WHO Survey on Cesareans and Pregnancy Outcomes in Asia

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Associated Press released an article today about the China’s high cesarean rate.

Nearly half of all births in China are delivered by cesarean section, the world’s highest rate, according to a survey by the World Health Organization — a shift toward modernization that isn’t necessarily a good thing.

The boom in unnecessary surgeries is jeopardizing women’s health, the U.N. health agency warned in the report published online Tuesday in the medical journal The Lancet.

Unnecessary C-sections are costlier than natural births and raise the risk of complications for the mother, said the report surveying nine Asian nations. It noted C-sections have reached “epidemic proportions” in many countries worldwide.

Read more of the article…


The study, Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007—08, is available online.

The first paragraph of the introduction details a few key factors associated with the worldwide unnecessary cesarean trend. [Emphasis mine]

Several factors, including the increased perception of safety, have contributed to a worldwide increase in rates of caesarean section. In many countries, these rates have reached epidemic proportions, motivating a debate about whether the high rates are appropriate. Unnecessary caesarean section is a classic example of the mismatch between evidence and practice in obstetrics. This debate also draws attention to the complexities that attempts to change practice entail. On the one hand, some are concerned about possible additional maternal and perinatal morbidity caused by unnecessary caesarean sections. On the other hand, assessment of whether the caesarean section operation poses an intrinsic risk to the mother or the baby is difficult. Ethical and practical constraints prevent assessment of intrinsic risks related to caesarean sections with use of a randomised controlled trial.

Table 1 (modified here to fit on page) shows numbers of women by country and method of delivery


The discussion of how risk was calculated in the absence of an RCT was interesting.

Intrinsic risk associated with the caesarean section operation is not easy to separate from the medical and obstetrical indications that lead to the procedure. In the previous survey, the intrinsic risk was investigated by dividing the method of delivery into three categories: vaginal, elective caesarean section, and intrapartum caesarean section with elective caesarean section as a proxy.

Instead of three categories, this survey used six categories (see above table).

We identified six categories as described in the results. Assisted vaginal delivery represents a high-risk situation, and combination of such deliveries with spontaneous vaginal deliveries as the reference group might not be appropriate. Second, we noticed that several births that were recorded as elective had an indication for caesarean section. The group with no medical indication therefore is probably a more appropriate group to assess the intrinsic risk associated with this procedure.

The following is considered the most important finding of the survey.

The most important finding of the survey is the increased risk of maternal mortality and severe morbidity, which was analysed as a composite outcome (the maternal mortality and morbidity index), in women who undergo caesarean section with no medical indication. The findings for the individual outcomes that make up the composite outcome suggest that the increased risk is mainly attributable to increased admission to ICU and blood transfusion. Although we acknowledge that both ICU admission and blood transfusion depend on the availability of those services and the potentially differing thresholds for giving blood and for admission of women to ICU or referral to higher levels of care, this outcome is nevertheless important.


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