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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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“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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“This is in contrast to the USA where increases appear to be similar across all gestational age categories [4].”
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“Previous research has highlighted potential reasons for the increasing CS rate including maternal request [14,15] and associated ethical and litigious issues, [15-17] obesity [18,19] and increasing maternal age [20-22].”
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“The decision to perform a primary CS has important implications for maternal morbidity in the current pregnancy and mode of delivery and maternal morbidity in subsequent pregnancies [11-13].”
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“Such research has demonstrated that primary CS rates appear to be unrelated to the medical risk profile of mothers, and change in a similar pattern to the overall CS rates [23].”
Background
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“The proportion of Caesarean section births has also increased (Bailit et al., 2004; Villar et al., 2006; Barber et al., 2011; Stavrou et al., 2011), and women who have only ever had a Caesarean section are often viewed as nulliparous with respect to IUC placement.”
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“5% in Cohort 2, table 1) and makes a continued and stable contribution to caesarean section rates.(6) 31 Decreasing breech presentation as a means of reducing caesarean section rates should not be overlooked, as external cephalic version is evidence-based and likely to be achievable with training and education for bot…”
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“…of primary cesarean section is consistently higher (Betrán et al., 2007; Declercq et al., 2011; Menacker & Hamilton, 2010) than the 10-15% calculated as appropriate (WHO, 2009), suggesting factors other than clinical indications influence the deliveries (Bragg et al., 2010; Stavrou et al., 2011).”
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“[11,24,25] The changing pattern towards fewer births commencing spontaneously and increased use of caesarean section has in itself potential adverse health consequences for both mothers and infants.”
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ResultTrends in Cesarean Delivery: Rate and Indications
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“The increasing trend of CDMR was also observed in other countries [27,28].”
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Atuheire, E. B., Opio, D. N., Kadobera, D., Ario, A. R., Matovu, J. K. B., Harris, J. R., Bulage, L., Nakiganda, B., Tumwesigye, N. M., Zhu, B., et al. (2019) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-019-2279-6 · Cited by 35
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“8%) CS rates from 1998 to 2008 in Australia [12].”
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“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].”
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“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
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“…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,…”
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“One of the greatest contributors to the overall CS rate is a woman having an elective repeat CS (ERCS) [1].”
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“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].”
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“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].”
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“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?
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“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].”
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“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).”
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“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
Predictors of cesarean delivery in women undergoing labor induction with a Foley balloon
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“…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
“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
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
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
Ziller, V., Taskan, S., Sechet, I., & Kostev, K. (2016) · Geburtshilfe und Frauenheilkunde · doi:10.1055/s-0036-1593189 · Cited by 8
Thompson, F., Dempsey, K., & Mishra, G. D. (2016) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.13881 · Cited by 7
Murugesan, K., & Rengaraj, S. (2021) · International Journal of Advanced Medical and Health Research · doi:10.4103/ijamr.ijamr_152_21 · Cited by 7
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
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
“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
“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
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
Self-citationKhumalo, M., Leonard, T., Scribante, J., & Perrie, H. (2022) · International Journal of Women s Health · doi:10.2147/ijwh.s382518 · Cited by 6
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
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
“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
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 8
“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
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
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
“…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
“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
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
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
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
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
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
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
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
Metadata
- 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 › Anesthesiology and Pain Medicine › 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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