Study Addresses Optimal C-Section Rate for Maternal and Fetal Health Interview with:
Alex Haynes, MD, MPH
Assistant Professor of Surgery, Harvard Medical School
Assistant in Surgery, Massachusetts General Hospital Division of Surgical Oncology
Associate Program Director, Safe Surgery, Ariadne Labs
Research Associate Harvard School of Public Health and
George Molina, MD, MPH
Surgical Research Resident
Massachusetts General Hospital 

Medical Research: What is the background for this study? What are the main findings?

Response: We have previously done work looking at the global volume of operations, and in particular the surgical volume at a country level. This work was based on the hypothesis that a certain level of surgical care is necessary for healthy populations. In doing this work, we found that cesarean delivery makes up a large proportion of all operations that happen globally.

In the mid-1980’s, based on existing data the World Health Organization made the recommendation that at a country-level, the cesarean delivery rate should not exceed 10 to 15 per 100 live births. We wanted to see if this recommendation was still applicable using current data. In order to answer this question, we used multiple imputation to estimate country-level cesarean delivery rates for all 194 countries in the world in 2012 to investigate the association between country-level cesarean delivery rates and maternal and neonatal mortality.

We found that at a population level, as the cesarean delivery rate increased up to about 19 per 100 live births, there was a decrease in country-level maternal and neonatal mortality. However, as country-level cesarean delivery rates rose above this level there were no associated changes in maternal or neonatal mortality.

Medical Research: What should clinicians and patients take away from your report?

Response: These findings apply to countries at large, and not to individual patients and/or hospitals/facilities. Our findings are meant to be used by policy makers, researchers, and national and international health agencies that influence the allocation of resources in the health care sector.

It is paramount that our findings are placed in the context of comprehensive health care systems that are able to provide safe, reliable, and timely cesarean delivery when needed. We do not think that countries should increase the number cesarean deliveries they perform without doing so in the context of overall health system strengthening. It is not at all clear that raising cesarean delivery rates in isolation would result in better health outcomes.

Additionally, a goal of this analysis is to demonstrate the links between surgical services and population health. Cesarean delivery is one of three bellwether procedures (along with exploratory laparotomy and long bone fracture repair) that the Lancet Commission on Global Surgery has proposed as indicators of surgical care access. Ensuring safe and timely access to surgical services is important for many aspects of health care in all environments in the world and our analysis suggests that this plays a role in improving important maternal and child health indicators.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: We hope this work influences the discussion around healthcare system strengthening globally. This work complements the work being done at Ariadne Labs on improving the safety of childbirth in the context of improvement and implementation science in the Indian state of Uttar Pradesh, and work by Dr. Neal Shah at Ariadne Labs that looks at the processes of childbirth at healthcare facilities in the USA. Further research in low resource settings could identify components of safe perioperative care that optimize health outcomes.


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Dr. Alex Haynes and Dr. George Molina (2015). Study Addresses Optimal C-Section Rate for Maternal and Fetal Health 

Last Updated on December 4, 2015 by Marie Benz MD FAAD