Cesarean Section: Short- and Long-Term Consequences

Abstract

Cesarean section is invasive procedure that performed in the women abdomen and uterus when vaginal delivery poses risk to the mother and fetus. There are different types of cesarean section based on timing and incision site or section and position. While cesarean sections can be lifesaving for both mothers and babies, they are not without their risks and consequences. Cesarean sections are performed for two main reasons: to save the life of the mother or fetus in urgent situations, and electively for non-emergency reasons. Each type of cesarean section has its own set of short-term and long-term consequences. The effect is broadly classified as maternal and neonatal/infant related. Despite those risks, the rate cesarean section increased steadily due to the advanced health care system, technology, and maternal requests. It is crucial for women and healthcare professionals to be well-informed about the potential short- and long-term consequences of cesarean sections. While this procedure can be a valuable tool for safe childbirth, it is essential to carefully weigh the risks and benefits before deciding on this route of delivery.

1. Introduction

Cesarean section (CS) is invasive procedure that performed in the women abdomen and uterus when vaginal delivery poses risk to the mother and fetus. After delivering the baby, the medical professional meticulously sutures the uterus and abdomen closed using absorbable sutures, which will dissolve naturally over time [1, 2, 3]. Caesarean sections can be planned in advance (elective) or performed unexpectedly during labor (emergency) depending on the health of the mother and baby. There’s another key distinction in how the surgeon accesses the uterus. The preferred method is a lower segment caesarean section (LSCS) which utilizes a horizontal cut in the lower part of the uterus. This offers a faster recovery and fewer complications. In less common situations, a vertical incision in the upper part of the uterus (classical caesarean section) might be necessary. Even within the LSCS category, there are slight variations in incision placement depending on factors like available space or delivering multiples. These variations include the standard Pfannenstiel incision, the Maylard modification, the Kerr incision used in some emergencies, and the Joel-Cohen incision for specific situations.

The exact origin of the CS remains obscure with various legends and myths across cultures suggesting abdominal deliveries. In Greek mythology, the birth of Asclepius, the god of healing, involved Apollo, Bacchus, and Jupiter extracting him from his mother’s womb through an abdominal incision [4]. Another prominent narrative associates the term “cesarean” with Julius Caesar’s birth through an abdominal incision, although his mother’s survival is disputed. Some scholars propose the term originates from his name [5]. Additionally, the Latin verb “caedare” or “caesones” refers to individuals born through postmortem cesarean sections, while the Roman law Lex Regis or Lex Cesare mandated the abdominal delivery of infants following maternal death to enable separate burial [6, 7, 8]. However, most evidence suggests that the first documented successful cesarean section occurred in Switzerland in 1500. Jacob Nufer, a sow gelder, performed the operation on his wife [9].

Since its introduction, CS has increased tremendously and become one of the most common procedures [10, 11, 12, 13]. Globally, a recent report indicates that cesarean section rates have risen from around 7% in 1990 to 21%. Projections estimate that the global CS rate will reach 29% by 2030, translating to approximately 38 million caesareans performed annually. This rate is expected to vary significantly by region, ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia [14, 15, 16]. There is also a great gap between higher- and lower-resource settings. The rate of cesarean section is only 5% in sub-Saharan Africa due to different several factors such as the level of advancement in the healthcare system (both in skilled personnel and technology), focus on saving the lives of both mother and fetus, and awareness and literacy levels. On the contrary, it is very high in Latin America and the Caribbean, which accounted 43% or four in 10 of all births. Cesarean section rates have surpassed those of vaginal deliveries in five countries, namely Dominican Republic, Brazil, Cyprus, Egypt, and Turkey [14, 17]. Evidence also stipulated that the rate of cesarean delivery was higher at the private and tertiary care hospitals [18, 19].

Available data from 172 countries show that the proportion of CS varied 0.5% in South Sudan and 58.1% in the Dominican Republic. At the regional level, the lowest proportion of CS was observed in the WHO Africa region with an average of 7%. Conversely, the highest proportion was found in the Americas with an average of 31.8%. Notably, 90 countries (52%) had CS proportions less than or equal to 19%, while 82 countries (48%) had proportions exceeding the target range (Figure 1) [20].

Figure 1.

Global distribution of cesarean birth proportions. CS, cesarean section. Source: Hoxha and Fink [20].

A study similarly found that CS rates have changed globally, regionally, and sub-regionally between 1990 and 2018. This data was based on information from 159 countries, representing 96.9% of live births worldwide. Due to insufficient data coverage (10.5%), changes in CS rates for Melanesia, Micronesia, and Polynesia were not calculated (Table 1 and Figure 2) [16].

Figure 2.

Trends (1990–2018) and projections (2030) in global, regional, and subregional estimates of CS rates. Solid lines are trend estimates and dotted lines are projections. (A) World; (B) Africa; (C) Asia; (D) Americas; (E) Europe; (F) Oceania. Rates and projections for the Melanesia, Micronesia, and Polynesia were not calculated due to the low coverage of data in this subregion of Oceania. Source: Betran et al. [16].

Region/subregion*	N	Coverage (%)	Rate changes (%, 95% Cl)
			1990–2000	2000–2010	2010–2018	1990–2018
Africa	48	94.4	1.5 (0.7 to 2.4)	3.7 (1.5 to 5.8)	2.3 (1.3 to 3.3)	7.5 (3.7 to 11.3)
Northern Africa	5	97.4	6.2 (0.4 to 12.0)	16.2 (−2.2 to 34.7)	9.1 (3.3 to 14.8)	31.5 (2.6 to 60.5)
Sub-Saharan Africa	43	93.9	0.8 (0.3 to 1.3)	1.6 (1.1 to 2.2)	1.2 (0.8 to 1.6)	3.6 (2.4 to 4.8)
Asia	42	98.4	6.2 (5.1 to 7.2)	10.6 (8.1 to 13.1)	7.7 (5.9 to 9.6)	24.5 (19.5 to 29.4)
Central Asia	5	100	1.8 (0.3 to 3.2)	4.8 (2.3 to 7.2)	3.4 (2.1 to 4.8)	9.9 (5.2 to 14.6)
Eastern Asia	5	100	8.7 (5.4 to 11.9)	20.9 (11.3 to 30.4)	15.3 (9.0 to 21.6)	44.9 (28.8 to 60.9)
South-eastern Asia	8	90.1	4.5 (1.7 to 7.3)	6.7 (4.1 to 9.3)	4.5 (1.5 to 7.6)	15.8 (8.7 to 22.8)
Southern Asia	8	100	4.8 (3.3 to 6.3)	6.7 (4.2 to 9.3)	4.9 (1.9 to 7.9)	16.4 (10.9 to 21.9)
Western Asia	16	99.0	12.1 (9.0 to 15.2)	12.9 (7.2 to 18.6)	9.7 (7.3 to 12.0)	34.7 (24.0 to 45.3)
Europe	38	98.5	7.1 (6.1 to 8.1)	7.3 (5.9 to 8.7)	4.5 (3.5 to 5.5)	18.9 (16.1 to 21.8)
Eastern Europe	10	100	7.9 (5.9 to 9.8)	9.7 (6.8 to 12.7)	6.3 (4.6 to 7.9)	23.9 (17.7 to 30.0)
Northern Europe	10	100	7.4 (5.4 to 9.5)	3.8 (2.3 to 5.2)	2.8 (1.0 to 4.5)	14.0 (9.8 to 18.1)
Southern Europe	11	92.4	9.3 (7.3 to 11.2)	6.1 (3.3 to 8.9)	5.4 (3.1 to 7.7)	20.7 (16.2 to 25.3)
Western Europe	7	100	4.3 (2.9 to 5.7)	6.6 (3.3 to 9.9)	2.1 (0.1 to 4.1)	13.0 (7.1 to 18.9)
Americas	25	96.0	5.6 (3.1 to 8.2)	11.2 (9.5 to 12.8)	3.5 (1.7 to 5.3)	20.3 (15.1 to 25.5)
Latin America and the Caribbean	23	94.3	7.8 (5.2 to 10.4)	11.8 (9.9 to 13.8)	5.2 (3.5 to 6.9)	24.9 (19.5 to 30.3)
Northern America	2	100	0.5 (−14.2 to 15.2)	9.5 (−7.2 to 26.2)	−0.5 (−17.5 to 16.4)	9.5 (−5.4 to 24.5)
Oceania†	6	60.8	4.7 (1.3 to 8.2)	6.6 (2.2 to 11)	4.4 (2.2 to 6.7)	15.8 (5.9 to 25.6)
Australia and New Zealand	2	100	5.4 (−6.8 to 17.6)	7.3 (−19.7 to 34.3)	4.8 (−0.2 to 9.8)	17.5 (−26.6 to 61.7)
World total	159	96.9	5.0 (4.3 to 5.6)	8.7 (7.5 to 9.9)	5.7 (4.8 to 6.5)	19.4 (16.9 to 21.9)
More developed countries	45	99.1	4.8 (3.7 to 6.0)	7.6 (6.5 to 8.7)	2.6 (1.6 to 3.6)	15.1 (12.7 to 17.4)
Less developed countries	75	98.8	6.0 (5.0 to 7.0)	10.2 (8.3 to 12.2)	6.7 (5.4 to 8.0)	22.9 (19.1 to 26.8)
Least developed countries	39	89.5	1.4 (1.0 to 1.8)	3.7 (2.2 to 5.3)	3.4 (1.9 to 5.0)	8.6 (5.3 to 11.8)

Table 1.

Cesarean section (CS) rate changes in regions/sub-regions from 1990 to 2018.

^*

Countries categorized according to the UN geographical grouping.

^†

Changes of CS rates in Melanesia, Micronesia and Polynesia are not presented due to the low coverage in this subregion (10.5%).

Source: Betran et al. [16].

Cesarean sections can be lifesaving for both mothers and babies, and they can significantly reduce maternal and neonatal morbidity and mortality. However, they are not without risk and consequences, and there are indications that elective cesareans, unless medically necessary, can lead to unnecessary short- and long-term consequences for both mother and neonate. Additionally, cesareans may increase the risk of developing certain noncommunicable diseases and immune-related conditions in babies later in life [14, 15]. Therefore, critical attention must be paid before deciding to perform a cesarean section (CS). Dr. Ian Askew, Director at WHO, stated: “Cesarean sections are absolutely essential to save lives when vaginal deliveries would pose risks, so all health systems must ensure timely access for all women when needed.” However, not all CSs performed are necessary for medical reasons. Unnecessary surgical procedures can be harmful, both for the woman and her baby. Similarly, Dr. Ana Pilar Betran, Medical Officer at WHO and human reproduction programme (HRP), emphasized: “It’s important for all women to be able to talk to healthcare providers and be involved in the decision-making on their birth, receiving adequate information, including the risks and benefits. Emotional support is a critical aspect of quality care throughout pregnancy and childbirth.” [14].

This book chapter focuses on cesarean sections, with a particular emphasis on the short- and long-term effects on both mothers and newborns. The briefing highlights the importance of considering these consequences carefully as cesarean sections should only be performed when absolutely necessary and in life-threatening situations for mother and fetus. It is crucial for both women and healthcare professionals to be fully informed about the potential short- and long-term impacts of cesarean sections before making a decision.

2. Cesarean section consequences

2.1 Short-term effect

Immediately after delivery or during the postpartum period, the mother and/or neonate may experience various complications or undesirable outcomes following a cesarean section. These conditions require close attention to prevent further complications, which can lead to prolonged health issues or even death. Evidence indicated different short-term effects of cesarean section on mother and neonate. Commonly reported effects are stated below [21, 22, 23, 24].

2.1.1 Maternal effect

• Postpartum hemorrhage (PPH)

• Surgical site infection (SSI)

• Puerperal fever

• Wound dehiscence

• Respiratory tract infection (RTI)

• Fistula

• Anemia

• Reactions to anesthesia

• Blood clots

• Surgical injury

• Psychological effects like anxiety, depression

• Length of hospital stay and recovery time

• Maternal mortality

A study found that cesarean sections may increase a woman’s risk of intraoperative and postoperative complications (Figures 3 and 4) [25].

Figure 3.

Intraoperative maternal complications among mothers who underwent a cesarean section. Source: Negese and Belachew [25].

Figure 4.

Postoperative maternal complications among mothers who underwent a cesarean section. Source: Negese and Belachew [25].

2.1.2 Neonatal/infant effect

• Increased risk of infections, such as neonatal sepsis

• Breathing problems such as perinatal asphyxia (PNA), transient tachypnea of the newborn (TTN), and respiratory distress syndrome (RDS)

• Delayed gut colonization and potential digestive issues

• Low Apgar score

• Meconium aspiration syndrome (MAS)

• Impact on breastfeeding

• Surgical injury

• Increased neonatal intensive care unit (NICU) admission

• Increase need for oxygenation

• Neonatal/infant death

Cesarean sections potentially increase the risk of transient tachypnea of the newborn, respiratory distress syndrome (RDS), and the need for oxygenation in neonates. Moreover, the number of previous CS has a significant effect on those conditions (Figure 5a–c) [26].

Figure 5.

(a) Number of previous CS and RDS/TTN. Source: Thomas et al. [26]. (b) Number of previous CS and NICU admission. Source: Thomas et al. [26]. (c) Number of previous CS and need for oxygenation. Source: Thomas et al. [26].

2.2 Long-term effect

Cesarean sections may have long-term effects on both the mother and the neonate. Commonly reported effects are listed below [22, 27].

2.2.1 Maternal

• Increased risk of placenta previa, placenta accreta, and placental abruption in subsequent pregnancies

• Increased risk of miscarriage

• Uterine rupture risk

• Pelvic floor dysfunction

• Chronic pain and adhesions

• Stillbirth in subsequent pregnancy

• Possible association with certain cancers, such as cervical cancer

2.2.2 Neonatal/infant

• Potential for increased risk of allergies, atopy, and altered immune development

• Asthma and respiratory problems

• Obesity and metabolic syndrome

• Reduced intestinal gut microbiome diversity and potential long-term health implications

• Neurodevelopmental differences, though research is ongoing

One of the study findings conducted in Bangladesh shows that cesarean sections have significant long-term effects on the health and behavioral outcomes of the mother and child compared with vaginal delivery (Tables 2 and 3) [28].

Physical problem	Vaginal delivery mothers, % (n = 300)	Cesarean delivery mothers, % (n = 300)	P-value
Headache
Yes	140 (46.7)	250 (83.3)	<0.01
No	160 (53.3)	50 (16.7)
After delivery hip pain
Yes	108 (36.0)	260 (86.7)	<0.01
No	192 (64.0)	40 (13.3)
Problem of daily activities
Yes	60 (20.0)	280 (93.3)	<0.01
No	240 (80.0)	20 (6.2)
Suffering physical problem
Yes	120 (40.0)	280 (93.3)	<0.01
No	180 (60.0)	20 (6.7)
Types of physical health problem
No problem	150 (50.0)	20 (6.7)	<0.01
Eye problem	50 (16.7)	70 (23.3)
Backbone pain	70 (23.3)	180 (60.0)
Breast feeding problem
Yes	111 (37.0)	250 (83.0)	<0.01
No	189 (63.0)	50 (17.0)

Table 2.

Mothers’ physical health problems by mode of delivery.

Source: Rahman et al. [28].

Categories	Vaginal delivery baby, % (N = 300)	Cesarean delivery baby, % (N = 300)	P-value
Breathing problem
Yes	60 (20.0)	217 (72.3)	<0.01
No	240 (80.0)	83 (28.0)
Frequent illness
Yes	52 (17.3)	230 (76.7)	<0.01
No	248 (82.7)	70 (23.3)
Behavioral characteristic
Obstinate	80 (26.7)	20 (6.7)	<0.05
Restless	80 (26.7)	160 (53.4)
Quite	140 (46.7)	120 (40.0)
Food demand
Little	44 (14.7)	240 (53.3)	<0.01
Normal	256 (85.3)	60 (20.0)
Sleeping tendency
Few	78 (26.0)	80 (26.7)	<0.01
Normal	222 (74.0)	220 (73.3)

Table 3.

Child health problems by mode of delivery.

Source: Rahman et al. [28].

Evidence also reports the effects or outcomes as primary and secondary outcomes of cesarean delivery, including maternal, childhood, and subsequent pregnancy outcomes (Table 4) [27].

Group	Primary outcome	Secondary outcomes
Maternal outcomes	Pelvic floor dysfunction (any of urinary incontinence, fecal incontinence, uterine prolapse, or vaginal prolapse)	Maternal death; Chronic pain (including pelvic pain); Dysmenorrhea; Menorrhagia; Sexual dysfunction (including dyspareunia); Healthcare usage; Subfertility
Childhood outcomes	Asthma (up to 12 years and from 15 years)	Wheeze (up to 5 years and 6–15 years); Allergy/atopy/hypersensitivity/dermatitis; Overweight (3–13 years); Obesity (up to 5 years, 6–15 years, and adulthood); Inflammatory bowel disease (up to 35 years)
Subsequent pregnancy outcomes	Perinatal death (from 22 weeks gestation to 1 week of age)	Placenta previa; Placenta accreta; Placental abruption; Uterine rupture; Miscarriage; Ectopic pregnancy; Stillbirth; Hysterectomy; Postpartum hemorrhage; Antepartum hemorrhage; Preterm labor; Fetal growth restriction (small for gestational age, low birth weight [<2500 g]); Neonatal death

Table 4.

Primary and secondary outcomes of cesarean delivery maternal, childhood, and subsequent pregnancy outcomes.

Source: Keag et al. [27].

3. Risk factors and decision-making for cesarean section

3.1 Risk factors

There are various reasons or risk factors for a CS. One or more of these factors may result in a CS in different ways. The risk factors mentioned are not absolute reasons for a cesarean section. The decision depends on various factors, including the mother’s knowledge, healthcare provider expertise, available technology, and facilities. Therefore, women may be able to give birth vaginally without any complications even in the presence of some of these risk factors. The factors are broadly classified as maternal, fetal, and others (Figure 6) [19, 23, 29, 30, 31].

Figure 6.

Percent proportion of obstetric indications for CS delivery. Source: Abebe et al. [29].

3.1.1 Maternal factors

• Advanced maternal age (AMA)

• Multiparty

• Race or ethnicity

• Obesity

• Medical condition (diabetes mellitus, hypertension, preeclampsia or eclampsia, human papillomavirus, HIV, group B streptococcus, polyhydramnios, and Chorioamnionitis)

• Previous CS or prior uterine scar

• Type of labor

• Time of admission

• Obstetric factors (uterine rupture, cord prolapse, placenta previa, vasa previa, abruption, or another obstetric emergency)

• Maternal preference (elective indications) due to various factors such as maternal request, those who desired a tubal ligation, social, or religious concerns

3.1.2 Fetal factors

• Non-reassuring fetal heart rate tracing or fetal distress

• Fetal malpresentation

• Gestational age (post-term or postdates)

• Fetal anomaly

• Fetal death

• Fetal weight (suspected fetal macrosomia)

• Number of fetuses (multiple gestation)

Another study conducted in Ethiopia also stated that the most common reasons for cesarean sections were non-reassuring fetal heart rate (24.5%), breech presentation (23.5%), and obstructed labor (OL) (15.3%) in public hospitals. In private hospitals, the top reasons were previous cesarean section scar (25.8%), non-reassuring fetal heart rate (NRFHR) (25.3%), and cephalo-pelvic disproportion (CPD) (20.2%). Notably, 8.1% of cesareans in private hospitals were performed due to maternal request (Figure 7) [32]. Report from the study indicated that the most common reasons for the subsequent cesarean section was maternal previous history (Table 5) [23].

Figure 7.

Indications of cesarean birth of women who delivered in the selected public and private health facility in Bahir Dar city, Amhara Regional State, Ethiopia 2019. Source: Melesse et al. [32].

Indication	Number	Percentage (%)
Previous CS/No VBAC trial	1108	42.8
Fetal distress	402	15.5
Maternal request	386	14.9
Breech presentation	199	7.7
Failure to progress	164	6.3
Multiple gestation	157	6.1
Preeclampsia	90	3.5
Antepartum hemorrhage	83	3.2
Others	2	0.1

Table 5.

Indications for CS.

CS: cesarean section, VBAC: vaginal birth after cesarean section.

Source: Khasawneh et al. [23].

3.2 Decision-making and informed consent

Findings from different studies reported several factors that affect the decision to accept CS. These factors can be broadly classified into three categories: (1) Patient-related factors, which include the behaviors and preferences of women and their families, (2) healthcare providers’ factors, which encompass the behavior and communication of healthcare professionals, and (3) healthcare organization factors, such as the availability of care, service quality, and financial arrangements [20, 30, 33, 34, 35, 36, 37, 38, 39].

Those complex phenomena and personal decisions are simplified as follows:

• Medical indications: The medical indications can be maternal and/or fetal indications [30, 38].

• Preferences: A woman’s decision regarding cesarean section may be influenced by several factors, including her socioeconomic background, cultural beliefs, family support (husband, partner, or relatives), and involvement in her community [30, 33, 34, 35, 36, 37, 39, 40].

• Potential risks and benefits: The baby’s life is at risk [30].

• Other alternatives: The alternative may be vaginal birth after cesarean (VBAC) if the woman has previous history of CS and knowledge about the procedure [30, 38].

4. Minimizing the risks of cesarean section

There are strategies to reduce unnecessary cesarean section and minimizing the risks. To effectively reduce the number of unnecessary cesarean sections, we need to address both the medical and nonmedical factors that contribute to their overuse. Those strategies can be targeted women, healthcare professionals, and health organizations or facilities [39, 41, 42, 43, 44, 45, 46].

4.1 Women targeted interventions

• Health education during antenatal care (ANC)

• Childbirth education

• Create awareness about the risks and benefits if there is a patient preference

• Strategies for promoting natural birth and vaginal birth after cesarean (VBAC)

4.2 Healthcare professionals targeted interventions

• Recommended to use evidence-based practices for improving cesarean section outcomes

• The care provider must be skillful and expertise.

4.3 Health organizations or facilities targeted interventions

• Collaborative midwifery-obstetrician model of care

• Financial strategies for healthcare professionals or healthcare organizations must be based on available evidence (Table 6) [47]

Author, Year	Intervention (effect)	Details of intervention strategies	Sample size	Outcome measure	Certainty (GARDE)
Keeler and Fok, 1996 [29]	Provider intervention: fee equalization for hospitals (no significant effect)	Fees for vaginal deliveries were increased by 3%, and fees for CS were reduced to the amount charged for vaginal deliveries (an average reduction of 18%).	11,767	CS rate (%); Before intervention 25.3; Post-intervention 24.6; P > 0.05	⊕⊕⊕⊖; MODERATE
Lo, 2008 [30]	Provider intervention: fee equalization for hospitals (no significant effect)	Fees for vaginal birth after cesarean section were raised to the level of cesarean section in April 2003; Fees for vaginal deliveries were also raised to the level of cesarean section in May 2005.	1,084,686	OR (95%Cl) for CS; Post-VBAC fee rose 1.05 (1.00–1.09); Post-fee equivalence 1.03 (0.97–1.09)	⊕⊕⊕⊕; HIGH
Hong and Linn, 2012 [32]	Provider intervention: fee equalization for hospitals (no significant effect)	The payment to hospitals for vaginal deliveries was raised in May 2005. Before this intervention, the payment for cesarean section with medical indications was $911 to $1132 but the payment for vaginal deliveries was only $506 to $609. After this intervention, the payment for deliveries was $911 to $1132 regardless of delivery mode.	51,085	OR (95%CI) for CS; aUnplanned CS 0.978 (0.90–1.07); aPlanned CS 0.995 (0.09–1.06); CDMR 0.862 (0.69–1.07)	⊕⊕⊕⊖; MODERATE
	Patient intervention: co-payment for CDMR for patients (no significant effect)	Between May 2005 and May 2006, the payment for CDMR was equal to that for vaginal deliveries ($911 to $ 1132). After the co-payment policy applied, the payment for CDMR was $506 and the co-payment for that was increased from $0 to $475–697.		OR (95%CI) for CS; aUnplanned CS 0.960 (0.88–1.05); aPlanned CS 0.942 (0.88–1.00); CDMR 1.083 (0.87–1.35)
Liu et al., 2013 [33]	Provider intervention: bthe global budget system for hospitals (no significant effect)	Fees for services plan were replaced by the global budgeting system at this tertiary hospital in July 2002 for controlling CS rates. The global budget system is prospective payment system, which aiming at allocating resource and controlling cost	35,616	CS rate (%); Before GBS 35.1; After GBS 36.7; P = 0.0525	⊕⊕⊖⊖; LOW
Chen et al., 2014 [34]	Provider intervention: fee equalization for hospitals (no significant effect)	A global fee ($905–1132) was set for obstetric services at different levels of medical institutions, regardless of the mode of delivery in May 2005.	1,003,412	OR for CS; 20–1.033; 25–1.009; 30–0.967; 35–0.966; 40–0.944; 45–0.923	⊕⊕⊕⊕; HIGH
	Patient intervention: co-payment for CDMR for patients (no significant effect)	After May 2006, the Bureau of National Health Insurance (BNH) took partial reimbursement for where mothers had to pay a co-payment. With this intervention, physicians still received the same total payments for CDMR, but their payments came from two components. For instance, in medical Centers, physicians obtain payments of $1132 for CDMR, which included the reimbursement of $609 for vaginal delivery and the copayment of $523, paid by the BNHI and mothers, respectively.		OR for CS; 20–1.037; 25–1.021; 30–1.007; 35–0.992; 40–0.977; 45–0.961
Liu et al., 2018 [36]	Provider intervention: ccase payment for hospitals (significant increase)	Insurance agencies took a payment reform in 2009 and completed in 2011, the traditional fee-for-service payment was transformed into case payment for cesarean sections. The case compensation standard for CS is higher than that of vaginal deliveries ($493.47 for CS without complications, $197.39 for vaginal deliveries without complications).	28,314	CS rate (%); Pre-CPR: 26.124%; Post-CPR: 32.475%; P < 0.001	⊕⊕⊕⊖; MODERATE
Misra, 2008 [31]	Provider intervention: drisk-adjusted capitation for hospitals (limited its increase)	In 1997, the Maryland Department of Health and Mental Hygiene replaced the mixed model of fee-for-service and voluntary managed Care enrollment for a majority of Medicaid enrollees with a mandatory managed care system called HealthChoice. HealthChoice capitation rates are risk-adjusted. The monthly payments to a managed care organization for providing all necessary services to a particular enrollee are based on the individual’s documented health status. Managed care organizations receive a higher payment when the more severe the patients’ clinical conditions.	128,743	OR (95%CI) for CS; Primary CS 0.67 (0.573 ∼ 0.774); Repeat CS 0.71 (0.623 ∼ 0.804)	⊕⊕⊕⊕; HIGH
Kim et al., 2016 [35]	Provider intervention: ethe diagnosis-related group payment for hospitals (significant decrease)	Vaginal deliveries followed the fee-for-service system and the cost for CS fallowed the diagnosis-related group payment system. In 2002, the diagnosis-related group payment system for cesarean section only in voluntary health sectors. From July 2012, the diagnosis-related group payment system became mandatory in hospital and clinics, and it was also applied to general hospitals and tertiary hospitals since July 2013.	1,289,989	OR (95%CI) for CS; Mandatory adoption of DBG system 0.823 (0.816–0830); A longer length of the DRG system adoption period 0.997 (0.996–0.998)	⊕⊕⊕⊕; HIGH
Kozhimannii, 2018 [37]	Provider intervention: fee equalization for hospitals and clinicians (significant decrease)	Before this intervention, facility fees were $3144 and $5266 for uncomplicated vaginal and cesarean births, respectively. After intervention, the policy changed the rate to $3528 for uncomplicated births regardless of the mode of delivery. Professional service fees also changed because of the policy, from $776.62 and $1147.42 for prenatal, delivery, and postpartum care for uncomplicated vaginal and cesarean births, respectively, to a single blended rate of $867.37.	671,177	CS rate (%); Intervention-group: decrease 3.24%; Control-group: increase 0.6%	⊕⊕⊕⊕; HIGH

Table 6.

Summary of financial interventions for reducing the cesarean section rate.

^a

Unplanned cesarean sections and planned cesarean sections are types of cesarean section with medical indications.

^b

Global Budget System is one of prospective reimbursements for healthcare providers and government set a target on the amount of overall cost for health providers.

^c

Case payment means that healthcare provider will get a fixed price per admission irrespective of the actual health cost incurred.

^d

Risk-adjustment capitation was charged monthly according to the applicants’ health status, and managed care organizations receive a higher payment, the more severe the patients’ clinical conditions.

^e

Diagnostic-related group payments means groups of patients with similar clinical conditions and these patients would incur comparable health costs.

CS: cesarean sections and CDMR: cesarean delivery on maternal request.

Source: Yu et al. [47].

5. Conclusions

Despite their lifesaving role, unnecessary cesarean sections expose mothers and babies to avoidable risks. Although various factors can lead to a cesarean, vaginal birth remains possible in many cases. The decision ultimately depends on factors such as maternal health, fetal well-being, and available resources. The steady increase in cesarean section rates, particularly elective cesareans, warrants attention. Further research should be conducted to inform policymakers and program planners on strategies to control unnecessary costs and potential long-term impacts on quality of life.

Competing interests

All authors assert that they have no competing interests.

Copyrights

The authors declare that there are no copyrights on this work. All figures, tables, and text messages from published sources were cited.

Abbreviations

AMA	advanced maternal age
ANC	antenatal care
APH	antepartum hemorrhage
CDMR	cesarean delivery on maternal request
CPD	cephalopelvic disproportion
CS	cesarean section
MAS	meconium aspiration syndrome
NICU	neonatal intensive care unit
NRFHR	none reassuring fetal heart rate
OL	obstructed labor
PNA	perinatal asphyxia
PPH	postpartum hemorrhage
RDS	respiratory distress syndrome
RTI	respiratory tract infection
SSI	surgical site infection
TTN	transient tachypnea of the newborn
VBAC	vaginal birth after cesarean