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Safer C-Sections – improving maternal health outcomes

Special WHA75 side event and film show the way forward to improving access to safe caesarean section services

At the halfway point of the Sustainable Development Goals (SDGs), the evidence is clear, unless we change something we are going to miss the SDG3 target of reducing the maternal mortality ratio (from currently 216) to less than 70 per 100,000 live births by 2030 1..

Every year, 300 000 women die during childbirth, 99% of whom are from low- and middle-income countries. In 2015, the maternal mortality ratio in low-income countries was 239 per 100 000 live births compared with 12 per 100 000 live births in high-income countries.

While the ratio is declining in middle-income countries, countries with the highest initial levels of maternal mortality have made virtually no progress in reducing maternal deaths over the past 15 years.2

Data from 1990 to 2017 shows that a quarter of all women who died while giving birth in low- and middle-income countries had undergone caesarean sections (CS)7.

CS deliveries are projected to account for nearly 30% of all births by 2030. If we are to realise the SDG targets around maternal health, there is an urgent need for health care systems to develop and roll out surgical obstetric services which are accessible, safe, and sustainable.

Shortfilm highlighting the impact of the Obstetric Safe Surgery Programme in Kenya.

Solution-focused debate

To help unpick what is going wrong and discuss ways to increase access to safe and affordable obstetric services, leading global health and human rights experts joined a special World Health Assembly (WHA) side event to discuss programmes that will improve caesarean section outcomes.  

With a focus on clinically indicated caesarean sections, the session evidenced the impact of programmes such as the Obstetrics Safe Surgery programme in Makueni County, Kenya which are helping to develop the clinical and leadership capacity of obstetric surgical teams to promote safe, timely and respectful CS services.

The session premiered a short film showing the impact of the programme which has successfully developed a more holistic surgical team-based approach to training, by breaking the tradition of different specialists being taught separately. Low-tech simulation training has also enabled clinicians to practice and engrain new skills in a conducive and safe learning environment.  

Presenters discussed how successful programmes can be scaled up and replicated in similar low-resource settings, and in doing so, protect, respect, and fulfil the human rights of women.

Speakers included:

  • Prof Walid Habre – WFSA (Moderator)
  • Dr Joe Lenai – Ministry of Health, Government of Kenya
  • Dr Stephen Okello – President, Kenyan Society of Anaesthesiologists
  • Ian Walker – Senior Director, Johnson and Johnson Foundation
  • Dr Daisy Ruto – Technical Lead, Jhpiego Kenya
  • Petra ten Hoope Bender – UNFPA
Recording of the Safer C-Sections WHA side-event

Access to SAFE C-sections

It is projected that Africa, Asia, and Latin America will perform over 300 million CS between 2021-2030. By 2030, nearly 30% of all births globally will be by CS– an increase of roughly 35% in just one decade 6. The one consistency with this growth is its global unevenness both in terms of:

Frequency – The average proportion of women who need a CS for safe delivery has been estimated to be approximately 10–15% of the population.  By 2030, surgeries are projected to account for 60% of deliveries in Eastern Asia but only 7% in Africa, with some African countries having a CS prevalence rate as low as 2%. 4

QualityCS-related maternal mortality is 100 times higher in low- and middle-income countries than in high-income countries7 .  In South Asia and Sub-Saharan Africa, it is estimated that up to 600,000 maternal deaths associated with CS are expected to occur between 2021 and 2030.

The WHO warns that inadequate access to a timely-quality caesarean section can result in perinatal asphyxia, stillbirth, uterine rupture, obstetric fistula and ultimately death.3

Low-income, rural, adolescent girls and other marginalized women are least likely to have access to care in general, and CS specifically, and suffer from a much higher risk of maternal morbidity and mortality8. Efforts must be tailored to different populations to increase access to safe, timely, and appropriate CS, particularly among vulnerable and underserved populations.

Strengthening C-Sections

Although lives are lost from poor access to care, poor quality care contributes to more deaths than no access to care5.

The essential components of maternal healthcare delivery are the staff who do the work; the equipment with which they work; the space they work in; and the systems they follow.  Initiatives to strengthen CS provision should include: increased support for the anaesthesia, obstetric and surgical workforce; improved data collection and analysis; user-friendly tools for labour management and decision making 9and internationally agreed standards of care.

Adequate CS services alone would avert 1 million disability-adjusted life-years (DALYs), with the local economy benefiting from a return on investment of $6 for every $1 spent.4 Investment in obstetric surgical services has the potential to positively impact sustainable development, economic growth, and human rights.

To achieve the SDGs and respect the human rights of women, obstetric surgery stakeholders face a complex challenge of identifying and implementing health care models which tackle insufficient access to safe CS for women who need the procedure, against a global backdrop of an oversupply of non-medically indicated CS for those that don’t.

The low-cost high-impact programmes which focus on both access and safety highlighted during the Safer C-Sections WHA side-event will need to be replicated across the globe if we are to stand any chance of realising our maternal health SDG targets. 

Event organisers:


  1. OHCHR, Maternal Morbidity and Mortality. (2020)  Information series on sexual and reproductive health and rights.
  2. The United Nations Population Fund (UNFPA) (2019) Preventable Maternal Morbidity and Mortality and Human Rights for inclusion into the thematic study on the subject requested by the Human Rights Council Resolution 11/8. 2019
  3. Maswime, ( 2019 )Improving access to caesarean sections and perioperative care in LMICs. VOLUME 393, ISSUE 10184, P1919-1920, MAY 11, 2019
  4. Betran A, et al. WHO statement on caesarean section rates (2016) BJOG. 2016; 123: 667-670
  5. Trends and projections of caesarean section rates: global and regional estimates, BMJ Global Health.
  6. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. (2021) Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021 Jun;6(6):e005671. doi: 10.1136/bmjgh-2021-005671.
  7. Bishop D, Dyer R, Maswime S, et al. (2019) Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet GH  7:e513-522.
  8. Boatin AA, Schlotheuber A, Betran AP, et al. (2018) Within country inequalities in caesarean section rates: observational study of 72 low- and middle-income countries. BMJ; 360: k55.
  9. BMGF (2019)  Averting a Caesarean Section Disaster in Low-Income Countries. 2019