The Journal of Obstetrics and Gynecology of India

, Volume 69, Issue 6, pp 483–489 | Cite as

Rising Cesarean Rates: Are Primary Sections Overused?

  • Kalpana MahadikEmail author
Review Article


Doubling of C-section rates from year 2000 to 2015 globally was declared an eye-opener on October 13, 2018, in FIGO World Congress. Rapid increase in rates without clear evidence of concomitant decrease in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. This review addresses issues related to exponentially rising rates, reasons for it, and strategies to reduce. Previous cesarean delivery has main contribution to rising rates as per evidence from the literature search in last 5 years. Focus on optimizing indications of primary C-section resulted in making us rethink modifiable indications like labor dystocia, indeterminate fetal heart rate tracing, suspected fetal macrosomia, malposition, risk-adapted obstetrics, litigation fears, on demand cesarean in literate women and overuse of labor induction. Use of uniform classification system (Robson/WHO classification) with recommendations of WHO, FIGO and annual audits with cloud-based anonymous registry will streamline decisions for cesarean in nullipara and help to control the situation.


Rising cesarean rates Robson classification Modifiable indications of cesarean Primary cesarean Labor dystocia 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Boema T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341.CrossRefGoogle Scholar
  2. 2.
    Gregory KD, Jackson S, Korst L, et al. Caesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol. 2012;29:7–18.CrossRefGoogle Scholar
  3. 3.
    WHO statement on caesarean section rates. Geneva: World Health Organisation. 2015.Google Scholar
  4. 4.
    Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to caesarean delivery. Am J Obstet Gynecol. 2008;199:36e1–5.CrossRefGoogle Scholar
  5. 5.
    Editorial. Stemming the global caesarean section epidemic. The Lancet. 2018;392(10155): 1279.CrossRefGoogle Scholar
  6. 6.
    National Family Health Survey (NFHS-4) 2015-16. International Institute for Population Sciences, Mumbai, India.Google Scholar
  7. 7.
    Singh P, Hashmi G, Swain PK. High prevalence of cesarean section births in private sector health facilities- analysis of district level household survey-4 (DLHS-4) of India. BMC Public Health. 2018;18:613.CrossRefGoogle Scholar
  8. 8.
    Desai G, Anand A, Modi D, et al. Rates, indications, and outcomes of caesarean section deliveries: A comparison of tribal and non-tribal women in Gujarat, India. PLoS ONE. 2017;12(12):e0189260. Scholar
  9. 9.
    Tanaka K, Mahomed K. The ten-group Robson classification: a single centre approach identifying strategies to optimise caesarean section rates. Obst Gynecol Int 2017, 5648938, 5 p. Scholar
  10. 10.
    Torloni MR, Betran AP, Souza JP, et al. Classifications for Cesarean section: a systematic review. PLoS ONE. 2011;6(1):14566. Scholar
  11. 11.
    Zimmo MW, Laaine K, Hassan S, et al. Caesarean section in Palestine using the Robson Ten Group Classification System: a population-based birth cohort study. BMJ Open. 2018;1:2. Scholar
  12. 12.
    Nakamura-Pereira M, do Carmo Leal M, Esteves-Pereira AP, et al. Use of Robson classification to assess cesarean section rate in Brazil: the role of source of payment for childbirth. Reprod Health. 2016;13(3):128. Scholar
  13. 13.
    Farine D, Shepherd D. Classification of Caesarean Sections in Canada: the modified Robson Criteria. A Comm Opin Obstet Gynaecol Can. 2012;34(10):976–9.CrossRefGoogle Scholar
  14. 14.
    Betran AP, Vindevoghel N, Souza JP, et al. A systematic review of the Robson classification for Caesarean section: what works, doesn’t work and how to improve it. PLoS ONE. 2014;9(6):e97769. Scholar
  15. 15.
    Jacob KJ, Jayaprakash M, Hibina KP. TMC (Thrissur Medical College) modified Robson criteria for caesarean sections. Int J Reprod Contracept Obstet Gynecol. 2017;6:5038–43.CrossRefGoogle Scholar
  16. 16.
    Voge JP, Betrán AP, Vindevoghel N, et al. Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis on behalf of the WHO Multi-Country Survey on Maternal and Newborn Health Research Network. Lancet. 2015;3(5):e260–70.Google Scholar
  17. 17.
    Catherine Y, Sponge MD. Prevention of the first cesarean delivery. Obstet Gynecol Clin North Am. 2015;42(2):377–80. Scholar
  18. 18.
    Souza JP, Betran AP, Dumont A, et al. A global reference for caesarean section rates (:c-model) a multicountry cross-sectional study. BJOG. 2016;123:427–36.CrossRefGoogle Scholar
  19. 19.
    Liu S, Liston RM, Joseph KS, et al. Maternal mortality and severe morbidity associated with low- risk planned caesarean delivery versus planned vaginal delivery at term. Maternal Health Study Group of the Canadian Perinatal Surveillance System. CMAJ. 2007;176:455–60.CrossRefGoogle Scholar
  20. 20.
    Rajbhandary S, Shrivastava VR. Study of Indications and post-operative complications of primary caesarean section in tertiary care hospital in Nepal. Int J Reprod Contracept Obstet Gynecol. 2018;7(3):835–40.CrossRefGoogle Scholar
  21. 21.
    Bhowmik J, Kyal A, Das I, et al. Pregnancy with previous caesarean section: an overview of adverse of fetomaternal sequelae. Int J Reprod Contracept Obstet Gynecol. 2018;7(5):1817–21.CrossRefGoogle Scholar
  22. 22.
    Caughey AB, Cahill AG, Guise J-M, et al. Safe prevention of the primary caesarean delivery. Am J Obstet Gynecol. 2014;201(3):179–93.CrossRefGoogle Scholar
  23. 23.
    Zhang J, Landy H, Branch W, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116:1281–7.CrossRefGoogle Scholar
  24. 24.
    Spong CY, Berghella V, Wenstrom K, et al. Preventing the first Cesarean delivery; summary of a Joint Eunice Kennedy Shriver National Institute Of Child Health And Human Development, Society For Maternal- Fetal Medicine, and American College Of Obstetrician And Gynecologists Workshop. Obstet Gynecol. 2012;120:1181–93.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Nelson K, Sartwelle T, Rouse D. Electronic fetal monitoring, cerebral palsy, and caesareans: assumptions versus evidence. BMJ. 2016;355:16405.Google Scholar
  26. 26.
    Obstetric Care Consensus ACOG number 1, March 2014.Google Scholar
  27. 27.
    Wiklund I, Malata M, Cheung NF, Cadee F. Appropriate use of caesarean section globally requires a different approach. Lancet. 2018;392:1288–9.CrossRefGoogle Scholar
  28. 28.
  29. 29.
    Visser GHA, Ayres-de-Campos D, Barnea ER, et al. FIGO position paper: how to stop the caesarean section epidemic. Lancet. 2015;392(10155):1286–7. Scholar
  30. 30.
    Main EK, Chang S-C, et al. Safety assessment of a large-scale improvement collaborative to reduce nulliparous Cesarean delivery rates. Obstet Gynecol. 2019. Scholar

Copyright information

© Federation of Obstetric & Gynecological Societies of India 2019

Authors and Affiliations

  1. 1.Department of Obstetrics and GynaecologyR. D. Gardi Medical CollegeUjjainIndia

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