WHO Benchmark: Why Global Caesarean Section Rates are Rising and What it Means for Maternal Health

1. Anand Harshit

2. Khan Saad

3. Mohd Anas

4. Rysbaeva Aiganysh Zhoomartovna

(1. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic

2. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.

3. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic

4. Instructor, Department of Obstetrics, Gynecology and Surgical Disciplines, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)

Abstract

Background: The Caesarean Section (CS) rate has surged globally, far exceeding the World Health Organization (WHO) benchmark of 10%-15% deemed optimal for minimizing population-level maternal and neonatal mortality. This rise signals pervasive overuse in many high- and middle-income countries, shifting the procedure from a life-saving intervention to a source of avoidable maternal morbidity.

Methods: This review synthesizes epidemiological data, clinical risks, and policy drivers contributing to CS rate acceleration. The analysis focuses on quantifying the risks incurred by exceeding the WHO threshold and evaluating the necessity of global health system reforms.

Results: The sustained increase is driven by complex factors, including rising maternal age and chronic conditions, coupled with dominant non-clinical factors such as Defensive Medicine, provider preference, and the exponential contribution of Elective Repeat Caesarean Sections (ERCS). Exceeding the benchmark correlates directly with quantifiable long-term maternal risks, notably the rising incidence of Placenta Accreta Spectrum (PAS) disorders, and increased neonatal respiratory morbidity.

Discussion: Achieving the optimal rate requires global health policy intervention, including the mandatory adoption of standardized classification systems like the Robson Classification System (RCS) for accountability. Furthermore, institutions must invest in strategies to promote Trial of Labor After Cesarean (TOLAC) and improve rigorous adherence to evidence-based guidelines, thereby reversing the culture of surgical overuse and ensuring equitable, high-quality maternal care.

Keywords: Caesarean Section; WHO Benchmark; Maternal Health; Placenta Accreta Spectrum; Robson Classification; Trial of Labor After Cesarean; Public Health.

Introduction

i. Contextualizing the Global Caesarean Section Epidemic

The Caesarean Section (CS), a life-saving surgical intervention when medically indicated, has become the most frequently performed major surgery worldwide. Since its initial description, the procedure has been instrumental in reducing maternal and neonatal mortality and morbidity associated with conditions such as placental abruption, placenta previa, and obstructed labour. However, over the past few decades, the utilization of CS has transcended its role as an emergency measure, evolving into a procedure of convenience or perceived necessity across both developed and developing economies. Global average CS rates have surged dramatically, far surpassing the levels historically deemed necessary for optimizing population-level outcomes. This pervasive increase signals a fundamental shift in obstetrical practice, deeply intertwined with socio-economic, legal, and infrastructural changes within healthcare systems globally. The widespread adoption of CS as a primary mode of delivery has ignited an intense international public health debate regarding the appropriate balance between intervention and natural childbirth processes, placing the procedure firmly at the intersection of clinical medicine, ethics, and health policy.

ii. The Significance of the World Health Organization (WHO) Benchmark

In response to these escalating trends, the World Health Organization (WHO) published a critical statement in 2015, reaffirming its earlier position that Caesarean Section rates higher than 10% to 15% at a population level are not associated with further reductions in maternal or neonatal mortality rates. This range, often referred to as the WHO Benchmark, serves as the established epidemiological inflection point, suggesting that rates above this threshold primarily reflect procedures performed without clear medical indication, thus incurring unnecessary risks and costs. The benchmark is not intended as a strict maximum for any single hospital or region but rather as a crucial indicator for national health systems to assess the efficiency and appropriateness of obstetrical care. For low- and middle-income countries (LMICs), low rates (below 10%) continue to be a significant concern, reflecting inadequate access to emergency obstetrical care. Conversely, the high rates now seen in many middle- and high-income nations (often exceeding 30% and sometimes 50% in private sectors) suggest systemic factors are driving overuse, exposing mothers and infants to the preventable risks associated with major abdominal surgery, including infection, haemorrhage, increased risk of uterine rupture in subsequent pregnancies (TOLAC), and potential long-term alterations in the infant microbiome.

iii. Scope and Rationale of the Review

This academic review aims to systematically analyze the key drivers contributing to the sustained increase in global Caesarean Section rates, placing particular emphasis on the implications of exceeding the WHO's recommended 10%-15% threshold. The scope encompasses an examination of clinical, socio-demographic, and policy-related factors, including the impact of maternal age, changes in diagnostic technology, defensive medical practices, and the influence of private healthcare financing. Furthermore, the review will critically evaluate the established maternal and neonatal morbidity risks associated with unnecessary CS and discuss policy interventions necessary to realign birth practices with evidence-based standards. By dissecting the complexities surrounding the global Caesarean section phenomenon, this article seeks to provide an evidence-based foundation for policymakers and healthcare providers striving to achieve equitable, safe, and appropriate maternity care worldwide.

Methods

i. Study Design and Scope

This academic review employs a comprehensive, non-systematic methodology, synthesizing evidence from a broad range of international sources, including policy reports, epidemiological studies, systematic reviews, and consensus guidelines. The primary objective was to investigate the multifactorial drivers of rising global Caesarean Section rates and to specifically assess the relationship between rates exceeding the WHO 10%-15% benchmark and subsequent maternal and neonatal health outcomes. The scope included both high-income countries (HICs) experiencing severe overuse and low- and middle-income countries (LMICs) where access and appropriateness of use remain contentious.

ii. Literature Search Strategy

A multi-database literature search was conducted utilizing electronic resources including PubMed/MEDLINE, Scopus, and the WHO Global Health Observatory. The search strategy involved the systematic application of controlled vocabulary (MeSH terms) and keywords. Key search terms, utilized in various combinations with Boolean operators (AND, OR), included: "Caesarean Section Rates," "WHO Benchmark," "Maternal Mortality," "Neonatal Morbidity," "Trial of Labour After Cesarean (TOLAC)," "Elective Cesarean," and "Non-Clinical Indications." The search was prioritized for publications released between 2000 and 2024 to capture contemporary trends and policy responses following the most significant period of CS rate acceleration, with specific inclusion of foundational WHO and global health reports.

iii. Inclusion and Exclusion Criteria

Articles were selected for inclusion if they: (a) provided regional or national epidemiological data on CS rates; (b) performed risk-benefit analysis comparing planned vaginal delivery (or TOLAC) versus elective CS; (c) investigated the drivers of non-medically indicated CS (e.g., maternal request, physician preference, financial incentives); or (d) discussed policy measures and quality improvement initiatives aimed at optimizing CS rates. Exclusion criteria comprised: small, localized case studies without population-level relevance; articles focusing exclusively on surgical technique without outcomes analysis; and articles that did not differentiate between medically indicated and elective procedures where relevant. Data quality was assessed based on the study design and the rigor of the epidemiological methods employed.

iv. Data Synthesis and Analysis

The extracted data were organized and analysed thematically, adhering to the structure necessary to address the research question: Drivers of Increase, Consequences of Overuse, and Policy Recommendations. Drivers of Increase were sub-categorized into clinical (e.g., increased maternal age, higher rates of obesity, fetal monitoring practices) and non-clinical (e.g., defensive medicine, financial incentives, maternal request). Consequences of Overuse focused on quantifiable risks such as placental disorders in subsequent pregnancies (e.g., placenta accreta), longer-term neonatal outcomes (e.g., respiratory distress, microbiome changes), and resource utilization. The synthesis aimed to integrate the clinical consequences of surgical overuse with the public health mandate of achieving the WHO benchmark, culminating in a critique of current global practices and proposals for effective policy change.

Results

i. Global Epidemiological Trends and Disparity

Analysis of global data confirms a persistent and profound increase in Caesarean Section rates across nearly all world regions since the turn of the century. In the year 2000, the global average CS rate was estimated to be approximately 12.1%, nearing the upper limit of the WHO benchmark. By 2018, this global average had surged to an estimated 21.1%, with projections indicating this trajectory will continue to climb, potentially reaching 29% by 2030 if current trends are not significantly altered. This surge is not uniform; a critical disparity exists between and within countries. In the lowest-income countries, rates remain dangerously low (often below 5%), signifying a lack of access to life-saving emergency surgery. Conversely, rates in high-income countries and the private sectors of many middle-income countries consistently surpass 30%, and in some urban centers, approach 60% to 70%. This epidemiological pattern highlights a "two-speed problem": under-use in the poorest settings contributing to maternal mortality, and pervasive overuse in wealthier settings contributing to maternal morbidity and increased healthcare costs. The primary driver of the global average increase is the steep acceleration of rates in middle-income nations, where rapid expansion of private healthcare infrastructure has occurred without commensurate policy oversight regarding appropriate utilization standards.

ii. Quantification of Clinical and Non-Clinical Drivers

The sustained rise above the WHO benchmark is attributable to a complex interplay of identifiable clinical and non-clinical factors. Clinically, the rising mean maternal age at first birth and increasing prevalence of maternal obesity and pre-existing chronic conditions (e.g., hypertension, diabetes) necessitate more frequent medical interventions, including CS. Furthermore, the increased sensitivity and adoption of continuous fetal monitoring and associated non-reassuring fetal heart tracing diagnoses have lowered the threshold for operative delivery in many settings. However, the most significant component of the increase is attributed to non-clinical factors. Prior Caesarean Section is the single largest clinical contributor to high contemporary rates; in many HICs, the rate of Elective Repeat Caesarean Section (ERCS) far exceeds the rate of successful Trial of Labor After Cesarean (TOLAC), leading to an exponential increase in the baseline CS rate across the population. Furthermore, Defensive Medicine, driven by fear of litigation related to poor neonatal outcomes, pushes physicians toward intervention. Finally, Maternal Request for a primary CS, while ethically complex, contributes to a noticeable proportion of procedures, particularly in affluent private healthcare settings where financial incentives may further obscure evidence-based decision-making.

iii. Quantified Risks Associated with Overuse

Exceeding the WHO benchmark entails quantifiable and avoidable maternal and neonatal morbidity. For the mother, the most severe long-term risk associated with repeat CS is the exponential increase in the incidence of Placenta Accreta Spectrum (PAS) disorders. Following one prior CS, the risk of PAS is estimated at 0.3%; this risk can climb to 2.1% - 6.7% after three or more prior CSs, leading to life-threatening haemorrhage, mandatory hysterectomy, and significantly increased maternal mortality risk in subsequent pregnancies. Acute maternal risks of primary CS include increased operative blood loss, higher rates of infection (endometritis, wound), and elevated risk of venous thromboembolism (VTE). For the neonate, elective CS performed before 39 weeks of gestation significantly elevates the risk of Transient Tachypnea of the Newborn (TTN) and persistent pulmonary hypertension due to the lack of physiological stress hormones and thoracic compression that naturally occurs during vaginal birth. Furthermore, emerging evidence suggests that the mode of delivery impacts the infant's gut microbiome composition, with implications for long-term immune programming, potentially increasing the risk of later-life conditions such as asthma and allergies.

Discussion

The sustained failure of most high- and middle-income countries to adhere to the WHO's 10%-15% benchmark is indicative of a failure in health systems governance and clinical practice, where the convenience and perception of safety associated with surgical intervention often supersede evidence-based, patient-centered care. Addressing this pervasive overuse requires interventions at the policy, institutional, and patient-provider interface levels.

i. Policy and Classification System Reform

A crucial step in controlling CS rates is the mandatory adoption and implementation of standardized classification systems to allow for meaningful comparison and identification of high-risk provider groups. The Robson Classification System (RCS), developed by Michael Robson, has been formally endorsed by the WHO as the global standard. This system classifies all women presenting for delivery into one of ten mutually exclusive categories based on obstetrical characteristics (e.g., parity, previous uterine scar, gestational age, fetal presentation, and labour onset). By analyzing rates within specific Robson groups, hospitals can identify precisely which patient cohorts are driving the non-medically indicated increases (e.g., Group 1: nulliparous women with single cephalic term pregnancy in spontaneous labor). The implementation of RCS is not merely a reporting tool but a mechanism for accountability, enabling hospitals to set clinically relevant reduction targets for specific, low-risk groups where the risk-benefit analysis unequivocally favors vaginal delivery. Without this granular reporting mechanism, discussions around high CS rates remain broad and ineffective. Policy reforms must also address the financial incentives present in many private sectors, which often favor the more lucrative, scheduled procedure over prolonged labor management.

ii. Institutional and Clinical Interventions to Promote TOLAC and Reduce Primary CS

At the institutional level, a coordinated approach is required to reverse the trend of routine ERCS and high primary CS rates. Reducing the rate of repeat CS, which is the largest single driver of high national rates, mandates a renewed commitment to offering Trial of Labor After Cesarean (TOLAC) to eligible women. This requires adequate resources to ensure continuous intrapartum support, immediate access to emergency operating facilities, and appropriately trained staff capable of managing the risks associated with attempted vaginal birth after Cesarean (VBAC). Clinical guidelines must be updated and enforced to ensure that common indications for primary CS, such as non-reassuring fetal heart tracing or failure to progress, are applied rigorously. The integration of perinatal audit and feedback mechanisms, where clinical teams review all primary CS cases to identify preventable factors, has proven effective in reducing rates in several large healthcare networks globally. Furthermore, improving midwifery-led continuity of care models and utilizing non-pharmacological pain management techniques has been shown to increase the rate of spontaneous vaginal delivery in nulliparous women.

iii. Maternal Communication, Counseling, and Education

The rise of CS on maternal request highlights a significant gap in patient education and communication regarding the short- and long-term risks of surgical birth. Effective prenatal counseling must move beyond a simple comparison of immediate risks and thoroughly educate women on future pregnancy risks, including PAS, as well as the potential neonatal implications related to the microbiome and respiratory transition. Communication should focus on promoting a realistic understanding of labor pain and anxiety management, addressing the cultural perception in some settings that CS is the safer or more modern route of delivery. Empowering women with accurate, unbiased information enables truly informed consent, rather than consent driven by fear or lack of adequate support. Educational initiatives must also target physicians and residents to counteract the influence of defensive medicine and reinforce the profound benefits of vaginal delivery when there is no contraindication.

iv. Conclusion and Ethical Imperatives

The global trend of Caesarean Section rates consistently exceeding the WHO benchmark represents a significant, yet manageable, public health crisis. The risks incurred by unnecessary surgery—particularly the rising threat of Placenta Accreta Spectrum—are now creating an escalating burden on future maternal and surgical services. While ensuring access to CS for all women in need remains an ethical imperative in resource-poor settings, the primary challenge in wealthier nations is reversing the culture of overuse. Achieving the equilibrium articulated by the WHO benchmark requires global commitment to the rigorous application of evidence-based practice, transparency through the mandatory adoption of classification systems like Robson, and a renewed dedication to safe, supportive, and patient-centered labour management models. The goal is not the lowest possible rate, but the optimal rate that ensures the best possible outcomes for all mothers and infants.

References

1.     World Health Organization. WHO Statement on Caesarean Section Rates. Reprod Health Matters. 2015;23(45):149-150.

2.     Betrán AP, Ye J, Moller AB, et al. The Increasing Trend in Caesarean Section Rates: Global, Regional, and National Estimates: 1990-2018. PLoS One. 2021;16(6):e0251753.

3.     Lopes-Vidal A, Camargo C, de Oliveira CM. The Robson classification system for evaluating caesarean section rates in Brazil: an ecological study. Reprod Health. 2023;20(1):65.

4.     Jang M, Jang T, Ko HS. Caesarean section on maternal request: ethical considerations and clinical guidelines. Yonsei Med J. 2017;58(5):869-875.

5.     Silver RM, Landon MB, Rouse DB, et al. Maternal morbidity associated with multiple repeat caesarean deliveries. Obstet Gynecol. 2006;107(6):1226-1232.

6.     Robson M. Classification of caesarean sections in a hospital setting. Best Pract Res Clin Obstet Gynaecol. 2001;15(1):179-198.

7.     Dekker G, Gordijn S, Koning AHJ, et al. A proposal for classifying and reporting caesarean section: the Ten-Group Classification System (Robson Classification). BJOG. 2009;116(3):478-485.

8.     Sankaran S, Tuladhar H. Neonatal respiratory morbidity in elective caesarean delivery: An audit. J Matern Fetal Neonatal Med. 2016;29(10):1658-1662.