Publications & Reports

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

J P Souza, A P Betran, A Dumont, B de Mucio, C M Gibbs Pickens, C Deneux-Tharaux, E Ortiz-Panozo, E Sullivan, E Ota, G Togoobaatar, G Carroli, H Knight, J Zhang, J G Cecatti, J P Vogel, K Jayaratne, M C Leal, M Gissler, N Morisaki, N Lack, O T Oladapo, O Tuncalp, P Lumbiganon, R Mori, S Quintana, A D Costa Passos, A C Marcolin, A Zongo, B Blondel, B Hernandez, C J Hogue, C Prunet, C Landman, C Ochir, C Cuesta, C Pileggi-Castro, D Walker, D Alves, E Abalos, Ecd Moises, E M Vieira, G Duarte, G Perdona, I Gurol-Urganci, K Takahiko, L Moscovici, L Campodonico, L Oliveira-Ciabati, M Laopaiboon, M Danansuriya, M Nakamura-Pereira, M L Costa, M R Torloni, M R Kramer, P Borges, P B Olkhanud, R Perez-Cuevas, S B Agampodi, S Mittal, S Serruya, V Bataglia, Z Li, M Temmerman, A M Gulmezoglu
Department of Social Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil.


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 ( /). 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.


  • Journal: BJOG
  • Published: 01/02/2016
  • Volume: 123
  • Issue: 3
  • Pagination: 427-436