Trend of Cesarean Section Rates and Correlations with Adverse Maternal and Neonatal Outcomes: A Secondary Analysis of Thai Universal Coverage Scheme Data
04 May 2019
16 July 2019
30 October 2019 (online)
Objectives The main purpose of this article is to estimate the trend and projection of cesarean section rates (CSRs) and explore correlations between CSRs with adverse maternal and perinatal outcomes, namely maternal mortality ratios (MMRs), rates of postpartum hemorrhage (PPH), neonatal mortality rates (NMRs), and birth asphyxia per 1,000 live births across all regions of Thailand.
Study design A secondary analysis of the hospital-based database of pregnant women and newborns under the Thai Universal Coverage Scheme between January 2009 and December 2017 was conducted.
Results Overall annual CSR significantly increased from 23.2% in 2009 to 32.5% in 2017. With the same rate of increase, the CSR of 59.1% was projected by the year 2030 that could be reduced to 30.0% if an annual rate of CS reduction of 1% was assumed using Joinpoint regression. The increasing CSRs were significantly correlated with higher MMRs (r= 0.20, p = 0.03) and birth asphyxia (r= 0.39, p < 0.001). The correlation trends were similar when the analyses were stratified by year in the majority of years. Overall correlations between CSRs and rates of PPH or NMRs were not statistically significant.
Conclusion CSRs in Thailand continuously increased and were correlated with adverse maternal and perinatal outcomes. More effort at the national level to reduce unnecessary CS is urgently required.
Keywordscesarean section rates - maternal and perinatal outcomes - trend - Universal Coverage Scheme
Disclosure of Any Source of Financial Support or Funding
All authors declare no conflict of interest. No funding sources were involved in this secondary analysis.
Contributions to Authorship
All authors participated in the concept of the study. TL obtained the necessary permissions for data utilization, and participated in data analysis and interpretation, and drafting the manuscript. JS participated in data analysis and interpretation. JT participated in data extraction and management. PL helped with data interpretation. All authors reviewed the draft of the manuscript and approved the final manuscript for submission.
Details of Ethical Approval
A study protocol of secondary analysis was approved by the Institute Ethics Committee of the Faculty of Medicine, Prince of Songkla University with the reference number of REC 60–439–18–1 (Exempt determination), date of approval on 27 November 2017.
- 1 Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? whose benefits?. Am J Perinatol 2012; 29 (01) 7-18
- 2 World Health Organization. WHO statement on caesarean section rates. Geneva: World Health Organization; 2015
- 3 Vogel JP, Betrán AP, Vindevoghel N. , et al; WHO Multi-Country Survey on Maternal and Newborn Health Research Network. Use of the Robson classification to assess caesarean section trends in 21 countries: a secondary analysis of two WHO multicountry surveys. Lancet Glob Health 2015; 3 (05) e260-e270
- 4 World Health Organization. World Health Statistics 2010. Geneva: World Health Organization; 2010
- 5 National Statistical Office and United Nations Children's Fund. Thailand multiple indicator cluster survey 2015–2016, final report. Bangkok: National Statistical Office and United Nations Children's Fund; 2016
- 6 Souza JP, Gülmezoglu A, Lumbiganon P. , et al; WHO Global Survey on Maternal and Perinatal Health Research Group. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO global survey on maternal and perinatal health. BMC Med 2010; 8: 71
- 7 Ye J, Zhang J, Mikolajczyk R, Torloni MR, Gülmezoglu AM, Betran AP. Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data. BJOG 2016; 123 (05) 745-753
- 8 Villar J, Valladares E, Wojdyla D. , et al; WHO 2005 global survey on maternal and perinatal health research group. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006; 367 (9525): 1819-1829
- 9 Cristina Rossi A, Mullin P. The etiology of maternal mortality in developed countries: a systematic review of literature. Arch Gynecol Obstet 2012; 285 (06) 1499-1503
- 10 Kupari M, Talola N, Luukkaala T, Tihtonen K. Does an increased cesarean section rate improve neonatal outcome in term pregnancies?. Arch Gynecol Obstet 2016; 294 (01) 41-46
- 11 Sakunphanit T. Universal health care coverage through pluralistic approaches: experience from Thailand. Bangkok: International Labour Organization; 2008
- 12 Tangcharoensathien V, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, Mills A. Health systems development in Thailand: a solid platform for successful implementation of universal health coverage. Lancet 2018; 391 (10126): 1205-1223
- 13 Paek SC, Meemon N, Wan TTH. Thailand's Universal Coverage Scheme and its impact on health-seeking behavior. Springerplus 2016; 5 (01) 1952
- 14 Kongsri S, Limwattananon S, Sirilak S, Prakongsai P, Tangcharoensathien V. Equity of access to and utilization of reproductive health services in Thailand: national Reproductive Health Survey data, 2006 and 2009. Reprod Health Matters 2011; 19 (37) 86-97
- 15 Patcharanarumol W, Panichkriangkrai W, Sommanuttaweechai A, Hanson K, Wanwong Y, Tangcharoensathien V. Strategic purchasing and health system efficiency: a comparison of two financing schemes in Thailand. PLoS One 2018; 13 (04) e0195179
- 16 Kim MK, Lee SM, Bae S-H. , et al. Socioeconomic status can affect pregnancy outcomes and complications, even with a universal healthcare system. Int J Equity Health 2018; 17 (01) 2
- 17 Teerawattananon Y, Tangcharoensathien V. Designing a reproductive health services package in the universal health insurance scheme in Thailand: match and mismatch of need, demand and supply. Health Policy Plan 2004; 19 (Suppl. 01) i31-i39
- 18 Rosa W. , Ed. Transforming Our World: The 2030 Agenda for Sustainable Development. In: A New Era in Global Health [Internet]. New York, NY: Springer Publishing Company; 2017. [cited 2018 Nov 30]. Available from: http://connect.springerpub.com/lookup/doi/10.1891/9780826190123.ap02
- 19 Charoenboon C, Srisupundit K, Tongsong T. Rise in cesarean section rate over a 20-year period in a public sector hospital in northern Thailand. Arch Gynecol Obstet 2013; 287 (01) 47-52
- 20 Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990-2014. PLoS One 2016; 11 (02) e0148343
- 21 Giang HTN, Ulrich S, Tran HT, Bechtold-Dalla Pozza S. Monitoring and interventions are needed to reduce the very high caesarean section rates in Vietnam. Acta Paediatr 2018; 107 (12) 2109-2114
- 22 Tapia V, Betran AP, Gonzales GF. Caesarean section in Peru: analysis of trends using the Robson classification system. PLOS ONE 2016; 11 (02) e0148138
- 23 Yamasmit W, Chaithongwongwatthana S. Attitude and preference of Thai pregnant women towards mode of delivery. J Med Assoc Thai 2012; 95 (05) 619-624
- 24 Kovavisarach E, Ruttanapan K. Self-preferred route of delivery of Thai obstetricians and gynecologists. J Med Assoc Thai 2016; 99 (Suppl. 02) S84-S90
- 25 Mariani GL, Vain NE. The rising incidence and impact of non-medically indicated pre-labour cesarean section in Latin America. Semin Fetal Neonatal Med 2019; 24 (01) 11-17
- 26 Santas G, Santas F. Trends of caesarean section rates in Turkey. J Obstet Gynaecol 2018; 38 (05) 658-662
- 27 Norum J, Svee TE. Caesarean section rates and activity-based funding in Northern Norway: a model-based study using the World Health Organization's recommendation. Obstet Gynecol Int 2018; 2018: 6764258
- 28 Maeda E, Ishihara O, Tomio J. , et al. Cesarean section rates and local resources for perinatal care in Japan: a nationwide ecological study using the national database of health insurance claims. J Obstet Gynaecol Res 2018; 44 (02) 208-216
- 29 Chen I, Opiyo N, Tavender E. , et al. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Effective Practice and Organisation of Care Group, editor. Cochrane Database Syst Rev [Internet]. 2018 [cited 2018 Oct 10]; Available from: http://doi.wiley.com/10.1002/14651858.CD005528.pub3
- 30 Lesieur E, Blanc J, Loundou A. , et al. Teaching and performing audits on caesarean delivery reduce the caesarean delivery rate. PLoS One 2018; 13 (08) e0202475
- 31 World Health Organization, UNICEF, UNFPA, World Bank Group and the United Nations Population Division Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division [Internet]. 2015 [cited 2018 Oct 16]. Available from: http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/
- 32 O'Dwyer V, Hogan JL, Farah N, Kennelly MM, Fitzpatrick C, Turner MJ. Maternal mortality and the rising cesarean rate. Int J Gynaecol Obstet 2012; 116 (02) 162-164
- 33 Ford JB, Roberts CL, Simpson JM, Vaughan J, Cameron CA. Increased postpartum hemorrhage rates in Australia. Int J Gynaecol Obstet 2007; 98 (03) 237-243
- 34 Mehrabadi A, Liu S, Bartholomew S. , et al; Maternal Health Study Group of the Canadian Perinatal Surveillance System (Public Health Agency of Canada). Temporal trends in postpartum hemorrhage and severe postpartum hemorrhage in Canada from 2003 to 2010. J Obstet Gynaecol Can 2014; 36 (01) 21-33
- 35 Rueangchainikhom W, Srisuwan S, Prommas S, Sarapak S. Risk factors for primary postpartum hemorrhage in Bhumibol Adulyadej Hospital. J Med Assoc Thai 2009; 92 (12) 1586-1590
- 36 Ngwenya S. Postpartum hemorrhage: incidence, risk factors, and outcomes in a low-resource setting. Int J Womens Health 2016; 8: 647-650
- 37 Al-Zirqi I, Vangen S, Forsén L, Stray-Pedersen B. Effects of onset of labor and mode of delivery on severe postpartum hemorrhage. Am J Obstet Gynecol 2009; 201 (03) 273.e1-273.e9
- 38 Lumbiganon P, Laopaiboon M, Gülmezoglu AM. , et al; World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet 2010; 375 (9713): 490-499
- 39 Zhao Y, Zhang J, Zamora J. , et al. Increases in caesarean delivery rates and change of perinatal outcomes in low- and middle-income countries: a hospital-level analysis of two WHO surveys. Paediatr Perinat Epidemiol 2017; 31 (04) 251-262
- 40 Chumpathong S, Sirithanetbhol S, Salakij B, Visalyaputra S, Parakkamodom S, Wataganara T. Maternal and neonatal outcomes in women with severe pre-eclampsia undergoing cesarean section: a 10-year retrospective study from a single tertiary care center: anesthetic point of view. J Matern Fetal Neonatal Med 2016; 29 (24) 4096-4100