title: Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality.
abstract: OBJECTIVE
  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.
  
  
  OBJECTIVE
  To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality.
  
  
  METHODS
  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.
  
  
  METHODS
  Cesarean delivery rate.
  
  
  METHODS
  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
  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.
authors.affiliation: Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts2Massachusetts General Hospital, Department of Surgery, Boston.
authors.forename: George
authors.initials: G
authors.lastname: Molina
authors.affiliation: Stanford University, Department of Surgery, Stanford, California.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Weiser
authors.affiliation: Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts4Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Stuart R
authors.initials: SR
authors.lastname: Lipsitz
authors.affiliation: Stanford University, Department of Surgery, Stanford, California.
authors.forename: Micaela M
authors.initials: MM
authors.lastname: Esquivel
authors.affiliation: Stanford University, Department of Surgery, Stanford, California.
authors.forename: Tarsicio
authors.initials: T
authors.lastname: Uribe-Leitz
authors.affiliation: Stanford University School of Medicine, Stanford, California.
authors.forename: Tej
authors.initials: T
authors.lastname: Azad
authors.affiliation: Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts6Beth Israel Deaconess Medical Center, Department of Obstetrics and Gynecology, Boston, Massachusetts.
authors.forename: Neel
authors.initials: N
authors.lastname: Shah
authors.affiliation: Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
authors.forename: Katherine
authors.initials: K
authors.lastname: Semrau
authors.affiliation: Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
authors.forename: William R
authors.initials: WR
authors.lastname: Berry
authors.affiliation: Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
authors.affiliation: Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts2Massachusetts General Hospital, Department of Surgery, Boston.
authors.forename: Alex B
authors.initials: AB
authors.lastname: Haynes
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005260:Female; D005865:Gestational Age; D014943:Global Health; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D008428:Maternal Mortality / Q000639:trends*; D049590:Postpartum Period; D011247:Pregnancy