98 Paediatric and Perinatal Epidemiology, 21, 98–113. ©2007 The Authors, Journal Compilation ©2007 Blackwell Publishing Ltd. Blackwell Publishing LtdOxford, UKPPEPaediatric and Perinatal Epidemiology0269-5022© 2006 The Authors; Journal Compilation © 2006 Blackwell Publishing Ltd 20062198113Original ArticleRates of caesarean sectionA. P. Betrán et al. Correspondence: Dr Ana P. Betrán, Department of Making Pregnancy Safer, World Health Organisation, 1211 Geneva 27, Switzerland. E-mail: betrana@who.int Caesarean section Rates of caesarean section: analysis of global, regional and national estimates Ana P. Betrán a , Mario Merialdi b , Jeremy A. Lauer c , Wang Bing-Shun d , Jane Thomas e , Paul Van Look b and Marsden Wagner f a Department of Making Pregnancy Safer, b Department of Reproductive Health and Research, c Department of Health Systems Financing, World Health Organisation, Geneva, Switzerland, d Department of Biostatistics, Shanghai Second Medical University, Shanghai, China, e Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford, UK, and f Takoma Park, MD, USA Summary Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. Rates of caesarean section: analysis of global, regional and national estimates. Paediatric and Perinatal Epidemiology 2007; 21: 98–113. Rates of caesarean section are of concern in both developed and developing countries. We set out to estimate the proportion of births by caesarean section (CS) at national, regional and global levels, describe regional and subregional patterns and correlate rates with other reproductive health indicators. We analysed nationally representative data available from surveys or vital registration systems on the proportion of births by CS. We used local non-parametric regression techniques to correlate CS with mater- nal mortality ratio, infant and neonatal mortality rates, and the proportion of births attended by skilled health personnel. Although very unevenly distributed, 15% of births worldwide occur by CS. Latin America and the Caribbean show the highest rate (29.2%), and Africa shows the lowest (3.5%). In developed countries, the proportion of caesarean births is 21.1% whereas in least developed countries only 2% of deliveries are by CS. The analysis suggests a strong inverse association between CS rates and maternal, infant and neonatal mortality in countries with high mortality levels. There is some suggestion of a direct positive association at lower levels of mortality. CS levels may respond primarily to economic determinants. Keywords: caesarean section, geographic variation, maternal mortality, neonatal mortality, infant mortality. Introduction In 1985 the World Health Organisation stated: ‘There is no justification for any region to have caesarean section (CS) rates higher than 10–15%’. 1 Two decades later, however, the optimal rate of births by CS remains controversial in both developing and developed coun- tries. 2–4 In many developed countries, CS rates have increased, and attention has focused on strategies to reduce use due to concern that higher CS rates do not confer additional health gain but may increase mater- nal risks, they have implications for future pregnancies and have resource implications for health services. 5,6 In developing countries, on the other hand, lack of avail- ability of, or access to, maternal health services and the corresponding underuse of CS are part of a web of factors predisposing to high maternal and perinatal mortality. 7 We set out to compile available CS rates by country and to calculate regional and global estimates of the proportion of caesarean deliveries so as to establish an epidemiological basis for global and regional needs assessment and further public health research and action. Furthermore, we correlate CS rates with mater- nal, infant and neonatal mortality, and with the pro- portion of births attended by skilled health personnel to assess ecological associations.