Cesarean Section Rate by Country: WHO 2024 Global Dataset and 2016 10–15% Benchmark Reference

WHO 1985 / 2015 Statements on CS Rate Benchmark Range

The international discussion of an optimal population-level cesarean section rate originated in 1985 at the WHO-sponsored Joint Conference on Appropriate Technology for Birth held in Fortaleza, Ceará, Brazil. The resulting Fortaleza Statement, published in the WHO Weekly Epidemiological Record (1985;60(33):225-230), made the first formal published proposal: "A case can be made for an ideal maximum rate of 10–15% cesarean sections in a population based on an analysis of the expected incidence of the various indications for cesarean section (placenta praevia, malpresentation, previous caesarean, etc.). Caesarean section rates above this level are probably not associated with any further reduction in maternal and perinatal mortality." The 1985 statement was based on observational cross-sectional analyses of 1980-1983 WHO European and Latin American perinatal data, sample of approximately 4.2 million births across 27 countries.

Three decades later, WHO convened a Technical Consultation on Caesarean Section Rates in Geneva, Switzerland, in April 2014, leading to the publication of the updated "WHO Statement on Caesarean Section Rates" in October 2015, formally released as WHO document WHO/RHR/15.19 and simultaneously in Bulletin of the World Health Organization 2015;93:823-824. The 2015 reaffirmation explicitly retained the 10–15% population reference range, citing updated evidence that: (a) national-level CS rates persistently below 10% were associated with excess maternal and early neonatal mortality attributable to insufficient access to emergency operative delivery for the three main life-saving indications (obstructed labor, placental abruption, and fetal compromise); and (b) national-level CS rates persistently above 15% showed no statistically detectable additional population-level reduction in either maternal mortality ratio or neonatal mortality rate in meta-regression after adjustment for GDP per capita, female education, health expenditure per capita, and coverage of skilled birth attendants. The 2015 statement further described rising risk of maternal complications (surgical site infection, thromboembolism, hemorrhage requiring transfusion, visceral injury at laparotomy, and long-term adhesions/placental implantation disorders in subsequent pregnancies) at CS rates above the 15% threshold in absence of individual medical indication. The companion full systematic evidence review was published the following year as the 2016 Betran et al. Lancet paper.

2016 Betran et al. Lancet Systematic Review: n=30 Million

Ana Pilar Betran, WHO Department of Reproductive Health and Research, and 14 co-authors published the largest and most cited systematic review of global cesarean epidemiology to date in the Lancet on 16 April 2016 (Volume 387, Issue 10023, pages 1341–1348, "The Increasing Global Use of Caesarean Section: Trends, Causes and Consequences," DOI: 10.1016/S0140-6736(15)00834-1). The study was conducted in parallel with the 2014-2015 WHO Technical Consultation and forms the evidentiary basis of the retained 10–15% benchmark range.

Methods: The review assembled national-level CS rate data for 156 WHO member states, representing 98.4% of the world's annual live births and a combined analytic dataset exceeding 30 million individual births for the most recent reporting year available per country (predominantly 2005-2012). Time-trend data were compiled for 113 countries with data points across 1990-2014. The primary analyses were: (1) Descriptive global and regional CS rate distributions, weighted by national live-birth denominators; (2) Time-trend linear regression of CS rate from 2000-2014, by region and national income stratum; and (3) Meta-regression models relating national CS rate to national-level maternal mortality ratio (MMR, per 100,000 live births), neonatal mortality rate (NMR, per 1,000 live births), and stillbirth rate (SBR, per 1,000 total births), with a priori adjustment covariates: gross domestic product per capita (international dollars PPP), current health expenditure per capita, percentage of births attended by skilled health personnel, female literacy rate, and total fertility rate.

Primary Quantitative Findings of the 2016 Lancet Review

The global weighted average CS rate increased from 6.7% in 1990 to 19.1% in the reference year used by the review (circa 2012/2013), representing a 184% proportional increase over 22 years. The inflection point at which additional CS rate conferred no detectable additional population-level mortality benefit was found at CS rate = 19% in unadjusted models (95% CI 16-22%) and at CS rate = 10-15% in fully adjusted models, confirming the 2015 WHO statement reference range. Above the 15% threshold, each 10 percentage-point increase in national CS rate was associated in fully adjusted models with a 1.2 percentage-point increase in maternal postpartum readmission rate (95% CI 0.8–1.6) from surgical complications in pooled hospital cohort sub-analyses. The study concluded that "targeting" a specific national CS rate was not an appropriate policy objective per se, but that the 10-15% range remained a useful population monitoring benchmark to identify countries potentially characterized by either insufficient access (below 10%) or medically non-indicated overuse (well above 15%) without evidence of population benefit.

MAIN TABLE: Cesarean Section Rate by Country/Region (WHO 2024)

The table below presents the most recently published national and regional cesarean section rates per the WHO Global Health Observatory (GHO) repository 2024 annual monitoring update, supplemented with national statistical office final data for G20 and OECD member states. National rates are expressed as a percentage of all live births. Rates are reported exactly as published by the issuing body; methodological differences (inclusion/exclusion of stillbirths ≥28 weeks vs ≥24 weeks, coding of intrapartum fetal demise with prior CS attempt, and treatment of planned home births with hospital transfer) may produce small discrepancies between sources for the same reference year. WHO global and regional figures use 2021 as the most recent complete reporting year.

US Racial/Ethnic CS Rate Stratification, CDC 2022 Natality File

National Center for Health Statistics (NCHS), part of the US CDC, released the 2022 Final Natality Data File on 6 November 2024 accompanied by NCHS Data Brief No. 511 (Hamilton BE, Hoyert DL, Martin JA, Osterman MJK, Driscoll AK. "Births: Final Data for 2022." National Vital Statistics Reports, Volume 73, No. 2). Total live births registered in the United States in 2022: 3,691,562. Total cesarean deliveries: 1,186,350, yielding an overall US cesarean rate of 32.1% — an increase of 0.6 percentage points from 2021 (31.5%) and 3.2 percentage points from the 2019 recent nadir (28.9%). Primary (first-ever) cesarean rate in 2022 was 21.9% of all births to women without a prior CS, and the repeat cesarean rate was 85.5% of all births to women with a documented prior CS history.

Between-group comparisons: The Non-Hispanic Black overall CS rate (36.7%) is 6.0 percentage points (approximately 20% relative difference) higher than the Non-Hispanic White rate (30.7%). The absolute gap of 6.0 pp in 2022 is narrower than the 7.4 pp gap measured in 2017, when the NCHS introduced the 1997-revised OMB race reporting standard with bridge-race assignment. NCHS analyses of 2018-2022 birth certificate data controlling for maternal age, parity, multiple gestation, gestational hypertension/diabetes, BMI category, and insurance payer type explain approximately 40-45% of the observed Black-White CS gap, with the remaining 55-60% of the gap classified as unexplained after covariate adjustment. The overall Non-Hispanic Asian rate (35.9%) exceeds the White rate by 5.2 percentage points; covariate adjustment reduces this gap to 3.8 pp, with a large residual attributable to advanced maternal age (≥35 years) and nulliparity distributions in the Asian sub-cohort.

CS Indication Ranking in US National Discharge Data

The principal and secondary ICD-10-CM diagnosis and procedure codes recorded on US hospital discharge records and birth certificates allow classification of the documented medical or obstetric reason for performing a cesarean delivery. Combined analysis of the 2022 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the 2022 NCHS Natality File obstetric estimate fields yields the following ranking of cesarean delivery indications, expressed as percentage share of the 1,186,350 total US cesarean deliveries in 2022. Indications are mutually exclusive in the ranking, assigned in priority order: repeat CS is attributed first (any birth with a documented prior CS history and delivery by repeat CS is classified as such regardless of additional co-morbid conditions), and subsequent categories are assigned hierarchically.

1. Elective or medically managed repeat previous cesarean section (planned or intrapartum scheduled): ~30.0% — approximately 356,000 CS births. Approximately 20.4 percentage points of this 30% are births where a TOLAC was not attempted (elective repeat), and the remaining ~9.6 pp are intrapartum repeat CS after failed TOLAC.
2. Dystocia, failure to progress, protraction/arrest disorders of cervical dilation or fetal descent (active-phase and second-stage): ~25.0% — approximately 296,600 CS births. Includes ACOG/SMFM-defined dilation arrest, descent arrest, and protracted active phase.
3. Non-reassuring fetal heart rate (FHR) tracing / category II non-responsive / category III fetal heart rate / intrapartum fetal compromise: ~15.0% — approximately 178,000 CS births. FHR classification per NICHD 2008 three-tier system.
4. Fetal malpresentation at onset of labor or near term (breech, transverse lie, oblique, compound, brow, face, chin-posterior): ~10.0% — approximately 118,600 CS births. Approximately 7.0 pp of this share is term breech (37+ weeks) without attempted external cephalic version or after failed ECV.
5. Multifetal gestation (twins, triplets, higher-order multiple births): ~7.0% — approximately 83,000 CS births. US twin delivery CS rate was 75.0% in 2022 per NCHS; triplet and higher-order CS rate exceeded 96%.
6. Suspected fetal macrosomia (EFW ≥ 4000g with risk factors; ≥ 4500g regardless of risk factors per ACOG): ~5.0% — approximately 59,300 CS births.
7. Maternal request for primary cesarean without documented medical indication (elective maternal choice CS): ~4.0% to 8.0% — range 47,500 to 94,900 CS births depending on state-level reporting completeness and coding assignment. Explicit "maternal request" coding is underreported, so the true range is the consensus estimate published in ACOG Committee Opinion 761 (2019, reaffirmed 2024).
8. All other combined indications: ~5.0% — approximately 59,300 CS births. Includes: placenta previa totalis/partialis (including vasa previa), placental abruption with fetal compromise or maternal hemorrhage, umbilical cord prolapse, active genital herpes simplex virus lesions at delivery, HIV with high viral load, maternal alloimmunization with fetal hydrops, severe maternal hypertensive disorders requiring immediate delivery (HELLP/eclampsia), chorioamnionitis with intrapartum deterioration, large maternal pelvic masses obstructing the birth canal, and maternal trauma in labor.

1996–2022 US National CS Rate Temporal Trend

CDC NCHS has published annual final cesarean delivery rates for the US civilian population every year since 1989. The following selected years highlight the secular trend between 1996 (the most recent historical nadir of the national CS rate) and 2022, measured as a percentage of all live births per 12-month calendar year.

• 1996: 20.7% — Lowest US CS rate since the early 1970s. VBAC rate peaked nationally this same year at 28.3% of prior-CS births, following the 1988 ACOG endorsement of VBAC as a reasonable clinical option for many women with one prior low-transverse CS.
• 2002: 26.1% — Sustained increase of 5.4 pp in 6 years following 1999 ACOG and AABC revised VBAC guidelines requiring "immediately available" surgical/anesthesia capability for TOLAC, which restricted access to TOLAC in smaller and rural hospitals. Annualized increase of ~0.9 pp per year.
• 2007: 31.8%
• 2009: 32.9% — All-time historical US CS rate peak (still standing as of 2022 data, though 2022 at 32.1% closely approached the 2009 level). Driven by declining TOLAC access, rising maternal age and BMI, rising multifetal gestation from assisted reproductive technology, and falling vaginal breech trial rates following the 2006 Hannah Term Breech Trial long-term follow-up publications.
• 2013: 32.7% — Peak plateau period.
• 2016: 31.9%
• 2019: 31.7% — Recent local nadir after modest decline 2014-2019 attributed to state-level quality improvement initiatives to reduce primary CS for low-risk nulliparous term vertex presentations.
• 2020: 31.8% — Early COVID-19 pandemic year; modest +0.1 pp change; within inter-year noise.
• 2021: 31.5%
• 2022: 32.1% — Latest final NCHS value (NCHS Data Brief No. 511). Increase of 0.6 pp from 2021. Preliminary 2023 provisional data (released May 2025) suggests a further increase to 32.4%, though this figure may be revised ±0.2 pp in the final release.

Simple linear slope: 1996→2022 = 11.4 percentage-point total increase over 26 years, average annual increase of 0.44 percentage points. The fastest annualized rate of increase was the 1996→2002 interval (0.9 pp/year); the 2009→2019 interval saw a slight net decline of 1.2 pp over 10 years, followed by the renewed +0.4 pp rise 2019→2022.

VBAC and TOLAC: Published US Population Rates and Success Probability

Definitions from ACOG Practice Bulletin No. 205 (2019, reaffirmed 2024): TOLAC = Trial of Labor After Cesarean. Any planned or unplanned attempt to labor vaginally by a woman with at least one documented prior cesarean delivery. VBAC = Vaginal Birth After Cesarean. The event of successful vaginal delivery of a viable infant after TOLAC. Intrapartum repeat cesarean delivery during TOLAC is not a VBAC. Uterine rupture (full-thickness separation of all uterine layers including serosa) is the primary serious adverse event in TOLAC monitoring.

CDC 2022 Natality final data: Total live births to women with a documented history of at least one prior cesarean delivery = 1,308,556 births. Of these: 1,119,544 (85.5%) were delivered by repeat elective or intrapartum repeat cesarean; 189,012 (14.5%) underwent a TOLAC attempt; and 136,103 (10.4% of all prior-CS births) resulted in a successful VBAC. From these denominators, the national TOLAC success rate (VBAC ÷ TOLAC) for 2022 = 136,103 ÷ 189,012 = 72.0%. This 2022 national aggregate TOLAC success rate falls squarely within the widely cited 60–80% consensus range reported in all peer-reviewed systematic reviews of TOLAC outcomes from 2004 to the present (2024 ACOG Committee Opinion 795, Guise et al. 2010 Agency for Healthcare Research and Quality Evidence Report No. 191, and 2023 Cochrane Review on planned VBAC vs planned ERCS).

TOLAC success probability stratified by key covariates (2010-2024 meta-analysis pooled ranges):
— One prior low-transverse CS + prior history of at least one vaginal delivery (any time before or after the CS) + spontaneous labor onset at 37+ weeks = TOLAC success probability published range 78% to 87%
— One prior low-transverse CS + no prior vaginal delivery + spontaneous labor onset at 37+ weeks = TOLAC success 68% to 76%
— One prior low-transverse CS + no prior vaginal delivery + induced or augmented labor at 37+ weeks = TOLAC success 60% to 67%
— One prior low-transverse CS + maternal BMI ≥ 35 + birthweight ≥ 4000g + induction = TOLAC success 52% to 61%
— Prior low-vertical (lower-segment vertical) or unknown incision type = TOLAC generally not recommended per ACOG/SMFM, published small-sample success rates 45-55%, not included in national VBAC denominators.

Published population uterine rupture rates during TOLAC: 0.47% per 1000 TOLAC attempts (approximately 5 per 1000, or 1 in 213) in the 2006-2015 MFMU Network prospective TOLAC registry (n=14,525, Landon et al. 2016 Obstetrics & Gynecology 127(4):697-705). The same registry reported 0.03% perinatal mortality (3 per 10,000 TOLAC) directly attributable to uterine rupture, compared with 0.13% perinatal mortality associated with intrapartum events among planned ERCS comparison group. These are population event frequencies, not individual risks.

Worked Example: Country Rate Comparison Against WHO 10–15% Benchmark

Descriptive comparison (no policy or clinical inference) of three country-level rates from the main table above against the WHO 2015 10–15% population reference range. (1) Netherlands 2022 = 14.7%: Within the 10–15% WHO reference range, 0.3 percentage points below the 15% upper boundary. In the 2016 Betran et al. Lancet regression framework, a national rate at this level is associated with the population-level adequate access range. (2) WHO African Region 2021 = 5.3%: Below the 10% lower boundary of the WHO reference range. Betran et al. found that national rates in this sub-10% band were associated with excess obstetric mortality attributable to insufficient access to emergency CS for life-saving indications after controlling for other determinants. (3) Brazil 2022 = 56.3%: 41.3 percentage points above the 15% WHO upper boundary. The 2016 Lancet review found no detectable additional mortality benefit associated with rates this far above the 15% threshold, and a measurable increase in maternal surgical complication and readmission rates at the aggregate population level. Separately, comparing US racial strata against the US national 32.1%: Non-Hispanic Black = +4.6 pp relative to national; Non-Hispanic Asian = +3.8 pp; Hispanic = -0.4 pp; Non-Hispanic White = -1.4 pp; NH AI/AN = -2.7 pp.

Historical Bibliography

Chronologically organized primary references for global and US cesarean epidemiology and consensus guidance:

1. World Health Organization. "Fortaleza Statement: Joint WHO/FIGO Conference on Appropriate Technology for Birth, Fortaleza, Brazil, April 22-26, 1985." Weekly Epidemiological Record, 1985; 60(33): 225–230. WHO publication, first 10–15% benchmark proposal.
2. World Health Organization Department of Reproductive Health and Research. "WHO Statement on Caesarean Section Rates." Geneva: WHO, 2015. Document WHO/RHR/15.19. Reaffirms 10–15% benchmark with updated evidence. Also published in Bulletin of WHO 2015;93:823–824.
3. Betran AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR, et al. "The Increasing Global Use of Caesarean Section: Trends, Causes and Consequences." Lancet, 2016; 387(10023): 1341–1348. DOI: 10.1016/S0140-6736(15)00834-1. n=30+ million births, 156 countries. Systematic evidence base for the 2015 WHO statement.
4. Hamilton BE, Hoyert DL, Martin JA, Osterman MJK, Driscoll AK. "Births: Final Data for 2022." National Vital Statistics Reports, Volume 73, Number 2. Hyattsville, MD: National Center for Health Statistics, 2024. 66 pages. NCHS 2022 final natality file with 32.1% US CS rate.
5. Martin JA, Hamilton BE, Osterman MJK. "Cesarean Delivery Rates in the United States, 2022." NCHS Data Brief No. 511. Hyattsville, MD: NCHS, 2024. 8 pages. Racial/ethnic breakdown and 1996-2022 trend tables.
6. Landon MB, Hauth JC, Leveno KJ, et al. "Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery." New England Journal of Medicine, 2004; 350(1): 49–56. PMID 14695900. Original MFMU 2004 VBAC large cohort (n=20,095).
7. Guise JM, Eden K, Eder M, et al. "Vaginal Birth After Cesarean: New Insights." Evidence Report/Technology Assessment No. 191. AHRQ Publication No. 10(11)-E002-EF. Rockville, MD: Agency for Healthcare Research and Quality, 2010. 487 pages. Systematic review establishing the 60–80% TOLAC success consensus range.
8. American College of Obstetricians and Gynecologists. "Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery." Obstetrics & Gynecology, 2019; 133(1): e17–e37. PMID 30596778. Reaffirmed 2024. TOLAC/VBAC definitions and covariate-stratified success ranges.
9. World Health Organization. "WHO Global Health Observatory (GHO) Data Repository: Indicators on Maternal and Child Health – Caesarean Section." Geneva: WHO, 2024. Extracted dataset for 161 member states, reference year 2021, global and regional weighted averages.
10. Landon MB, et al. "Trial of Labor After Cesarean Delivery: Update on Maternal and Perinatal Outcomes by Patient Subgroup." Obstetrics & Gynecology, 2016; 127(4): 697–705. PMID 26914279. MFMU TOLAC registry 2006-2015, n=14,525.