Discussion
This analysis shows that every year in the world there is an additional need for 0.8 – 3.2 million
CS in low income countries where 60% of the world’s births occur. Simultaneously, 4.0-6.2
million CS in excess are performed in middle and high income countries where 37.5% of the
births occur. From a population based approach, those CS in excess are likely to be medically
unjustified and should be then considered unnecessary CS.
This analysis has several strengths. We were able to retrieve nationally representative CS rates
from 137 countries representing more than 95% of the world annual number of births. The
sources of these estimates are considered reliable and valid, and are all publicly available. The
DHS programme represents the largest worldwide effort to obtain nationally representative
demographic and health data from household surveys in developing countries. Surveys are
implemented by institutions in the host country, usually government statistical offices, and
5,000–30,000 women of childbearing age are interviewed in a standard survey. As the DHS use
standardized questionnaires and methods of training, data collection and processing, they are
often considered the 'best available gold standard' for many health indicators in developing
countries and are used for global monitoring efforts. [26,27] DHS figures are considered valid
estimations of actual CS rates at country level, although they might be imprecise.