A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

BJOG. 2016 Feb;123(3):427-36. doi: 10.1111/1471-0528.13509. Epub 2015 Aug 10.


Objective: To generate a global reference for caesarean section (CS) rates at health facilities.

Design: Cross-sectional study.

Setting: Health facilities from 43 countries.

Population/sample: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing.

Methods: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models.

Main outcome measures: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract: The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Keywords: Benchmarking; caesarean delivery rates; caesarean section rates; logistic regression.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cesarean Section / statistics & numerical data*
  • Cross-Sectional Studies
  • Female
  • Humans
  • Internationality
  • Models, Statistical*
  • Pregnancy
  • Reference Values