Are there social inequalities in caesarean section rates in Europe?

BACKGROUND: Lower socioeconomic status (SES) is strongly associated with adverse perinatal health outcome, such as preterm birth and stillbirth. We investigated whether the caesarean section (CS) rate, which may reflect a greater prevalence of maternal health complications, was also higher in disadvantaged populations. METHODS: The study uses aggregate routine birth data from European countries collected with the Euro-Peristat federated analysis protocol. We analysed CS rates (total births by CS/total births) by SES from 2015 to 2020. Mothers’ education level (primary/lower secondary; upper secondary; postsecondary) was the preferred SES indicator; if unavailable, parents’ occupation or area-based deprivation scores were used and harmonised into three groups (low, medium, high). RESULTS: 17 countries provided data on maternal education, 5 on area-based deprivation, 1 on parents’ occupation. CS rates ranged from 16.7% (Lithuania) to 48.5% (Cyprus) in the low SES group and from 16.8% (the Netherlands) to 55.2% (Cyprus) in the high SES group. Patterns across SES groups were diverse, with greater use of CS in higher SES groups (Croatia: 19.6%, 24.1%, 26.7% and Ireland: 30.3%, 33.4%, 35.5% for low, medium and high SES respectively), whereas elsewhere, more disadvantaged SES groups had higher CS rates: Italy: 37.1%, 35.2%, 33.7%, Denmark: 22.0%, 21.9%; 19.8% and Luxembourg: 34.5%, 33.2%, 29.9%. In some countries, rates were similar across groups (France: 21.3%, 20.7%, 21.3% and the Netherlands: 17.2%, 17.0%, 16.8%). Risk ratios of CS in low versus high SES groups ranged from 0.74 (95% CI R0.70-0.77) in Croatia to 1.15 (95% CI 1.12-1.19) in Luxembourg. CONCLUSIONS: Our results do not show that CS was consistently associated with social disadvantage. Instead, we found surprising variations in the SES gradient between countries, raising questions about CS practices and their interaction with maternal characteristics in European countries.