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New rules for caesarean section

Partner Institute: 
Centre for Health, Economics Research and Evaluation (CHERE), University of Technology, Sydney
Survey no: 
Gallego, Gisselle
Health Policy Issues: 
Quality Improvement
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no
Featured in half-yearly report: Health Policy Developments 11


The number of caesarean births in Australia is increasing and there is concern about the risks and health care resources used for the procedure. In the state of New South Wales, caesarean delivery accounts for 28% of all deliveries. The policy aims to reduce the number of elective caesarean births without a medical indication, avoid elective caesarean section before 39 weeks gestation and ensure that women understand the implications of an elective caesarean section.

Purpose of health policy or idea

The policy was developed to reduce the number of caesarean sections (CS) without medical indication in New South Wales (NSW), recognising that maternal request on its own is not an indication for elective CS. In addition, the policy aims to ensure that evidence based information and support is provided to women to enable them to make informed decisions about childbirth. Ideally, this will involve a discussion about the benefits and risks of CS compared with vaginal birth. Furthermore, in response to new evidence [1-3] and guidance from the Royal and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) [4], the policy endorses that the timing of elective and pre-labour caesarean section in women without additional risks should be carried out at approximately 39 weeks of gestation.[5]

Main points

Main objectives

To policy has three objectives:

1) To advise women against electing to have a caesarean birth without a medical reason.

2) To avoid elective caesarean section before 39 weeks gestation unless there are clinical reasons.

3) To ensure women understand the implications of an elective caesarean section on future pregnancies.

Type of incentives


Groups affected

Women, Obstetricians, Midwives

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Characteristics of this policy

Degree of Innovation traditional traditional innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-neutral system-neutral

Political and economic background

The policy was devised to tackle the increasing rate of elective CS in NSW. In 2005 one in six births was by elective CS, many planned in advance for medical reasons.[6] There are strong economic arguments for reducing the number of unnecessary elective CS. The cost of elective CS is almost double that of vaginal birth. This is due to longer length of stay in hospital, increased nursing and medical care, plus longer recovery time at home. Elective CS can place a heavy economic burden on the already overstretched public hospital system.

Some doctors have reported that women are opting for caesarean as a result of personal preference in what has been known as the "too posh to push" phenomenon. However some consider that it is unknown how much choice women actually have and how much of a decision is influenced by other factors with many women being "talked into it". It is worth noting that caesarean section delivery is more common among privately than publicly insured mothers.[6]  

Up to date, there has been a perception that elective CS is safe and less risky for both mother and baby. However the policy was also initiated because of concerns about the rising number of babies admitted to intensive care after CS birth, especially those performed too early. The policy alludes to an epidemiological study conducted in the United States of more than five million births which found that overall neonatal mortality rate for CS births was 2.9 times the rate for vaginal births (1.77 deaths per 1,000 live births).[2]  

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Origins of health policy idea

Since 1996 the rate of birth by CS in Australia has increased from 19.5 to 30.3 percent in 2005.[7] In New South Wales (NSW), the most populous state, CS accounts for 28% of all deliveries with the percentage increasing from 23.6 in 2001 to 28.1 percent in 2005.[6] The number of births in 2005 was 90,6106, so even a 1 percent rise in CS will translate into additional hospital bed days, as well as diversion of scarce clinical resources in already overstretched public hospitals. The policy also took account of recent evidence about the increased risk of respiratory morbidity in babies born by caesarean section before labour based.[1-3] The policy directive is based on the United Kingdom National Collaborating Centre for Women's and Children's Health National Institute of Clinical Excellence (NICE) Guidelines on Caesarean section.[8]

Initiators of idea/main actors

  • Government
  • Providers
  • Patients, Consumers

Stakeholder positions

The Australian College of Midwives welcomed the policy directive. However, some experts considered that the policy is destined to fail unless state and federal government overhaul the funding and design of maternity services.    

The chairman of the National Association of Specialist Obstetricians and Gynaecologists considers that if NSW health is serious about decreasing the number of unnecessary CS, the policy needs to be linked to extra resources.  

The Maternity Coalition (Australia's National Maternity Consumer Organisation) called for a federal-state cooperation. The spokesperson blamed government funding for the caesarean rate and the crisis in maternity services, which according to the coalition pushed women into fragmented and inappropriate models of care.

Actors and positions

Description of actors and their positions
State Govermentvery supportivevery supportive strongly opposed
Midwivesvery supportivevery supportive strongly opposed
Obstetriciansvery supportivesupportive strongly opposed
Patients, Consumers
Maternity Coalitionvery supportivevery supportive strongly opposed

Actors and influence

Description of actors and their influence

State Govermentvery strongstrong none
Midwivesvery strongneutral none
Obstetriciansvery strongvery strong none
Patients, Consumers
Maternity Coalitionvery strongneutral none
Midwives, Maternity CoalitionState GovermentObstetricians

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Area Health Services (AHS) in News South Wales were required to have procedures controlling the timing of elective or pre-labour caesarean sections.

Monitoring and evaluation

No formal evaluation of the policy has been announced. The gestation for elective or pre-labour caesarean section will be reported for each public hospital providing maternity services in the annual NSW Mothers and Babies. A new policy "A New Direction for NSW Maternity Services Towards 2012" is also expected to be introduced mid 2008.

Expected outcome

To reduce the number of CS with no underlying medical indication and decrease the number of elective CS performed before 39 weeks gestation unless there are clinical reasons. To improve the information and decision making process for women considering elective CS.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable two system more equitable
Cost Efficiency very low neutral very high


Sources of Information

1. Callaghan WM, MacDorman MF, Rasmussen SA, Qin C, Lackritz EM. The contribution of preterm birth to infant mortality rates in the United States. Pediatrics: 118(4): 1566-73, 2006

2. MacDorman MF, Declercq E, Menacker F, Malloy MH. Infant and neonatal mortality for primary caesarean and vaginal births to women with "No indicated risk," United States, 1998-2001 birth cohorts. Birth : 33(3): 175-82, 2006

3. Zanardo V, Simbi AK, Franzoi M, Solda G, Salvadori A, Trevisanuto D. Neonatal respiratory morbidity risk and mode of delivery at term: Influence of timing of elective caesarean delivery. Acta Paediatrica : 93(5): 643-7, 2004

4. The Royal Australian and New Zealand College of Obstetricians. College statement: Timing of elective caesarean section. 2006. 

5. NSW Health. Policy directive: Maternity timing of elective or pre-labour caesarean section. North Sydney: Department of Health, NSW; 2007. 

6. Centre for Epidemiology and Research. NSW Department of Health. New South Wales mothers and babies 2005. NSW Public Health Bulletin Supplement 2007;18 (S-1): 1-135.

7. Laws P, Abeywardana S, Walker J, Sullivan EA. Australia's mothers and babies 2005. Sydney: AIHW National Perinatal Statistics Unit; 2007. 

8. National Institute for Clinical Excellence, Caesarean section: Clinical guideline 13. London: National Institute for Clinical Excellence; 2004.  

Other resources

Maternal coalition:  

Author/s and/or contributors to this survey

Gallego, Gisselle

Suggested citation for this online article

Gallego, Gisselle. "New rules for caesarean section". Health Policy Monitor, April 2008. Available at