Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality

Cesarean deliveries are lifesaving for obstructed labor and other emergency obstetrical conditions. As per theWorld Health Organization (WHO) recommendation, cesarean delivery rates should not exceed 10 to 15 per 100 live births; however, in reality, the rates are higher in many countries. The aim of this study was to provide better estimates for the contemporary relationship between national cesarean delivery rates, and neonatal and maternal mortality. Maternal and neonatalmortality rates were estimated from themost recent data available during the period 2005 to 2012 for all 194WHO member states from theWorld BankWorld Development Indicators database. For 2012, data were available for 54 countries; for the 118 countries for which these data were not available, the 2012 cesarean delivery rates were inferred from other years, and for the 22 countries for which these rates were not available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percentage of urban population, and geographic region. An important goal of this study was to relate 2012 population-level cesarean delivery rates with maternal mortality ratios (maternal death from pregnancy-related causes during pregnancy or up to 42 days postpartum per 100,000 live births) and neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births). The total estimated number of cesarean deliveries in 2012 was 22.9 million (95% confidence interval [ CI], 22.5 million to 23.2 million). Cesarean delivery rates at the country level were estimated to be inversely correlated with maternal mortality up to a rate of 19.1 per 100 live births (95% CI, 16.3-21.9). Similarly, cesarean delivery rates at the country level were estimated to be inversely correlated to neonatal mortality rates up to 19.4 per 100 live births (95% CI, 18.6-20.3). It was noted that higher cesarean delivery rates above these thresholds 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 rates yielded a similar result: cesarean delivery rates greater than 6.9% were inversely correlated with the maternal mortality ratio (slope coefficient, -21.3; 95% CI, -32.2 to -10.5; P < 0.001) up to a rate of 20.1%. Cesarean delivery rates between 12.6 and 24.0 per 100 live births were inversely correlated with neonatal mortality (slope coefficient, -1.4; 95% CI, -2.3 to -0.4; P = 0.004). The study thus showed that national cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatalmortality amongWHO member states. It also suggests that the optimal cesarean delivery rate may be higher than that previously estimated by the WHO.