Sexual and reproductive health

WHO Statement on Caesarean Section Rates: Frequently asked questions

Does WHO recommend a specific caesarean section rate at country level?

No, through this Statement WHO does not recommend a specific rate for countries to achieve at population level. The work conducted by WHO found that as countries increase their caesarean section rates up to 10%, maternal and neonatal mortality decrease. However, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates. Despite this, mortality is not the only outcome to consider. Other important outcomes would be short- and long-term maternal and perinatal morbidity, for example, obstetric fistula, birth asphyxia, or psychosocial implications regarding the maternal¬–¬infant relationship, women’s psychological health, women’s ability to successfully initiate breastfeeding and paediatric outcomes. Lack of data prevented the inclusion of these and other outcomes in the WHO analysis.

Does WHO recommend a specific caesarean section rate at hospital level?

No, through this Statement, WHO does not recommend a specific caesarean section rate in the hospitals. The need for caesarean section at each hospital can vary dramatically depending of the type of population served by the hospital. For example, larger hospitals tend to receive referrals of most complicated pregnancies or deliveries which in turn, may need more caesarean sections. On the other hand, some small facilities may not even be equipped to conduct caesarean sections. Recommending a caesarean section rate for all hospitals would be inappropriate.

Why a caesarean section rate at population level cannot be applied or used at hospital level?

In population-based studies, populations are often defined within geopolitical boundaries (e.g. state, country). A caesarean section rate at population level includes, thus, all deliveries in such a geopolitical area. On the other hand, the medical and obstetric characteristics of the women attending any particular hospital may and in fact, normally are very different from those of the overall population resulting in different needs for caesarean section and thus different caesarean section rates. For example, larger hospitals tend to receive referrals of most complicated pregnancies or deliveries which in turn, may need more caesarean sections. On the other hand, some small facilities may not even be equipped to conduct caesarean sections.

Why are more women giving birth by caesarean section nowadays?

In the last decades, the proportion of birth by caesarean section has increased in an unprecedented way. This is a multifactorial phenomenon and in many cases country- and culture-specific. Caesarean section has become a very safe procedure in many parts of the world to the point of considering it almost infallible. Some of the most omnipresent reasons behind this rise are the fear of pain during birth including the pain of uterine contractions, the convenience to schedule the birth when it is most suitable for families or health care professionals, or because it is perceived as being less traumatic for the baby. In some cultures, caesarean section allows choosing and setting the day of the birth according to certain believes of luck or better auspicious for the newborn’s future. In many countries, societal consensus has imposed a demand for the perfect outcome and doctors are sued when the results are not as expected fueling the fear of litigation. In addition, in some societies, delivery by caesarean section is perceived to preserve better the pelvic floor resulting in less urinary incontinence in the future or sooner and more satisfactory return to sexual life.

Why could caesarean sections be dangerous?

When medically justified, caesarean sections can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of caesarean delivery for women or infants who did not require the procedure. Although caesarean section has become a very safe procedure in many parts of the world, it is not without risk. As with any surgery, caesarean section is associated with short- and long-term risks with potential implications in future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care and in settings that lack the facilities and the capacity to properly conduct safe surgery and appropriately manage its complications.

Why is a standardized system to classify caesarean sections necessary?

Particularly in the hospitals, it is important to be able to compare caesarean section rates and outcomes in a reliable manner. For example, doctors and midwives need tools to analyze the impact of their practices, clinical protocols and changes. Historically, we have classified caesareans according to their indications or causes (e.g. intrapartum fetal distress, dystocia, failure to progress). The challenge with this type of systems has been the low reproducility as definitions vary and different doctors may categorize the same caesarean section under different indication. This has prevented meaningful comparisons not only between hospitals but even within hospitals over time. The Robson (also known as the “10 groups”) system overcomes some of the inherent problems of the indications classifications. It is simple, robust, reproducible, and clinically relevant. It allows comparisons and analysis of caesarean section rates more reliably across different facilities, cities and regions.

How can I implement the Robson classification in my hospital?

The Robson classification requires minimal resources and it is being implemented in many facilities worldwide. The system stratifies women into one of 10 categories for which only five obstetric characteristics are necessary. These variables are routinely collected in most maternities worldwide:

  • parity (nulliparous, multiparous with and without previous caesarean section);
  • onset of labour (spontaneous, induced or pre-labour caesarean section);
  • gestational age (preterm or term);
  • foetal presentation (cephalic, breech or transverse);
  • and (5) number of foetuses (single or multiple).

The use of a simple spreadsheet will allow you to calculate the proportion of women and caesarean section rates in each group. In order to assist healthcare facilities in adopting the Robson classification, WHO is currently developing guidelines for its use, implementation and interpretation, including standardization of terms and definitions.