Caesarean Delivery Rates and Pregnancy Outcomes: The 2005 WHO Global Survey on Maternal and Perinatal Health in Latin America

Abstract

Rates of cesarean section continue to increase throughout the world. The authors analyzed data from the 2005 World Health Organization global survey on maternal and perinatal health in an attempt to clarify the association between operative delivery and pregnancy outcome at the institutional level. The database consisted of a multistage stratified sample of 24 geographic regions in 8 Latin American countries. Data were collected for all women admitted to 120 institutions (randomly chosen from 410 hospitals) who were admitted for delivery over a 3-month period. Data were obtained for 97,095 of 106,546 deliveries—a coverage rate of 91%. The median rate of cesarean delivery was 33%. Factors that helped to determine operative delivery rates included primiparity, previous operative delivery, and institutional complexity. Private hospitals consistently had higher rates than did public institutions. After adjusting for risk factors, cesarean rates correlated positively with postpartum antibiotic treatment as well as with severe maternal morbidity and mortality. The most common indication for cesarean delivery was the spectrum of cephalopelvic disproportion/dystocia/failure to progress. Next most common in public hospitals was fetal distress and at private centers, previous cesarean delivery without complications. On multiple linear regression analysis, the only factors independently associated with cesarean delivery were primiparity, previous cesarean delivery, and institutional complexity. Only primiparity and previous cesarean delivery remained significant for elective operative deliveries. After adjusting for preterm delivery, an increased rate of cesarean delivery correlated with increased fetal mortality and more frequent admission of infants to intensive care for 1 week or longer. The frequency of preterm delivery and neonatal mortality increased when rates of cesarean delivery reached 10% to 20%. These findings indicate that a high cesarean delivery rate does not necessarily indicate good-quality care. Perinatal outcomes should be closely scrutinized at institutions where high operative delivery rates prevail.