuscriptfor important

intellectual content All authors

Statistical analysis Molina Weiser Lipsitz Semrau

Haynes

Administrative technical or material support

Esquivel Uribe-Leitz AzadSemrau Berry Haynes

Study supervision WeiserLipsitz Gawande

Haynes

Conflict of Interest Disclosures All authors have

completedand submittedtheICMJEFormfor

Disclosure of PotentialConflicts of Interestand

nonewere reported

Additional Contributions Wethank Pandup

Tshering MBBSMPH PGD for providing cesarean

delivery data forBhutanHe didnot receive any

compensation for his contribution

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and beyond 2015 httpwwwunorg

millenniumgoals Accessed October 1 2014

2 United Nations sustainabledevelopment

knowledgeplatform OpenWorkingGroup

proposal for sustainabledevelopment goals

httpssustainabledevelopmentunorg

sdgsproposal Accessed July 282015

3 World Health Organization Appropriate

technologyfor birth Lancet 19852(8452)436-437

4 DeclercqE Young R CabralH EckerJ Is a rising

cesarean delivery rate inevitabletrends in

industrialized countries 1987to 2007 Birth 2011

38(2)99-104

5 YeJ BetraacutenAP Guerrero Vela M Souza JP

ZhangJ Searchingfor theoptimal rate of medically

necessary cesarean deliveryBirth 201441(3)237-

244

6 Shah A Fawole B MrsquoimunyaJM etal Cesarean

delivery outcomes fromtheWHO globalsurveyon

maternal and perinatal health in Africa Int J

Gynaecol Obstet 2009107(3)191-1977 Lumbiganon P Laopaiboon M GuumllmezogluAM

et alWorldHealthOrganizationGlobal Surveyon

Maternal and Perinatal Health Research Group

Methodof delivery andpregnancy outcomes in

Asia theWHOglobalsurvey on maternal and

perinatal health 2007-08 Lancet 2010375(9713)

490-499

8 VillarJ ValladaresE Wojdyla Det alWHO

2005 globalsurveyon maternal andperinatal

health research groupCaesareandelivery ratesand

pregnancy outcomes the 2005WHO globalsurvey





7232019 joi150140



on maternal andperinatal healthin Latin America

Lancet 2006367(9525)1819-1829

9 VolpeFM Correlationof Cesarean ratesto

maternal and infant mortality ratesan ecologic

studyof officialinternational dataRevPanamSalud

Publica 201129(5)303-308

10 BetraacutenAPMerialdiM Lauer JAet alRatesof

caesarean section analysis of globalregional and

national estimates Paediatr Perinat Epidemiol

200721(2)98-113

11 WorldBank World development indicators http

dataworldbankorgindicatorAccessed

September 12 2014

12 United Nations StatisticsDivision World

statistics pocketbook httpsdataunorg

CountryProfileaspx Accessed September 10

2014

13 World HealthOrganization Globalhealth

observatory data repository httpappswhoint

ghodatatheme=mainAccessed Septemer10

2014

14 CentralIntelligence Agency Theworld

factbook countrylisting httpwwwemprendedor

comfactbookcountrylistinghtmlAccessed

September 102014

15 UnitedStatesBureauof Labor Statistics

Inflation calculator httpdatablsgovcgi-bin

cpicalcpl Accessed September22 2014

16 Wilmoth JR Mizoguchi N Oestergaard MZ

etal A Newmethod forderivingglobalestimates of

maternal mortality Stat Politics Policy 20123(2)

2151-75091038

17 Organizationfor Economic Co-operation

and Development iLibrary Health careat a glance

health careactivitiescaesareansections

httpwwwoecd-ilibraryorgsiteshealth_glance

-2013-en0408indexhtmljsessionid

=lw2d1sbqyqezx-oecd-live-02contentType

=ampitemId=2fcontent2fchapter2fhealth

_glance-2013-39-enampmimeType=text2fhtml

ampcontainerItemId=2fcontent2fserial

2f19991312ampaccessItemIds=2fcontent2fbook

2fhealth_glance-2013-enAccessed October 3

2014

18 DatabaseOECDOECD health statistics

httpstatsoecdorgBrandedViewaspxoecd_bv

_id=health-data-enampdoi=data-00542-en Accessed

October 3 2014

19 European Healthfor all Database (HFA-DB)

WorldHealth OrganizationRegionalOffice for

Europe httpdataeurowhointhfadb AccessedJanuary 192015

20 ProgramDHS Demographicand Health

Surveys STATcompiler wwwlegacy

statcompilercom Accessed September 22 2014

21 World Health Organization Globalhealth

observatory datarepositorybirths by caesarean

section () httpappswhointghodatanode

mainREPWOMEN39lang=en Accessed October

3 2014

22 WorldHealth Organization WorldHealth

Statistics 2010 201088-94 httpwwwwhoint

whosiswhostatEN_WHS10_TOCintropdfua=1

Accessed October 2 2014

23 UNICEFMaternalHealthDelivery of

CaremdashCesarean Section Database httpdata

uniceforgmaternal-healthdelivery

-carehtml Accessed January 192015

24 Kyu HHShannonHS GeorgiadesK Boyle MH

Caesarean delivery and neonatal mortality ratesin

46 low-and middle-income countries

a propensity-scorematchingand meta-analysis of

Demographicand HealthSurveydata IntJ Epidemiol

201342(3)781-791

25 AlthabeFSosa C Belizaacuten JMGibbonsL

JacqueriozFBergel E Cesareansection ratesand

maternal and neonatal mortality in low-medium-

and high-income countriesan ecologicalstudyBirth

200633(4)270-277

26 Stanton CKDubourg DDe Brouwere V

Pujades MRonsmansC Reliability of data on

caesarean sections in developingcountriesBull

World HealthOrgan 200583(6)449-455

27 Weiser TGRegenbogen SE Thompson KD

etal Anestimation of theglobal volumeof surgery

a modellingstrategy basedon availabledata Lancet

2008372(9633)139-144

28 Conover W Iman R Rank Transformations as a

bridgebetweenparametricand nonparametric

statistics Am Stat 198135(3)124-129doi101080

00031305198110479327

29 Mehta CRPatel NRExactlogisticregression

theoryand examples Stat Med 199514(19)2143-2160

30 CarrollR RuppertD StefanskiL Crainiceanu C

MeasurementError in NonlinearModels

A Modern Perspective 2nded Boca RatonFlorida

Chapman amp HallCRC 2006

31 World Health Organization Indicators to

monitor maternal healthgoals reportof a technical

working groupGeneva8-12 November 1993

Geneva Switzerland 199420-21 httpwwwwho

intirishandle1066560261 Accessed November

12 2015

32 McClure EMGoldenberg RLBannCM

Maternal mortality stillbirth and measures of

obstetric care in developingand developed

countries IntJ GynaecolObstet 200796(2)139-146

33 StantonCK HoltzSA Levels andtrends in

cesarean birth in the developingworld Stud Fam

Plann 200637(1)41-48

34 RonsmansC Holtz SStanton C

Socioeconomic differentials in caesarean ratesin

developing countries a retrospectiveanalysisLancet

2006368(9546)1516-1523

35 Kozhimannil KBLaw MRVirnig BACesarean

delivery ratesvary tenfold amongUS hospitals

reducing variation may address quality and cost

issues HealthAff (Millwood) 201332(3)527-535

36 Solheim KNEsakoffTFLittle SECheng YW

SparksTN Caughey ABThe effectof cesarean

delivery rateson thefuture incidenceof placenta

previaplacentaaccreta and maternal mortality

J Matern Fetal Neonatal Med 201124(11)1341-1346




7232019 joi150140



Cesarean delivery is lifesaving for obstructed labor and

other emergency obstetrical conditions ensuring ac-

cess to cesarean delivery is an essential strategy for

meeting the Millennium Development Goals983089 and the forth-

coming Sustainable Development Goals983090 forreducingchild and

maternal mortality However as a surgical procedurethere are

risks of complications and overuse can be harmful to both

mothers and neonates Although the optimal population-

level cesarean delivery rate is difficult to know the World

Health Organization(WHO) recommended that national rates

notexceed983089983088 to 983089983093 cesarean deliveries per983089983088983088 live births983091 De-

spite this cesarean delivery rates in many countries are sub-

stantially higher983092983093

Studies of the relationship between cesarean delivery

rate and mortality have yielded inconsistent results983094-983096 In

Latin American hospitals increasing cesarean delivery rates

from 983089983088 to 983090983088 was associated with greater preterm deliv-

ery and neonatal mortality983096 In Asian hospitals there was a

higher risk of maternal mortality and morbidity from cesar-

ean deliveries983095 Conversely in Africa where the median

cesarean delivery rate was 983096983096 the risk of neonatal death

was lower in facilities having higher elective cesarean rates983094

Three studies of cesarean delivery reported that cesarean

rates of up to 983089983088 to 983089983093 cesarean deliveries per 983089983088983088 live births

were associated with optimal neonatal983093 and maternal mortal-

ity outcomes983093983097983089983088 These studies were limited by either hav-

ing incomplete data or relying on averaged cesarean delivery

rates from multiple years without accounting for year-to-year

variation in these estimates

Thepurposeof this study wasto provide betterestimates

for the relationship between cesareandelivery rates and neo-

natal and maternal mortality Optimal cesarean rates associ-

ated withminimal maternal andneonatal mortality rates were

estimated from the most recent data available and limited to

estimates for a single year 983090983088983089983090

Methods

PopulationandHealth Databases

Population and health data were obtained for all 983089983097983092 WHO

member states from the World Bank World Development

Indicators (WDI) database983089983089 These data included total popu-

lation life expectancy at birth percent urban population

gross domestic product (GDP) per capita total health expen-

diture per capita total fertility rate and the national birth

rate Fifteen countries did not have all of these variables in

the WDI database In these instances data were obtainedfrom other sources including the United Nations983089983090 WHO983089983091

and the Central Intelligence Agency983089983092 Information was col-

lected for 983090983088983089983090 and for the years 983090983088983088983093 through 983090983088983089983089 when

983090983088983089983090 data were not available When total health expenditure

per capita was not available for the year for which cesarean

delivery data were obtained either the subsequent or previ-

ous yearrsquos figure was used in that order of preference (see

Statistical Appendix in the Supplement for countries without

recent total health expenditure data) Since health expendi-

ture data were reported in US dollars by the World Bank all

expenditure figures were adjusted to 983090983088983089983090 US dollars using

the consumer price index to account for inflation983089983093

Additional data obtained from the WDI database in-

cluded 983090983088983089983090 neonatal mortality rate (neonates who die be-

fore reaching 983090983096daysof age per983089983088983088983088 live births) and the 983090983088983089983091

maternal mortality ratio(death from pregnancy-related causes

while pregnant or up to 983092983090 days postpartum per983089983088983088 983088983088983088 live

births)983089983089Maternal mortalityis typicallypresented as a ratio to

live birthssince other measures of pregnancynot resulting in

live births are usually not recorded by statistical agencies in

any standardized way983089983094

Of the 983089983097983092 WHO member states 983091 did not have neonatal

mortalityrate informationand 983089983091 didnot have maternal mor-

tality ratios These countries were not included in the analy-

sisevaluatingthe relationshipbetweencesarean delivery rate

and maternal and neonatal mortality Maternal mortality ra-

tio data were from 983090983088983089983091 since these ratios are only periodi-

cally reported and the closest year to 983090983088983089983090 for which data are

available was 983090983088983089983091 The reliability of the data sources is dis-

cussed in the Data Source Appendix in the Supplement

The institutional review board is not necessary for pub-

licly available population-level statistics because it does not

involve human subjects research

CesareanDeliveryDataSources

Country-level cesarean delivery rates for the most recent

year in the period ranging from 983090983088983088983093 to 983090983088983089983090 were obtained

from various sources as described below (eTable 983089 in the

Supplement) Only the most recent cesarean delivery rate

was used so that all countries only had one cesarean

delivery rate used in this analysis The Organization of Eco-

nomic Co-operation and Development (OECD) Health Statis-

tics Database983089983095983089983096 the European Health for All Database

(HFA-DB)983089983097 and the Demographic and Health Surveys (DHS)

program database983090983088

were consulted first due to their qualityassurance mechanisms and rigorous methods If cesarean

delivery rates differed by sources the most recent data from

the OECD DHS and HFA-DB were prioritized in that order

Other data sources included the WHO Global Health

Observatory Data Repository983090983089 The WHO World Health

Statistics 983090983088983089983088 report983090983090 the UNICEF Global Databases

983090983088983089983092983090983091 health-related databases and the peer-reviewed lit-

erature on PubMed (See the Statistical Appendix for more

details regarding sources of available data and see Data

Source Appendix for documentation for each of the primary

and secondary data sources in the Supplement) In particu-

lar the DHS program methods have been previously

described

983090983092983090983093

and have been shown to be reliable

983090983094

BuildingModels toEstimateCountry-Level

CesareanDeliveryRates

The goal of this study wasto relate 983090983088983089983090 population-level ce-

sarean delivery rate with maternal mortality ratios and neo-

natal mortality rates Cesarean delivery rate information for

983090983088983089983090 wasavailable for983093983092 countriesFor983089983089983096 countriesthe one

mostrecentcesarean delivery rate available wasfrom 983090983088983088983093to

983090983088983089983089 Twenty-twoof the 983089983097983092 countriesdid not have anycesar-

eandelivery rate informationfor any of theyears we studied





7232019 joi150140












































ther details)






























Supplement


RateandMortality









































7232019 joi150140

















Results











with available data









































Mean (95 CI)





02














1069 (788-1350) 898 (543-1253) 68


product



models









7232019 joi150140


































Discussion





























M e a n ( 9 5

C I ) a

O v e r a

l l M e a n ( 9 5

C I )

le 7

2

gt 7

2 -

1 9

1

gt 1 9

1 -

2 7

3

gt 2 7

3


D e l i v e r

i e s


D e l i v e r y

R a t e

C o u n t r i e s

N o

4 5

4 8

4 8

5 3


1 2 9

3 4 1

3 0 6

2 2 4


2 5 7

3 8 0

2 0 4

1 5 9


l i v e b i r t h s i n 2 0 1 2

4 4

( 3 8 - 5 1

)

1 3 3

( 1 2 3 - 1 4 4

)

2 3 7

( 2 2 3 - 2 5 1

)

3 5 3

( 3 3 1 - 3 7 5

)

1 9 4

( 1 8 5 - 2 0 3

)


i n m i l l i o n s i n 2 0 1 2

1 4

( 1 3 - 1 4

)

6 5

( 6 4 - 6 7

)

6 8

( 6 6 - 6 9

)

8 2

( 8 0 - 8 4

)

2 2 9

( 2 2 5 - 2 3 2

)


6 0

( 5 7 - 6 4

)

2 8 6

( 2 7 6 - 2 9 7

)

2 9 6

( 2 8 4 - 3 0 8

)

3 5 7

( 3 4 3 - 3 7 2

)


4 6 3 3

( 3 9 3 6 - 5 3 3 1 )

1 3 7 0

( 1 0 0 4 - 1 7 3 5

)

3 5 9

( 2 1 6 - 5 0 2

)

3 6 7

( 2 7 7 - 4 5 8

)


3 0 2

( 2 7 6 - 3 2 7

)

1 7 3

( 1 4 1 - 2 0 5

)

6 7

( 5 2 - 8 1

)

6 3

( 5 3 - 7 3

)


1 2

U S $

8 6 ( 3 6 - 1 3 6 )

7 2 2 ( 3 1 4 - 1 1 3 1 )

1 7 7 4 ( 1 0 7 0 - 2 4 7 8 )

1 5 0 9 ( 1 0 3 1 - 1 9 8 7 )

a




b


( 6 f o r gt 7 2 - 1 9 1

1 f o r t h e gt 1 9 1 -

2 7 3 a n d 6


c



gt 1 9 1 -


a t e g r o u p s )





7232019 joi150140













































50

40

30

20

10

20

0

0 40 5010 30 60


p e r 1 0 0 0 L i v e B i r t h s












change points



1000

1200

800

600

400

200

20

0

0 40 5010 30 60























7232019 joi150140






























































Conclusions





too low

ARTICLE INFORMATION





















ShahHaynes





Haynes




Haynes




Haynes




nonewere reported





REFERENCES














38(2)99-104




244










490-499









7232019 joi150140




Lancet 2006367(9525)1819-1829




Publica 201129(5)303-308




200721(2)98-113



September 12 2014




2014




2014




September 102014







2151-75091038












2014




October 3 2014











3 2014














201342(3)781-791





200633(4)270-277








2008372(9633)139-144




00031305198110479327












12 2015







Plann 200637(1)41-48




2006368(9546)1516-1523













7232019 joi150140












































ther details)






























Supplement


RateandMortality









































7232019 joi150140

















Results











with available data









































Mean (95 CI)





02














1069 (788-1350) 898 (543-1253) 68


product



models









7232019 joi150140


































Discussion





























M e a n ( 9 5

C I ) a

O v e r a

l l M e a n ( 9 5

C I )

le 7

2

gt 7

2 -

1 9

1

gt 1 9

1 -

2 7

3

gt 2 7

3


D e l i v e r

i e s


D e l i v e r y

R a t e

C o u n t r i e s

N o

4 5

4 8

4 8

5 3


1 2 9

3 4 1

3 0 6

2 2 4


2 5 7

3 8 0

2 0 4

1 5 9


l i v e b i r t h s i n 2 0 1 2

4 4

( 3 8 - 5 1

)

1 3 3

( 1 2 3 - 1 4 4

)

2 3 7

( 2 2 3 - 2 5 1

)

3 5 3

( 3 3 1 - 3 7 5

)

1 9 4

( 1 8 5 - 2 0 3

)


i n m i l l i o n s i n 2 0 1 2

1 4

( 1 3 - 1 4

)

6 5

( 6 4 - 6 7

)

6 8

( 6 6 - 6 9

)

8 2

( 8 0 - 8 4

)

2 2 9

( 2 2 5 - 2 3 2

)


6 0

( 5 7 - 6 4

)

2 8 6

( 2 7 6 - 2 9 7

)

2 9 6

( 2 8 4 - 3 0 8

)

3 5 7

( 3 4 3 - 3 7 2

)


4 6 3 3

( 3 9 3 6 - 5 3 3 1 )

1 3 7 0

( 1 0 0 4 - 1 7 3 5

)

3 5 9

( 2 1 6 - 5 0 2

)

3 6 7

( 2 7 7 - 4 5 8

)


3 0 2

( 2 7 6 - 3 2 7

)

1 7 3

( 1 4 1 - 2 0 5

)

6 7

( 5 2 - 8 1

)

6 3

( 5 3 - 7 3

)


1 2

U S $

8 6 ( 3 6 - 1 3 6 )

7 2 2 ( 3 1 4 - 1 1 3 1 )

1 7 7 4 ( 1 0 7 0 - 2 4 7 8 )

1 5 0 9 ( 1 0 3 1 - 1 9 8 7 )

a




b


( 6 f o r gt 7 2 - 1 9 1

1 f o r t h e gt 1 9 1 -

2 7 3 a n d 6


c



gt 1 9 1 -


a t e g r o u p s )





7232019 joi150140













































50

40

30

20

10

20

0

0 40 5010 30 60


p e r 1 0 0 0 L i v e B i r t h s












change points



1000

1200

800

600

400

200

20

0

0 40 5010 30 60























7232019 joi150140






























































Conclusions





too low

ARTICLE INFORMATION





















ShahHaynes





Haynes




Haynes




Haynes




nonewere reported





REFERENCES














38(2)99-104




244










490-499









7232019 joi150140




Lancet 2006367(9525)1819-1829




Publica 201129(5)303-308




200721(2)98-113



September 12 2014




2014




2014




September 102014







2151-75091038












2014




October 3 2014











3 2014














201342(3)781-791





200633(4)270-277








2008372(9633)139-144




00031305198110479327












12 2015







Plann 200637(1)41-48




2006368(9546)1516-1523













7232019 joi150140

















Results











with available data









































Mean (95 CI)





02














1069 (788-1350) 898 (543-1253) 68


product



models









7232019 joi150140


































Discussion





























M e a n ( 9 5

C I ) a

O v e r a

l l M e a n ( 9 5

C I )

le 7

2

gt 7

2 -

1 9

1

gt 1 9

1 -

2 7

3

gt 2 7

3


D e l i v e r

i e s


D e l i v e r y

R a t e

C o u n t r i e s

N o

4 5

4 8

4 8

5 3


1 2 9

3 4 1

3 0 6

2 2 4


2 5 7

3 8 0

2 0 4

1 5 9


l i v e b i r t h s i n 2 0 1 2

4 4

( 3 8 - 5 1

)

1 3 3

( 1 2 3 - 1 4 4

)

2 3 7

( 2 2 3 - 2 5 1

)

3 5 3

( 3 3 1 - 3 7 5

)

1 9 4

( 1 8 5 - 2 0 3

)


i n m i l l i o n s i n 2 0 1 2

1 4

( 1 3 - 1 4

)

6 5

( 6 4 - 6 7

)

6 8

( 6 6 - 6 9

)

8 2

( 8 0 - 8 4

)

2 2 9

( 2 2 5 - 2 3 2

)


6 0

( 5 7 - 6 4

)

2 8 6

( 2 7 6 - 2 9 7

)

2 9 6

( 2 8 4 - 3 0 8

)

3 5 7

( 3 4 3 - 3 7 2

)


4 6 3 3

( 3 9 3 6 - 5 3 3 1 )

1 3 7 0

( 1 0 0 4 - 1 7 3 5

)

3 5 9

( 2 1 6 - 5 0 2

)

3 6 7

( 2 7 7 - 4 5 8

)


3 0 2

( 2 7 6 - 3 2 7

)

1 7 3

( 1 4 1 - 2 0 5

)

6 7

( 5 2 - 8 1

)

6 3

( 5 3 - 7 3

)


1 2

U S $

8 6 ( 3 6 - 1 3 6 )

7 2 2 ( 3 1 4 - 1 1 3 1 )

1 7 7 4 ( 1 0 7 0 - 2 4 7 8 )

1 5 0 9 ( 1 0 3 1 - 1 9 8 7 )

a




b


( 6 f o r gt 7 2 - 1 9 1

1 f o r t h e gt 1 9 1 -

2 7 3 a n d 6


c



gt 1 9 1 -


a t e g r o u p s )





7232019 joi150140













































50

40

30

20

10

20

0

0 40 5010 30 60


p e r 1 0 0 0 L i v e B i r t h s












change points



1000

1200

800

600

400

200

20

0

0 40 5010 30 60























7232019 joi150140






























































Conclusions





too low

ARTICLE INFORMATION





















ShahHaynes





Haynes




Haynes




Haynes




nonewere reported





REFERENCES














38(2)99-104




244










490-499









7232019 joi150140




Lancet 2006367(9525)1819-1829




Publica 201129(5)303-308




200721(2)98-113



September 12 2014




2014




2014




September 102014







2151-75091038












2014




October 3 2014











3 2014














201342(3)781-791





200633(4)270-277








2008372(9633)139-144




00031305198110479327












12 2015







Plann 200637(1)41-48




2006368(9546)1516-1523













7232019 joi150140


































Discussion





























M e a n ( 9 5

C I ) a

O v e r a

l l M e a n ( 9 5

C I )

le 7

2

gt 7

2 -

1 9

1

gt 1 9

1 -

2 7

3

gt 2 7

3


D e l i v e r

i e s


D e l i v e r y

R a t e

C o u n t r i e s

N o

4 5

4 8

4 8

5 3


1 2 9

3 4 1

3 0 6

2 2 4


2 5 7

3 8 0

2 0 4

1 5 9


l i v e b i r t h s i n 2 0 1 2

4 4

( 3 8 - 5 1

)

1 3 3

( 1 2 3 - 1 4 4

)

2 3 7

( 2 2 3 - 2 5 1

)

3 5 3

( 3 3 1 - 3 7 5

)

1 9 4

( 1 8 5 - 2 0 3

)


i n m i l l i o n s i n 2 0 1 2

1 4

( 1 3 - 1 4

)

6 5

( 6 4 - 6 7

)

6 8

( 6 6 - 6 9

)

8 2

( 8 0 - 8 4

)

2 2 9

( 2 2 5 - 2 3 2

)


6 0

( 5 7 - 6 4

)

2 8 6

( 2 7 6 - 2 9 7

)

2 9 6

( 2 8 4 - 3 0 8

)

3 5 7

( 3 4 3 - 3 7 2

)


4 6 3 3

( 3 9 3 6 - 5 3 3 1 )

1 3 7 0

( 1 0 0 4 - 1 7 3 5

)

3 5 9

( 2 1 6 - 5 0 2

)

3 6 7

( 2 7 7 - 4 5 8

)


3 0 2

( 2 7 6 - 3 2 7

)

1 7 3

( 1 4 1 - 2 0 5

)

6 7

( 5 2 - 8 1

)

6 3

( 5 3 - 7 3

)


1 2

U S $

8 6 ( 3 6 - 1 3 6 )

7 2 2 ( 3 1 4 - 1 1 3 1 )

1 7 7 4 ( 1 0 7 0 - 2 4 7 8 )

1 5 0 9 ( 1 0 3 1 - 1 9 8 7 )

a




b


( 6 f o r gt 7 2 - 1 9 1

1 f o r t h e gt 1 9 1 -

2 7 3 a n d 6


c



gt 1 9 1 -


a t e g r o u p s )





7232019 joi150140













































50

40

30

20

10

20

0

0 40 5010 30 60


p e r 1 0 0 0 L i v e B i r t h s












change points



1000

1200

800

600

400

200

20

0

0 40 5010 30 60























7232019 joi150140






























































Conclusions





too low

ARTICLE INFORMATION





















ShahHaynes





Haynes




Haynes




Haynes




nonewere reported





REFERENCES














38(2)99-104




244










490-499









7232019 joi150140




Lancet 2006367(9525)1819-1829




Publica 201129(5)303-308




200721(2)98-113



September 12 2014




2014




2014




September 102014







2151-75091038












2014




October 3 2014











3 2014














201342(3)781-791





200633(4)270-277








2008372(9633)139-144




00031305198110479327












12 2015







Plann 200637(1)41-48




2006368(9546)1516-1523













7232019 joi150140













































50

40

30

20

10

20

0

0 40 5010 30 60


p e r 1 0 0 0 L i v e B i r t h s












change points



1000

1200

800

600

400

200

20

0

0 40 5010 30 60























7232019 joi150140






























































Conclusions





too low

ARTICLE INFORMATION





















ShahHaynes





Haynes




Haynes




Haynes




nonewere reported





REFERENCES














38(2)99-104




244










490-499









7232019 joi150140




Lancet 2006367(9525)1819-1829




Publica 201129(5)303-308




200721(2)98-113



September 12 2014




2014




2014




September 102014







2151-75091038












2014




October 3 2014











3 2014














201342(3)781-791





200633(4)270-277








2008372(9633)139-144




00031305198110479327












12 2015







Plann 200637(1)41-48




2006368(9546)1516-1523













7232019 joi150140






























































Conclusions





too low

ARTICLE INFORMATION





















ShahHaynes





Haynes




Haynes




Haynes




nonewere reported





REFERENCES














38(2)99-104




244










490-499









7232019 joi150140




Lancet 2006367(9525)1819-1829




Publica 201129(5)303-308




200721(2)98-113



September 12 2014




2014




2014




September 102014







2151-75091038












2014




October 3 2014











3 2014














201342(3)781-791





200633(4)270-277








2008372(9633)139-144




00031305198110479327












12 2015







Plann 200637(1)41-48




2006368(9546)1516-1523













7232019 joi150140




Lancet 2006367(9525)1819-1829




Publica 201129(5)303-308




200721(2)98-113



September 12 2014




2014




2014




September 102014







2151-75091038












2014




October 3 2014











3 2014














201342(3)781-791





200633(4)270-277








2008372(9633)139-144




00031305198110479327












12 2015







Plann 200637(1)41-48




2006368(9546)1516-1523













Documents

joi150140