Guideline / position statementindependent cross-checkfull text checked★ key study I-ORG-110 in-depth review
WHO statement on caesarean section rates
WHO Statement on Caesarean Section Rates.
Overview
Betran AP et al.. BJOG 2016 · PMID 26681211 · DOI 10.1111/1471-0528.13526
Caesareans save lives when medically needed, but rates above about 10% in a population do not further reduce deaths.
Does the study support the specific claim? Partly · Methodological quality: moderate
Plain-language summary
Study explained simply
- What did the researchers want to find out?
State WHO's position on caesarean rates
- How was the study done?
Policy statement based on systematic review and ecological analysis
- How many people, animals or samples were studied?
Population data worldwide
- What was actually found?
No mortality gain above about 10% at population level; necessary CS prevents deaths
- How large was the observed effect?
n/a
- What do the results mean in everyday life?
Caesarean should be done when needed, not routinely
- What are the study's limitations?
Ecological data only
- What does it say about Elawady's specific claim?
Supports caution about overuse, refutes refusing all caesareans
- Do the results apply to Germany and Europe?
Applies in Europe and Egypt
- What can explicitly not be concluded from this study?
Cannot say what is right for an individual woman
Scientific in-depth review
1. Full reference
- Authors
- Betran AP et al.
- Journal
- BJOG
- Year
- 2016
- Identifier
- PMID 26681211 DOI 10.1111/1471-0528.13526
- Verification
- verified – PubMed efetch 2026-10-26; Crossref works API 2026-10-26
- Retracted
- no
- Corrections
- none
- Extent checked
- full text
- Conflicts of interest and funding
WHO working group statement; no commercial funding stated.
2. Research question
Current WHO position on caesarean section (CS) rates at population and facility level.
3. Study design and population
- Study design
- Guideline / position statement – WHO policy statement summary (commentary in BJOG by the WHO Working Group), based on a systematic review and ecological analysis
- Population
Women giving birth worldwide (population-level analyses)
- Country
Global (WHO)
- Period
WHO meeting October 2014; published 2016
- Sample size
Not applicable
- Inclusion and exclusion criteria
Not applicable
4. Methods and endpoints
- Exposure / intervention
Population caesarean section rate
- Comparator
n/a
- Endpoints
Maternal and newborn mortality (population level)
- Statistical methods
Summary of systematic review and ecological analysis
5. Actual results
- Results
At population level, CS rates higher than 10% were not associated with reductions in maternal and newborn mortality. When medically justified, CS can prevent maternal and perinatal mortality and morbidity; there is no evidence of benefit where it is not required; CS carries short- and long-term risks. Inadequate access to timely CS may result in perinatal asphyxia, stillbirth, uterine rupture or obstetric fistula. CS should be undertaken when medically necessary and efforts should focus on providing CS to all women in need rather than achieving a specific rate. Effects on morbidity and other outcomes could not be determined at population level. WHO endorses the Robson classification for monitoring.
- Absolute risks
Not applicable
- Authors' conclusion
CS should be provided to all women in need; the Robson classification should be used to monitor CS rates.
6. Strengths
- Authoritative WHO position
- Based on systematic review and ecological analysis
7. Weaknesses
- Ecological, population-level data
- No individual-level outcomes
8. Risk of bias
- Orienting tool
- none applicable
- Type of assessment
- simplified assessment (abstract only)
- Full formal assessment
- no
- Overall risk of bias
- not assessable
- Rationale
Policy statement; underlying ecological analyses at risk of ecological fallacy.
9. Assessment of the statistical interpretation
Ecological associations; cannot be applied to individual decisions.
10. Relevance to the specific claim
Speaks directly to both halves of the claim: CS overuse is a real concern, but medically necessary CS saves lives.
11. Independent contrary findings
Molina 2015 (JAMA, not added) found mortality benefit up to about 19 per 100 live births at country level.
12. Transferability to Germany and Europe
Global; applies to Europe and Egypt.
13. Overall methodological judgement
Supports concern about unnecessary caesareans; directly contradicts being 'against any operation including caesarean section'.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | moderate |
| Risk of bias | not assessable |
| Precision of results | not applicable |
| Directness | direct |
| Reproducibility | partly replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
Facility-level optimal rates by Robson group.