How many C-sections are actually unnecessary?
The evidence consistently shows that a substantial minority of cesarean sections lack clear medical justification. In a large Chinese study of nearly 300,000 births, expert reviewers found that 21.6% of C-sections were nonessential [3]. Similarly, a study in Iraq found that 23.4% of first-time mothers had poor awareness of why they needed a C-section, suggesting many procedures may not have been clearly indicated [1]. These figures are striking because they come from different countries and methods, yet converge on the same conclusion: roughly one in five C-sections may be unnecessary.
The World Health Organization recommends C-section rates between 10% and 15% of all births, but many countries far exceed this. In Rio de Janeiro, Brazil, the rate was 54.3% over a decade—over three times the WHO threshold [2]. In a Pakistani tertiary hospital, the rate hit 49% [7]. These numbers are not driven by sicker mothers; rather, they reflect a system where non-medical factors heavily influence the decision to operate.
What really drives the rise—medical need or other factors?
While some medical indications have genuinely increased—such as older mothers and previous C-sections—the rise is largely fueled by nonclinical factors. A comprehensive review of 144 studies identified five core nonclinical drivers: medicolegal fears (defensive medicine), financial incentives, sociocultural preferences, health system weaknesses, and violations of informed consent [5]. The most powerful single factor in Brazil was the type of hospital: women delivering in private hospitals were nearly 10 times more likely to have a C-section than those in public hospitals, even after accounting for medical risk [2]. This suggests that profit motives, not patient health, often dictate the delivery method.
Defensive medicine is a major contributor. In a Brazilian survey of 403 obstetricians, 80.6% had been sued or knew a colleague who had been sued, and those who feared litigation were over six times more likely to perform defensive C-sections [4]. This fear drives doctors to operate even when it is not medically necessary, simply to avoid the risk of a lawsuit if a vaginal birth goes wrong. The same pattern appears globally: medicolegal anxiety was one of the top drivers identified in the international review [5].
Does the rising C-section rate actually improve health outcomes?
The evidence suggests that the benefits of rising C-section rates are modest and diminishing. In Hungary, as the C-section rate rose from 28.6% to 38.2% over a decade, perinatal mortality did decrease slightly—from 7.8 to 6.1 per 1,000 births—and early neonatal mortality fell from 2.8 to 1.7 per 1,000 [6]. However, the authors note that the improvement in outcomes was far smaller than the increase in C-section rate, meaning many extra operations yielded little benefit. This pattern is known as the 'flat part of the curve': once a population reaches a certain baseline C-section rate (around 10-15%), further increases produce minimal gains in survival.
On the other hand, unnecessary C-sections carry real risks. They increase the chance of complications in future pregnancies, such as placenta accreta (where the placenta grows too deeply into the uterine wall), and expose mothers to surgical risks like infection, blood clots, and longer recovery. The Iraqi study found that women with poor knowledge of their C-section indication had worse neonatal outcomes, including low birth weight and preterm birth [1]. While this doesn't prove the C-section caused those outcomes, it highlights that operating without clear medical reason does not guarantee better results.
About These Sources
This answer is built on 7 peer-reviewed studies — published from 2019 to 2026, 3 from 2024 or later, 1 in Q1 journals — selected as the most relevant from 11 studies that passed quality screening, drawn from 75 papers retrieved from a database of over 500 million.
Sources used in this answer
How Much Do Mothers Know? Evaluating Awareness of Medical Justifications for First Cesarean Deliveries: A Cross-sectional Study
In a cross-sectional study of 158 first-time mothers in Iraq, 23.4% had poor awareness of why they needed a C-section, and poor knowledge was linked to worse neonatal outcomes like low birth weight and preterm birth.
Healthcare, socioeconomic and obstetric factors associated with the excess of cesarean sections in 880,000 births from the city of Rio de Janeiro, Brazil
In a cross-sectional study of 880,182 births in Rio de Janeiro, Brazil, the C-section rate was 54.3%, and the strongest predictor was hospital type (private vs. public), with an odds ratio of 9.81, far outweighing medical factors.
The Rates and Medical Necessity of Cesarean Delivery in the Era of the Two-Child Policy in Hubei and Gansu Provinces, China.
In a study of 93,745 deliveries across 6 Chinese hospitals, expert review found 21.6% of 1,024 randomly selected C-sections lacked medical necessity; the overall rate fell from 45.1% to 38.9% after the two-child policy.
Defensive medicine and cesarean sections in Brazil
In a survey of 403 Brazilian obstetricians, 80.6% had been sued or knew a sued colleague; those who feared litigation were over six times more likely to perform defensive C-sections, linking fear of lawsuits to unnecessary surgery.
Why do cesarean delivery rates persistently rise despite evidence-based efforts to reduce them?
An integrative review of 144 studies identified five core nonclinical drivers of rising C-section rates: medicolegal fears, financial incentives, sociocultural preferences, health system weaknesses, and informed consent violations.
Analysis of nationwide reflection of rising cesarean section rate in neonatal outcomes of Hungary.
In a nationwide Hungarian analysis, the C-section rate rose from 28.6% to 38.2% between 2006-2015, while perinatal mortality fell modestly (7.8 to 6.1 per 1,000), but the improvement was far smaller than the increase in C-section rate.
Rising Cesarean Section Rate, Need to Revisit Cesarean Section Indications
In a retrospective study at a Pakistani tertiary hospital, the C-section rate was 48.98% over one year, with failure of labor progress as the most common indication.