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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 93-100

Growing concern over rising caesarean section rates: Is it a problem for low- and middle-income countries only?

1 Oxford College of Arts, Business and Technology, 670 Progress Ave, Scarborough, ON M1H 3A4, Canada
2 The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan, Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur, Malaysia

Date of Submission20-Oct-2021
Date of Decision15-Nov-2021
Date of Acceptance30-Nov-2021
Date of Web Publication18-Jan-2022

Correspondence Address:
Mainul Haque
The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan, Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur, 57000
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_148_21

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The rising caesarean delivery rate is a global concern and is believed by many as a problem in low-income countries exclusively. It has been observed that utilisation of this lifesaving procedure is unusually high in many middle- and high-income countries. Caesarean section (CS) is indicated to save both the mother's and child's life in certain situations. When chosen in the proper indication, it is helpful towards reducing morbidity and mortality in both. There is a vast number of papers evidencing the injudicious use of this necessary procedure. There is an evident disparity in the utilisation of the process too. In some sub-Saharan African countries, women do not have access to or have very minimal access to caesarean delivery due to many factors. On the other hand, certain countries overutilise it. Being a South Asian country, Bangladesh is no different from many other countries, with rising caesarean delivery rates in rural and urban populations. It is of great concern for the Bangladeshi general community and the healthcare workers. There have been claims that it is overutilised injudiciously by the Bangladeshi health force. This review aims to find the facts related to the CSs and compare between the high-, middle- and low-income countries. Being healthcare professionals and medical educators by origin, the authors were explicitly interested in Bangladesh. They conducted the review to contribute to the development of the country's healthcare system.

Keywords: Baby, morbidity, mortality, mother, Normal vaginal delivery, OECD, SAARC

How to cite this article:
Umar BU, Haque M. Growing concern over rising caesarean section rates: Is it a problem for low- and middle-income countries only?. Adv Hum Biol 2022;12:93-100

How to cite this URL:
Umar BU, Haque M. Growing concern over rising caesarean section rates: Is it a problem for low- and middle-income countries only?. Adv Hum Biol [serial online] 2022 [cited 2022 Aug 15];12:93-100. Available from: https://www.aihbonline.com/text.asp?2022/12/2/93/336109

  Introduction Top

The problem

A caesarean section (CS) is a surgical procedure to deliver one or more babies by making an incision on the anterior abdominal wall of the pregnant mother.[1] It is usually performed when normal vaginal delivery (NVD) puts a mother's or baby's life at risk. Other accepted indications may include obstructed labour, breech or abnormal foetal presentation, excessive foetal size, non-reassuring foetal heart rate, increased maternal age and history of previous cesarean delivery.[1],[2],[3] Other conditions that might necessitate CS are placenta praevia, placental abruption, placenta accreta, prolapsed cord, maternal age, diabetes, obesity, hypertension, gestational diabetes, pre-eclampsia, eclampsia and maternal preference.[2] There has been considerable concern over the rising rates of CS over the past few decades.[4],[5],[6],[7],[8] Annually, an estimated 6.2 million unnecessary CS are performed globally, costing US$ 2.3 billion approximately.[9] In 2015, data from 169 countries showed that, out of 140.6 million live births, there were 29.7 million CS births, which nearly doubled in 15 years.[10] It has been an issue for developed countries and middle-income countries.[2],[11] In a research paper, Betrán et al.[12] stated that CS accounted for 18.6% of all births analysing data from 150 countries. Over the 24-year study period (1990–2014), trend analysis of data in 121 countries showed that there had been an average 12.4% increase in the CS rates, with an average annual rate of 4.4% rise. The highest (6.4%) and lowest (1.6%) annual increase rates were observed in Asia and North America, respectively.[12] Verma et al.[1] found CS rates to be as high as 13% in South-East Asian countries and going up to 19% while considering the institutional births only [Table 1].[1] Approximately 18.5 million CSs are performed yearly worldwide. World Health Organization (WHO), in a 2010 report of showed that amongst 137 countries, a large proportion of countries used CS at disproportionately high rates, and the cost of the global excess use in 2008 was US$ 2.32 billion.[13] CS rates of 172 low- and middle-income countries showed many disparities, with the highest of 58.9% in the Dominican Republic and the lowest 0.6% in South Sudan. The highest CS rates and most significant levels of absolute inequality are observed in the Americas region. The lowest rate in the African areas also has a minor level of total inequality. It was also observed that 26 out of 28 countries (93%) had an increasing trend in national CS rates, with Egypt and the Dominican Republic at the top (>2% on an average).[14] In their research article, Betran et al.[15] analysed data from 154 countries covering 94.5% of all live births in 2018 and found the average CS rate to be 21.1%. They also projected the rate to reach 28.5% in 2030. In the least trim and more developed regions of the world, the average CS rates were 8.2%, 24.2% and 27.2%, respectively.[15] Betran et al. (2021), in an analysis of data from 154 countries, predicted that, by 2030, global CS rates would reach 28.5% from the present 21.1%.[15]
Table 1: Caesarean section rates amongst the institutional Births in different South Asian countries in urban and rural settings[1]

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The WHO in 1985 declared that CS rates between 10% and 15% should be appropriate, and anything more than this would be considered high. There is a substantial lack of evidence that high rates of CS are beneficial to maternal or child health. Higher rates could adversely affect the health of both mother and the baby, increasing the morbidity and mortality rates.[1],[4] About 42% of the total CS performed globally are unnecessary, posing a risk to mother and child's health.[18]

This review was conducted to explore the Bangladesh situation and compare it with other developing and developed countries. “Is the CS rate unusually higher in Bangladesh compared to South Asian countries and other countries of the world?” is the question the review would try to answer. The reviewers originally hail from Bangladesh, so they were interested in exploring the Situation in Bangladesh compared to the global context.

  Bangladesh Situation Top

CS in Bangladesh soared from almost 3% in 2000 to nearly 24% in 2014.[7],[19],[20],[21] According to the 2007 Bangladesh Demographic and Health Surveys (BDHS), 8% of babies born before the study period were delivered by CS. Most of which were in the private sector (67%) and were positively associated with the mother's economic status and education level.[22] In BDHS 2014, the CS rate was 23%, and in BDHS 2017–2018, it reached up to 33%; one-third of all these deliveries were using CS.[23] According to WHO, the CS rate in Bangladesh was 2.37% in 2000, 3.38% in 2004 and in 2007, it reached 7.52%, almost double.[1] The overall CS rate in Bangladesh nearly 14% (21.82% in urban and 10.10% in rural settings, respectively). While considering the institutional births only, these rates went up to almost 59% (62.88% urban vs. 54.78% rural). There is a wide variation amongst the CS rates between urban and rural settings, both in the poorer and richer quintile.[24] A retrospective observational study conducted in Holy Family Red Crescent Medical College Hospital (HFRCMCH), Bangladesh, revealed that, over 10 years from 1995 to 2004, the CS rate rose from 45.85% to 70.55%. HFRCMCH is a private hospital where NVD dropped from 54.1% to 29.4%.[25] A more recent cross-sectional retrospective study done in 2019 in the same hospital found still higher rates of CS (81.82%).[26] Another retrospective observational study was done in a tertiary level teaching hospital in Barisal (Sher e Bangla Medical College Hospital) in 2019 uncovered very high rates of repeat CS (41.3%).[27] A cross-sectional study conducted in the Noakhali district of Bangladesh found 20% of higher rates than the national average of 2017 (33%).[28]

Some of the significant causes of CS were repeat CS, prolonged labor and foetal distress, which also showed an increasing trend.[25] A survey involving 110 pregnant women from different public and private hospitals in Bangladesh found that 69.1% preferred natural delivery, whereas 30.9% preferred CS. Preference rates for NVD were higher amongst rural women (94.7%) than urban women (55.6%). Working women picked CS at the same time housewives preferred NVD. These rates also varied between facilities. Women delivering in private hospitals preferred CS, whereas women in public hospitals preferred NVD.[29] In Bangladesh, the rate of CS increased ten times and reached 24.4% in 2014, with a wide variation by urban–rural dwelling and economic status. Amongst the poorest quintile, the rate was 7.3% and 54.1% amongst the richest. On average, a CS costs US$261 and requires 7 days of hospitalisation.[30] The CS rates of Bangladesh are depicted in [Table 2].[18],[26],[28],[31],[32],[33],[34]
Table 2: CS rates in Bangladesh: Selected publications[18],[26],[28],[31],[32],[33],[34]

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  The Situation in SAARC Countries Top

SAARC is the abbreviated form of the South Asian Association for Regional Cooperation. It was established with the signing of the SAARC Charter in the capital of Bangladesh, Dhaka, in 1985. Besides many other aims, the principal purposes of the formation of SAARC were promoting the welfare of the peoples of South Asian countries by improving their quality of life, economic growth and socio-cultural development.[35] According to Betrán et al.,[12] the average CS births in Southeast Asia was 14.8% (1.7%–32.0%), with an almost 11% absolute increase rate between 1990 and 2014. The global average was 18.6%, with a 12.4% total increase rate between 1990 and 2014.[12]

In India, analysing the data collected in 'district level household survey-4 from 19 states in 2011, it was found that there were 22,111 live births during that year. Of these, 13.7% and 37.9% deliveries were conducted by CS in public and private sectors, respectively.[36] According to WHO data, CS rates in India increased four-folds from 1992 to 2006 (2.40% and 8.37%, respectively).[24] Verma et al.[1] reported a much higher overall rate in India, almost 14% (24% in urban and 11% in rural population).[1] In another report overall country, CS rate for India was 9.8%, Pakistan 8.5%, Maldives 33.8% and Nepal 5.2%. In India, 16.1% of all CS took place in public facilities and 29.7% in a private settings. Maldives has CS rates of 34.0% and 40.1%, Pakistan 22.0% and 23.4% and Nepal 9.4% and 21.6%, respectively, in public and private facilities.[30] The Verma et al.[1] study revealed recent increasing rates for these countries. Overall CS rates in Pakistan were 12.15%, and Maldives 31.78%, only Nepal had 4.60%, which is lower than Benova L (2017)[30] report. The rate of CS varied according to the urban and rural settings. Bhandari, Dhungel and Rahman, by reviewing Nepal's 5 years National Demographic and Health Survey data (1996–2016), found increased rates of both the population base and institution-based CS rates.[37] According to a WHO report, CS rates in India, Bangladesh and Pakistan were much higher amongst the more affluent quintile population, Bangladesh exceeding 15%.[24] In addition, CS births in SAARC countries [Figure 1].[38]
Figure 1: Births by caesarean section in SAARC countries.[38]

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  The Situation in Other Asian Countries Top

Considering the institutional births, the overall CS rates in Indonesia, Cambodia and Vietnam were 21%, 8% and 12%, respectively.[1] The CS rate was almost 24%.[39] A study conducted in four South Asian Countries found high rates of CS, too [Figure 2].[38] Festin et al.[40] seen overall CS rates in Indonesia, Malaysia, The Philippines and Thailand as 29.6%, 19.1%, 22.7% and 34.8%, respectively.[4] Ravindran (2008),[41] in his short communication, described that there had been a 5% rise in the CS rates in Malaysian public hospitals (from 10.5% in 2000 to 15.7% in 2006).[41]
Figure 2: Caesarean section rates in some South Asian countries.[38]

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China also has concerns over the growing trend of CS. Starting from 1993 to 2002, there has been a steep rise in the CS rates in all regions of mainland China. In 2014, average CS rate in China was 34.9%.[42] In 1993–1994, overall CS rate in all areas of China was 4.9%, which reached up to 20.4% in 2002–2002.[43] According to another study, this rate was still higher. Caesarean deliveries amongst Chinese women increased significantly from 2·0% to 36.6% between 1978–1985 and 2006–2010 and reached 55% in 2014.[44] In 2013, South Korea had almost 36% CS rates.[45]

  The Situation in selected Middle Eastern Countries Top

Rising US rates have been of great concern in Iran, and it kept on rising persistently over the past decades. From 35% in 2000, it went up to almost 41% in 2005, and 2014 became 48%, even with much higher prevalence in some private facilities.[46] Bahadori, Hakimi and Heidarzade (2013),[47] in another article, published Iran's CS rates by provinces. They also found similar national rates (47.9%) in 2009.[47] According to the WHO Global Health Observatory data repository (2018), Iran had a CS rate of 45.6% [Figure 3].[38]
Figure 3: Caesarean section rates in selected middle eastern countries. (WHO, 2018)[38]

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Between 2002 and 2013, the national CS rate in Turkey was almost 37%, even higher in big cities like Istanbul (46.4%).[48] According to the WHO Global Health Observatory data repository (2018), Turkey had a CS rate of 48.1% [Figure 3].[38]

CS rates are also higher than WHO recommended rates in Saudi Arabia. Between 2008 and 2011, it was more than 19%.[49] According to 2018 WHO data, it was 30.2%.[38] In 2012, Iraq had a rate of above 24%[38],[50] CS rates in Qatar were 19.5%, Syria 26%, United Arab Emirates about 24% and Yemen 4.8% [Figure 3].[38] This shows a much broader regional variation, with higher rates in wealthier countries and less in resource-poor countries.

  The Situation in Selected African Countries Top

Despite the CS rates remaining low in many low- or middle-income African countries,[8] there has been a wide variation in CS rates.[24] It explains the disparities in health status and healthcare delivery in this region of the world. Egypt has almost 62% CS rates, whereas it is <1% in South Sudan. CS rates in some African countries varied from 1.4% to nearly 27% [Table 3].[38] In their report, Cavallaro et al.[24] stated that ten sub-Saharan African countries have CS rates of <2%, and Kenya, Ghana, Lesotho, Rwanda and Uganda had over 5%.[24]
Table 3: Cesarean section rates in selected African countries[38]

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  The Situation in the High-Income Countries Top

In 2015, the average US CS rate was 32%.[38] In 2018, it was also almost 32% out of 3.79 million births.[51] Long et al.[42] described still higher rates. There is concern over the rising rates in Canada too. From 2000 to 2008, it went from 21.45% to 26.7% and peaked at 28.8% in 2018.[52] According to the WHO data,[38] it is 27.9%, similar to Smith's (2019) finding [Figure 4]. Between 1979 and 2002, there has been a substantial rise in CS rates in Canada, reaching an all-time high in 2002 at almost 23%.[53]
Figure 4: Caesarean section rates in selected high-income countries [38].

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In the UK, there has been a decreasing trend in the CS rates from 2015 to 2017. In 2015–2016, it was 29.9% which went down to 27.8% in 2016–2017.[38] In Australia, between 1996 and 2012, the CS rates for first birth were almost 29%.[54] According to Betran et al.,[15] in Australia and New Zealand region, the CS rate in 2018 was 33.5%, which was higher than Northern America average rate (31.6%) and European rates (25.7%).[15] The CS rates of several other industrialised countries also were higher than the WHO threshold (15%), with Israel having the lowest being 15.54%, Turkey and Mexico having over 50% [Figure 5].[55]{Figure 4}

  Factors Contributing to High Rate of C-Section Top

Obstetrical causes such as obstructed labor, breech or abnormal foetal presentation, excessive foetal size, non-reassuring foetal heart rate, increased maternal age and history of previous caesarean delivery.[1],[2],[3] Other conditions that might necessitate CS are placenta praevia, placental abruption, placenta accreta, prolapsed cord, maternal age, diabetes, obesity, hypertension, gestational diabetes, pre-eclampsia, eclampsia and maternal preference.[2],[8],[56] Maternal request[3] due to psychological, sociocultural and reasons,[57] healthcare system or institutional factors, increased accessibility to institutionalised births,[58] comforts of the doctor[59] financial incentives or commercialisation of the birth process[3] and fear of litigation amongst doctors[60] are amongst some factors leading to increased utilisation of CS.

  The Complication of Cesarean Section Top

Despite significantly decreasing perinatal morbidity and mortality,[59] CS poses a tremendous maternal and neonatal health threat. Some of the complications and adverse outcomes of CS are-bleeding, anemia, prolonged hospitalisation, wound infection with dehiscence, urinary tract infections and endometritis.[59] CS can lead to maternal deaths too,[59] which may be the consequences of uncontrolled bleeding, aggravation of underlying systemic diseases, heart failure, etc.[56],[59],[61] Other complications may be uterine rupture, abnormal placentation for future pregnancies, ectopic pregnancies, preterm births and stillbirth.[62] Another significant adverse outcome is the increased cost to the client and the society or country. Vaginal delivery is, on average, at least 30% cheaper in the US (US$13,590 for CS vs. US$9,131 for vaginal deliveries per event.[58]

  Safety of Normal Vaginal Delivery Top

Considering full-term pregnancy, NVD is the safest mode of delivery for both the mother and baby. When appropriately prepared, adequately monitored NVD can minimise both maternal and neonatal morbidity and mortality.[62] The vaginal birth rate after previous CS is steadily rising in the US, making it a safer choice for multiparous women.[63] Women giving birth by NDV also had lower rates of morbidities from several causes.[64] Take the example of Bangladesh, where there has been substantial development in many areas of health towards the Millennium Development Goals 4 and 5, and the maternal mortality has declined almost by 40%. Over 60% of the deliveries are done at home and primarily by trained midwives of birth attendants. Women, especially from the rural and the poorer community, prefer normal delivery at home, which establishes that vaginal delivery could be the preferred mode of delivery in certain circumstances if adequate safety measures are taken.[65] Vaginal delivery may lead to maternal and neonatal risks such as urinary incontinence,[66] trauma to the perineum, levator ani complex, anal sphincter[67] and death of mother or baby. Delivering a baby using a vacuum extractor or forceps creates more risk of neonatal and maternal injuries, even death of the baby. Spontaneous vaginal delivery is relatively safer.[68]

  Conclusion Top

Despite a lifesaving surgical procedure to deliver a baby, CSs remain a challenge for the healthcare industry for many reasons. The principal concern is the overutilisation of the process, which has adverse health outcomes and economic constraints on the user and the system. CS rates were unusually high in every region of the world, not a problem for a particular area or country. In some parts of the world, women either do not have or have limited access to CS, reflecting too low rates, which is not expected. Bangladesh, a resource-poor country, has made substantial development in its 50 years, especially in the health sector. Overutilisation of CS is a concern for the Bangladeshi public as well the healthcare community. The rate in no way is unusually higher than in many parts of countries of the world. Measures must be taken to bring the high CS rates down to rational levels following the WHO guideline.


To optimise the rate of CS and better manage the rising rates of unnecessary CS, strategies can be made internationally or at national levels. Strategies that promote NVD amongst the clients and the healthcare workers are proved to be helpful. It has been found effective in different countries are creating and implementing guidelines such as the Robson Classification for Caesarean Section (CS). Endorse as mandatory to obtain a second opinion from specialist obstetrician about the need of CS. Additionally, post-cesarean surveillance, immediate care and monitoring of women in labor, external cephalic version for breech delivery facilities should develop and ensured. Furthermore, attempting and encouraging vaginal breech delivery, and NVD even after history of earlier delivery by C-Section, necessary skill should be ensure throughout country. Educational and emotional interventions for expecting mothers by health professionals is an urgent need. Training of health professionals, strict regulatory measures should be implemented regarding financial incentives for unnecessary CS. The fear of litigation amongst the gynae–obstetrics doctors regarding any negative consequences of NVD should be mitigated,. Thereby, ensures adequately resourced facilities for pregnant mothers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]


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