Epidemiology and trends for Caesarean section births in New South Wales, Australia: A population-based study
Open accessAbstract
Background: Caesarean section (CS) rates around the world have been increasing and in Australia have reached 30% of all births. Robson's Ten-Group Classification System (10-group classification) provides a clinically relevant classification of CS rates that provides a useful basis for international comparisons and trend analyses. This study aimed to investigate trends in CS rates in New South Wales (NSW), including trends in the components of the 10-group classification. Methods: We undertook a cross-sectional study using data from the Midwives Data Collection, a state-wide surveillance system that monitors patterns of pregnancy care, services and pregnancy outcomes in New South Wales, Australia. The study population included all women giving birth between 1 st January 1998 and 31st December 2008. Descriptive statistics are presented including age-standardised CS rates, annual percentage change as well as regression analyses. Results: From 1998 to 2008 the CS rate in NSW increased from 19.1 to 29.5 per 100 births. There was a significant average annual increase in primary 4.3% (95%CI 3.0-5.7%) and repeat 4.8% (95% CI 3.9-5.7%) CS rates from 1998 to 2008. After adjusting for maternal and pregnancy factors, the increase in CS delivery over time was maintained. When examining CS rates classified according to the 10-group classification, the greatest contributors to the overall CS rate and the largest annual increases occurred among nulliparae at term having elective CS and multipara having elective repeat CS. Conclusions: Given that the increased CS rate cannot be explained by known and collected maternal or pregnancy characteristics, the increase may be related to differences in clinical decision making or maternal request. Future efforts to reduce the overall CS rate should be focussed on reducing the primary CS rate.
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The growth in cesarean rates cannot be explained by increases in obstetric risk factors, including delayed and multiple infant pregnancy and maternal obesity.
“growth that cannot be explained by increases in obstetric risk factors, including those associated with delayed and multiple infant pregnancy and maternal obesity3–6”
From The relation between cesarean birth and child cognitive development (2017) · cites this paper as [6]
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Christensen, L. F., & Overgaard, C. (2017) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-016-1208-1 · Cited by 28 · see citing works
Kant, A., & Mendiratta, S. (2018) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.18203/2320-1770.ijrcog20184528 · Cited by 26 · see citing works
Johansson, M., Hildingsson, I., & Fenwick, J. (2014) · Women and Birth · doi:10.1016/j.wombi.2014.03.003 · Cited by 25 · see citing works
Trends in cesarean section rates at a large East African referral hospital from 2005-2010
Worjoloh, A., Manongi, R. N., Oneko, O., Hoyo, C., Daltveit, A. K., & Westreich, D. J. (2012) · Open Journal of Obstetrics and Gynecology · doi:10.4236/ojog.2012.23053 · Cited by 25 · see citing works
“The frequency of CS at KCMC does not mirror the rise in CS seen across many other countries [20,21], nor does it reflect the low prevalence of CS in Tanzania and other SSA countries [3,11,22].”
BackgroundXie, M., Lao, T. T.-H., Du, M., Sun, Q., Qu, Z., Ma, J., Song, X., Wang, M.-F., Xu, D., & Ma, R. (2019) · Journal of obstetrics and gynaecology research · doi:10.1111/jog.14048 · Cited by 23 · see citing works
Al-Kadri, H. M., Tamim, H., & Al-Anazi, S. (2015) · International Journal of Women s Health · doi:10.2147/ijwh.s85215 · Cited by 25 · see citing works
“A Chinese publication reported that CS delivery rate rose dramatically from 3.4% to 39.3% between the years 1988 and 2008.19 A similar rise in CS rate was observed in developed countries such as USA20 and Australia.21 Despite the significant increase in CS delivery rate in the studied institution, most of the studied…”
ResultInfluentialDoes a Caesarean section increase the time to a second live birth? A register-based cohort study
O’Neill, S. M., Khashan, A. S., Henriksen, T. B., Kenny, L. C., Kearney, P. M., Mortensen, P. B., Greene, R. A., & Agerbo, E. (2014) · Human Reproduction · doi:10.1093/humrep/deu217 · Cited by 25 · see citing works
“…College Cork, Cork, Ireland 3Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland 4Perinatal Epidemiology Research Unit, Department of Paediatrics, Aarhus University Hospital, Skejby DK – 8200 Aarhus N, Denmark 5Department of Epidemiology and Public Health,…”
BackgroundHomer, C., Besley, K., Bell, J., Davis, D. L., Adams, J., Porteous, A., & Foureur, M. J. (2013) · BMC Pregnancy and Childbirth · doi:10.1186/1471-2393-13-140 · Cited by 24 · see citing works
“One of the greatest contributors to the overall CS rate is a woman having an elective repeat CS (ERCS) [1].”
BackgroundInfluentialDunn, L., Flenady, V., & Kumar, S. (2016) · Journal of Translational Medicine · doi:10.1186/s12967-016-0769-0 · Cited by 23 · see citing works
“Current global caesarean section rates are far in excess of the WHO target rate, exceeding 25 % in the United States [41–43], the United Kingdom [44] and Australia [45].”
BackgroundAbduljabbar, H. S., Bahkali, N. M., AlBasri, S. F., Hachim, E. A., Shoudary, I. H., Dause, W. R., Mira, M. Y., & Khojah, M. (2016) · Saudi Medical Journal · doi:10.15537/smj.2016.7.13259 · Cited by 22 · see citing works
Li, W.-Y., Liabsuetrakul, T., & Stray‐Pedersen, B. (2014) · BMC Pregnancy and Childbirth · doi:10.1186/1471-2393-14-12 · Cited by 21 · see citing works
“Background The rate of cesarean delivery (CD) has been increasing worldwide, and is now higher than the upper limit of 15% recommended by the World Health Organization (WHO) [1-4].”
BackgroundInfluentialRay, A., & Jose, S. (2017) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.18203/2320-1770.ijrcog20170066 · Cited by 20 · see citing works
Zaigham, M., Hellström-Westas, L. K., Domellöf, M., & Andersson, O. (2020) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-020-03253-8 · Cited by 20 · see citing works
Comparative analysis of current diagnostic criteria for gestational diabetes mellitus
Boyadzhieva, M. V., Atanasova, I., Zacharieva, S., Tankova, T. I., & Dimitrova, V. (2012) · Obstetric Medicine · doi:10.1258/om.2011.110073 · Cited by 19 · see citing works
Secular trends in caesarean section rates over 20 years in a regional obstetric unit in Hong Kong
Chung, W., Kong, C., & To, W. W. K. (2017) · Hong Kong Medical Journal · doi:10.12809/hkmj176217 · Cited by 17 · see citing works
Hanson, C., Betrán, A. P., Opondo, C., Mkumbo, E., Manzi, F., Mbaruku, G. M., & Schellenberg, J. (2018) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.15534 · Cited by 17 · see citing works
“Population-based studies from high income countries report levels of 50% and above.(40,41) We also report very low CS rates in small babies.”
BackgroundWhy are caesarean section rates so high in facilities in Mali and Benin?
Schantz, C., Ravit, M., TRAORE, B. A., Aboubakar, M., Goyet, S., de Loenzien, M., & Dumont, A. (2018) · Sexual & Reproductive Healthcare · doi:10.1016/j.srhc.2018.01.001 · Cited by 15 · see citing works
Nippita, T. A. C., Khambalia, A., Seeho, S. K. M., Trevena, J. A., Ja, P., Ford, J. B., Morris, J. M., & Roberts, C. (2015) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.13478 · Cited by 15 · see citing works
Self-citationBirthing outcomes from an Australian HypnoBirthing programme
Phillips-Moore, J. (2012) · British Journal of Midwifery · doi:10.12968/bjom.2012.20.8.558 · Cited by 15 · see citing works
Pregnancy outcome in women with epilepsy in Western China: A prospective hospital based study
He, S., Zhu, H., Qiu, X., Zhu, X., Peng, A., Duan, J., & Chen, L. (2017) · Epilepsy & Behavior · doi:10.1016/j.yebeh.2017.05.034 · Cited by 15 · see citing works
Frequency Rate and Indications of Cesarean Sections at Prince Zaid Bin Al Hussein Hospital - Jordan
Omar, A. A. A., & Anza, S. H. A. (2012) · Cited by 14 · see citing works
Lotfi, F., Lohivash, S., Kavosi, Z., Owjimehr, S., & Bayati, M. (2021) · BMC Research Notes · doi:10.1186/s13104-021-05677-7 · Cited by 12 · see citing works
“In a study carried out in Turkey, two-third of pregnant women preferred to give birth through elective CS, and about 50% of them believed that choosing the type of delivery was the right of any woman [20].”
BackgroundRada, M. P., Ciortea, R., Măluţan, A. M., Prundeanu, I., Doumouchtsis, S. K., Bucuri, C. E., Blaga, L. D., & Mihu, D. (2022) · Journal of Perinatal Medicine · doi:10.1515/jpm-2021-0572 · Cited by 12 · see citing works
Cesarean Section Rate Analysis in University Hospital Tuzla - According to Robson's Classification
Fatušić, J., Hudić, I., Fatušić, Z., ZildzicMoralic, A., & Zivkovic, A. (2016) · Medical Archives · doi:10.5455/medarh.2016.70.213-216 · Cited by 12 · see citing works
Homer, C., Davis, D. L., Mollart, L. J., Turkmani, S., Smith, R., Bullard, M., Leiser, B., & Foureur, M. J. (2021) · Women and Birth · doi:10.1016/j.wombi.2021.05.010 · Cited by 13 · see citing works
Chen, J. S., Ford, J. B., Ampt, A. J., Simpson, J. M., & Roberts, C. L. (2013) · Paediatric and Perinatal Epidemiology · doi:10.1111/ppe.12039 · Cited by 11 · see citing works
Self-citationTrends and predictors of cesarean birth in Singapore, 2005‐2014: A population‐based cohort study
Chi, C., Pang, D., Aris, I. M., Teo, W. T., Li, S. W., Biswas, A., Yong, E., Chong, Y. S., Tan, K. B., & Kramer, M. S. (2018) · Birth · doi:10.1111/birt.12341 · Cited by 12 · see citing works
Malla, R. V., Hamal, C., Neupane, B., & Khatri, R. A. (2018) · Medical Journal of Shree Birendra Hospital · doi:10.3126/mjsbh.v17i2.20290 · Cited by 11 · see citing works
Rising cesarean deliveries in India: medical compulsions or convenience of the affluent?
Kumar, R., & Lakhtakia, S. (2020) · Health Care For Women International · doi:10.1080/07399332.2020.1798963 · Cited by 11 · see citing works
“Notwithstanding evidence against cesarean sections, the increasing cesarean sections are becoming a cause of concern in developed as well as developing countries (Betr an et al. 2016; Solanke, 2018; Stavrou et al., 2011: Roberts & Nippita, 2015; WHO, 2015).”
BackgroundSingh, D., & Kaur, L. (2017) · Journal of Clinical Ultrasound · doi:10.1002/jcu.22485 · Cited by 11 · see citing works
“There has been a rising trend in the incidence of cesarean section in recent times.(1) The rate of repeat cesarean section in the United States is 91%.”
BackgroundEthnicity and risk of caesarean section in a term, nulliparous N ew Z ealand obstetric cohort
Anderson, N. H., Sadler, L. C., Stewart, A. W., Fyfe, E. M., & McCowan, L. M. E. (2013) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.12036 · Cited by 10 · see citing works
Predictors of cesarean delivery in women undergoing labor induction with a Foley balloon
Delaney, S. S., Shaffer, B. L., Cheng, Y. W., Vargas, J., Sparks, T. N., Paul, K. J., & Caughey, A. B. (2014) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.3109/14767058.2014.944154 · Cited by 10 · see citing works
“…attempts at vaginal births after previous cesarean, more pregnancies with multiple gestations, higher proportion of women with medical complications of pregnancy, the rise in obesity, cesarean delivery (CD) by maternal request, medical-legal pressures and increased rates of labor induction [1–3].”
Prosser, S. J., Miller, Y. D., Thompson, R., & Redshaw, M. (2014) · BMC Pregnancy and Childbirth · doi:10.1186/1471-2393-14-149 · Cited by 10 · see citing works
“Unlike many previous studies that have used routinely collected data (such as hospital records or birth registrations) to examine rates of caesarean section [14,18,23], our findings are based on data reported by women and thus hinge on the reliability of this information.”
BackgroundResultPatterson, J. A., Francis, S., & Ford, J. B. (2016) · Maternal and Child Health Journal · doi:10.1007/s10995-016-1992-2 · Cited by 9 · see citing works
Self-citationQualitative website analysis of information on birth after caesarean section
Peddie, V. L., Whitelaw, N., Cumming, G., Bhattacharya, S., & Black, M. E. (2015) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-015-0614-0 · Cited by 8 · see citing works
Biró, M. A., Knight, M., Wallace, E. M., Papacostas, K., & East, C. E. (2013) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.12147 · Cited by 8 · see citing works
Ziller, V., Taskan, S., Sechet, I., & Kostev, K. (2016) · Geburtshilfe und Frauenheilkunde · doi:10.1055/s-0036-1593189 · Cited by 8 · see citing works
Thompson, F., Dempsey, K., & Mishra, G. D. (2016) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.13881 · Cited by 7 · see citing works
Murugesan, K., & Rengaraj, S. (2021) · International Journal of Advanced Medical and Health Research · doi:10.4103/ijamr.ijamr_152_21 · Cited by 7 · see citing works
A Study and Analysis of Cesarean Sections by Robson\'s Ten Group Classification System
Nimbkar, A. R., Panchbudhe, S. A., & Deshmukh, P. (2022) · Journal of South Asian Federation of Obstetrics and Gynaecology · doi:10.5005/jp-journals-10006-2084 · Cited by 7 · see citing works
Bonvicini, L., Candela, S., Evangelista, A., Bertani, D., Casoli, M., Lusvardi, A., Messori, A., & Rossi, P. G. (2014) · BMC Pregnancy and Childbirth · doi:10.1186/1471-2393-14-72 · Cited by 7 · see citing works
“This classification has been shown to be useful for monitoring CS rates and their components, allowing risk stratification [18-22].”
MethodMaso, G., Piccoli, M., Montico, M., Monasta, L., Ronfani, L., Parolin, S., Gigli, C., Domini, D., Fiscella, C., Casarsa, S., et al. (2013) · BioMed Research International · doi:10.1155/2013/786563 · Cited by 7 · see citing works
“Details on management of induction of labour were not available, but this finding might be useful to audit in each center marginal indications of induction, implementing an effective management to reduce unnecessary interventions [11, 12, 14].”
BackgroundReducing caesarean section rates – No easy task
Roberts, C. L., Algert, C. S., Todd, A. L., & Morris, J. M. (2013) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.12065 · Cited by 7 · see citing works
Self-citationHarpham, M. E., Nassar, N., Leung, S., Lainchbury, A., & Shand, A. (2018) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2018.1519537 · Cited by 7 · see citing works
Self-citationKhumalo, M., Leonard, T., Scribante, J., & Perrie, H. (2022) · International Journal of Women s Health · doi:10.2147/ijwh.s382518 · Cited by 6 · see citing works
Owen, K. B., Ibiebele, I., Simpson, J. M., Morton, R. L., Morris, J. M., & Torvaldsen, S. (2021) · Australian Health Review · doi:10.1071/ah20237 · Cited by 6 · see citing works
Self-citationHeera Shenoy, T., Shenoy, S. T., Anaswara, T., & Remash, K. (2019) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.18203/2320-1770.ijrcog20191956 · Cited by 6 · see citing works
“Therefore, induction of labour protocols needs to strictly adhered in order to reduce the burden of unnecessary surgical interventions.(26) In addition, encouraging vaginal birth after CS (VBAC) and deconstructing the stigma of “once a caesarean, always a caesarean has to be emphasised.”
BackgroundMekonnen, A. B., Teale, G. R., Vasilevski, V., & Sweet, L. P. (2025) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.15054 · Cited by 7 · see citing works
Análisis de la vía del parto en los diferentes escenarios asistenciales en Uruguay
Briozzo, L., Tomasso, G., & Colistro, V. (2019) · Revista Médica del Uruguay · doi:10.29193/rmu.35.2.1 · Cited by 5 · see citing works
“Stavrou E, Ford J, Shand A, Morris J, Roberts C. Epidemiology and trends for caesarean section births in New South Wales, Australia: a population-based study.”
BackgroundLabor and Delivery Outcomes in Australian Mothers after Kidney Transplantation
Tangirala, N., Hewawasam, E., Davies, C. E., Poprzeczny, A. J., Sullivan, E., McDonald, S. P., & Jesudason, S. (2024) · Journal of the American Society of Nephrology · doi:10.1681/asn.0000000559 · Cited by 4 · see citing works
Einarsdóttir, K., Ball, S. J., Pereira, G. F., Griffin, C., Jacoby, P., de Klerk, N. H., Leonard, H., & Stanley, F. J. (2015) · Paediatric and Perinatal Epidemiology · doi:10.1111/ppe.12202 · Cited by 4 · see citing works
Identifying better systems design in Australian maternity care: a Boundary Critique analysis
Donnellan-Fernandez, R. E., Newman, L., Reiger, K. M., & Tracy, S. (2013) · Health Systems · doi:10.1057/hs.2013.7 · Cited by 4 · see citing works
“…breastfeeding rates and associated increases in allergies, asthma, childhood obesity and diabetes, as well as high rates of perinatal depression (Donnellan-Fernandez, 2011b; Lynch, 2011; Stavrou et al, 2011; AIHW National Perinatal Epidemiology and Statistics Unit and AIHW, 2013; Hyde et al, 2012).”
BackgroundPractice of the Caesarean Section in Four Maternities in Benin Using Robson Classification
Hounkpatin, B. I. B., Aboubakar, M., Dangbemey, P., Tognifode, V., Schantz, C., Dumont, A., & René-Perrin, R.-X. (2020) · Open Journal of Obstetrics and Gynecology · doi:10.4236/ojog.2020.101006 · Cited by 4 · see citing works
“The same trend was found in a study in Switzerland [22] over a period of 11 years and by WHO in two multi-country surveys on maternal and neonatal health published in 2008 and 2011 [4].”
BackgroundResultInfluentialBrown, H. K., Hill, J., & Natale, R. (2014) · Journal of Obstetrics and Gynaecology Canada · doi:10.1016/s1701-2163(15)30537-5 · Cited by 4 · see citing works
Ghaedmohammadi, Z., Anaraki, A. N., Khajeian, A., Khajehian, M. M., & Ostovar, A. (2015) · Eastern Mediterranean Health Journal · doi:10.26719/2015.21.4.266 · Cited by 4 · see citing works
Is current rising trends of cesarean section –justified ?
Preetkamal, Kaur, H., & Nagpal, M. (2017) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.18203/2320-1770.ijrcog20170547 · Cited by 4 · see citing works
Fatima, S. S., Zeb, L., Shafqat, T., & Qazi, Q. (2022) · American Journal of Health Medicine and Nursing Practice · doi:10.47672/ajhmn.1001 · Cited by 3 · see citing works
Effect of Delivery Modes on Hearing Screening Results
Kepekçi, A. H. (2019) · Global Journal of Otolaryngology · doi:10.19080/gjo.2019.20.556045 · Cited by 3 · see citing works
A prospective comparative study of cesarean section in multiparous and primiparous women
SURESH, D. Y. A., & Suresh, Y. (2017) · International Journal of Pharma and Bio Sciences · doi:10.22376/ijpbs.2017.8.3.b890-895 · Cited by 2 · see citing works
Ouattara, A., Kiemtoré, S., Ouédraogo, I., Sawadogo, Y. A., Millogo, T., Bikienga, M., Kouanda, S., & Ouédraogo, C. M. R. (2021) · Open Journal of Obstetrics and Gynecology · doi:10.4236/ojog.2021.112021 · Cited by 2 · see citing works
Factors Associated with Caesarean Section Among Women Delivered at Kirehe District Hospital
Habiyakare, C., & Rutayisire, E. (2022) · Journal of Public Health International · doi:10.14302/issn.2641-4538.jphi-22-4325 · Cited by 2 · see citing works
- Authors
- Stavrou, E. P., Ford, J. B., Shand, A. W., Morris, J. M., & Roberts, C. L.
- Affiliations
- The University of Sydney (AU)
- Corresponding author
- Ford, Jane B
- Venue
- BMC Pregnancy and Childbirth
- Published
- 2011-01-20
- Volume
- 11
- Issue
- 1
- Pages
- 8-8
- ISSN
- 1471-2393 (ISSN-L)
- PMC
- PMC3037931
- OpenAlex
- W2085744854
- Cited by
- 137
- References
- 35
- Citations by year
- 2026: 3 · 2025: 1 · 2024: 3 · 2023: 1 · 2022: 8 · 2021: 8 · 2020: 11 · 2019: 9 · 2018: 9 · 2017: 15 · 2016: 13 · 2015: 10 · 2014: 13 · 2013: 18 · 2012: 15
- FWCI
- 18.95
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Pregnancy and Childbirth (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- National Health and Medical Research Council (573122)
- Topics
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
- Keywords
- cesarean section rate, primary cesarean section, repeat cesarean section, elective cesarean section, nulliparous women, multiparous women, term pregnancy, clinical decision-making, New South Wales
- MeSH terms
- Adolescent, Adult, Cesarean Section, Child, Cross-Sectional Studies, Female, Humans, Maternal Age, Middle Aged, New South Wales, Parity, Pregnancy, Regression Analysis, Elective Surgical Procedures, Cesarean Section, Repeat, Young Adult
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