Are differences in caesarean section rates between countries in Europe decreasing or increasing?

OBJECTIVE: Caesarean section (CS) rates differ greatly between European countries, but whether these variations in practices between countries are increasing or decreasing has not been investigated. Improved scientific evidence to underpin CS indications as well as common trends in maternal characteristics could lead to convergence of rates. This study aimed to analyse trends in CS rates between 2004 and 2020 for all births and for specific risk sub-groups. METHODS: The study uses data from the Euro-Peristat network which collected national-level routine data on CS overall and by sub-group using a standardised protocol on births in 2004, 2010 and 2015-2020. Sub-groups were: parity (nulliparous, multiparous), multiplicity (singleton, multiple), previous CS (yes/no), breech (yes/no) and preterm/term. 25 countries had data at all time points. We divided countries into terciles based on 2004 rates and analysed trajectories in these three groups. RESULTS: The CS rate ranged from 14.4% to 37.8% in 2004 and from 16.2% to 44.8% in 2020. Cutoffs for the terciles in 2004 were 19% et 25%. Countries in the first tercile (low rates, 9 countries) continued to have low rates with flat or mildly increasing trajectories. In the second tercile, there were two trajectories - flat or mildly increasing (3 countries) or sharper increases over time (4 countries). Countries in the highest tercile had increasing rates (8 countries). These patterns were observed most clearly in singleton and nulliparous pregnancies. For sub-group analyses, patterns varied, with some low CS countries having high CS rates for breech or preterm births, but practices within sub-groups were relatively stable over time. CONCLUSIONS: Differences in overall CS rates between European countries over time have widened with more marked clustering into high and low CS groups. These analyses suggest a lack of progress in developing an evidence-base that would lead to standardisation of practice.