Cesarean sections in Georgia and Norway - What contributes to too much, too little, or just right? The role of maternal risk factors and efforts to reduce high cesarean section rates

High rates of cesarean section are associated with increased mortality and morbidity. To decrease cesarean sections without medical indication is complex and requires in-depth knowledge of local context and which groups to target for possible interventions. Our aim was to assess the role of maternal risk factors in relation to cesarean section in Georgia and Norway, two countries with diverging rates of cesarean sections. In addition, we wanted to assess the impact of a financial punitive policy with the aim to curb the high cesarean section rate in Georgia. The thesis consists of three studies, all of which used data from national birth registries. The first study assessed the relationship between maternal factors and cesarean section among primiparous women in Georgia. The second study assessed the prevalence of maternal risk factors for cesarean section over time and their relationship with the observed increase in cesarean sections in Norway. The third study assessed the impact of a financially punitive policy on rates of CS and perinatal outcomes in Georgia. Among primiparous women in Georgia, age ≥35 years, obesity, and birthweight ≥4000 g were strongly associated with cesarean section, while the proportion of women with risk factors for cesarean section was not unusually high. In Norway, the proportion of women with risk factors for cesarean section increased over time. Despite this development, the national cesarean section rate has remained stable since 2005. The financial policy did reduce the cesarean section rate in Georgia, mainly among primiparous women. We could not find that the policy impacted transfer to neonatal intensive care units or perinatal mortality. Our findings from Georgia and Norway indicate that maternal risk factors are not an important contributor to the increasing proportions of cesarean section. Financial regulations may play a role in reducing high rates of cesarean section but should be implemented with caution