Objective
There has been growing concern with the increase in cesarean rates in industrialized, transition, and developing countries, a concern reflected in the recent consensus statement on “Safe prevention of the primary cesarean delivery.” This letter updates an earlier paper that examined trends in cesarean rates in industrialized countries through 2007.
Methods
To enhance comparability we included only the 21 countries that met 3 criteria: (1) ≥50,000 births annually; (2) per capita gross domestic product of at least $20,000 in 2013; and (3) consistent reporting of national cesarean rates from 1988 through 2013 ( Table ). Data were drawn from 3 public use sources: (1) the Organization for Economic Co-operation and Development; (2) the World Health Organization (WHO) European Health for All database; and (3) country reports where available. The analysis compared 5-year intervals to examine if the annual change in cesarean rates in a given interval differed from the annual change in the next period. The slope of each country’s trend line for a 5-year interval was compared by calculating an exponentiated change in rate (multiplicative scale), which measures the ratio of annual rate of change during 1 period (eg, 2008 through 2013) compared to a prior period (eg, 2003 through 2008). We had complete data for all countries from 2000 through 2013. From 1988 through 1999 we had complete data on 13 countries. In the case of some countries, data reporting did not begin until after 1990 (Israel 1998; Austria 1995) or there was a period of missing data (eg, Switzerland 1992 through 1997). The Table presents data back to 1988 for descriptive purposes, but analysis focuses on the period from 1993 through 2013 where data were relatively complete. Since the United States had almost half of all births, weighted averages are presented with and without the United States. The methods are described in more detail elsewhere.
| Country | 1988 | 1993 | 1998 | 2003 | 2008 | 2013 | Change 1993 through 2003 | Change 2003 through 2013 | Exponentiated change in rate 2003 through 2008 vs 1998 through 2003 | Exponentiated change in rate 2008 through 2013 vs 2003 through 2008 |
|---|---|---|---|---|---|---|---|---|---|---|
| Australia | 167 | 188 | 213 | 287 | 305 | 327 | 52.3% | 14.2% | 0.94 a | 1.00 |
| Austria | b | b | 146 | 207 | 271 | 288 | b | 39.1% | 0.98 a | 0.96 a |
| Belgium | 102 | 129 | 144 | 176 | 196 | 207 | 36.0% | 17.8% | 0.98 a | 0.99 |
| Canada | b | 175 | 188 | 248 | 264 | 273 | 41.5% | 10.2% | 0.95 a | 0.99 |
| Czech Republic | 75 | 91 | 123 | 153 | 205 | 249 | 68.0% | 62.7% | 1.02 a | 0.97 a |
| Denmark | 129 | 125 | 137 | 192 | 209 | 221 | 53.1% | 15.2% | 0.94 a | 0.98 |
| Finland | 138 | 146 | 153 | 162 | 165 | 158 | 10.8% | –2.3% | 0.99 a | 1.00 |
| France | 129 | 155 | 169 | 193 | 206 | 208 | 24.6% | 7.8% | 0.99 a | 0.99 a |
| Germany | b | 166 | 191 | 248 | 294 | 306 | 49.7% | 23.4% | 0.98 a | 0.97 a |
| Ireland | 97 | 116 | b | 234 | 256 | 285 | 101.7% | 21.7% | 0.97 a | 1.00 |
| Israel | b | b | 134 | 156 | 169 | 158 | b | 1.3% | 1.00 | 0.97 a |
| Italy | 188 | 241 | 291 | 378 | 386 | 361 | 56.9% | –4.4% | 0.95 a | 0.98 a |
| Netherlands | b | 84 | 111 | 135 | 143 | 164 | 60.3% | 21.2% | 0.97 a | 1.03 |
| New Zealand | 112 | 138 | 182 | 223 | 230 | 256 | 61.6% | 14.8% | 0.96 a | 1.02 |
| Norway | 128 | 125 | 137 | 155 | 169 | 164 | 24.1% | 5.7% | 0.99 | 0.98 a |
| Portugal | 148 | 225 | 276 | 319 | 356 | 350 | 41.4% | 9.9% | 0.98 | 0.97 a |
| Slovak Republic | b | 106 | 133 | 181 | 233 | 307 | 71.2% | 69.4% | 0.97 a | 1.02 |
| Spain | 129 | 173 | 205 | 238 | 247 | 252 | 37.2% | 5.8% | 0.97 a | 0.99 |
| Sweden | 112 | 116 | 138 | 165 | 167 | 164 | 42.2% | –0.7% | 0.96 a | 0.99 |
| Switzerland | 171 | b | 229 | 268 | 325 | 330 | b | 23.2% | 1.02 | 0.96 a |
| United Kingdom | b | 150 | 179 | 218 | 231 | 251 | 45.6% | 14.9% | 0.98 a | 1.00 |
| United States | 247 | 216 | 210 | 292 | 322 | 325 | 35.5% | 11.3% | 0.96 a | 0.97 a |
| Weighted average | 202 | 186 | 199 | 261 | 285 | 289 | 40.1% | 10.8% | 0.97 a | 0.98 |
| Weighted average without United States | 141 | 163 | 190 | 236 | 255 | 262 | 44.5% | 11.1% | 0.97 | 0.99 |
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