Postpartum Maternal Mortality and Cesarean
Catherine Deneux-Tharaux, MD, MPH, Elodie Carmona, MPH, Marie-Hélene Bouvier-Colle, PhD,
and Gérard Bréart, MD
OBJECTIVE: A continuous rise in the rate of cesarean
delivery has been reported in many countries during the
past decades. This trend has prompted the emergence of
a controversial debate on the risks and benefits associ-
ated with cesarean delivery. Our objective was to pro-
vide a valid estimate of the risk of postpartum maternal
death directly associated with cesarean as compared with
METHODS: A population-based case–control study was
designed, with subjects selected from recent nationwide
surveys in France. To control for indication bias, maternal
deaths due to antenatal morbidities were excluded. For
the 5-year study period 1996–2000, 65 cases were in-
cluded. The control group was selected from the 1998
French National Perinatal Survey and included 10,244
women. Multivariable logistic regression analysis was
used to adjust for confounders.
RESULTS: After adjustment for potential confounders,
the risk of postpartum death was 3.6 times higher after
cesarean than after vaginal delivery (odds ratio 3.64 95%
confidence interval 2.15–6.19). Both prepartum and in-
trapartum cesarean delivery were associated with a sig-
nificantly increased risk. Cesarean delivery was associ-
ated with a significantly increased risk of maternal death
from complications of anesthesia, puerperal infection,
and venous thromboembolism. The risk of death from
postpartum hemorrhage did not differ significantly be-
tween vaginal and cesarean deliveries.
CONCLUSION: Cesarean delivery is associated with an
increased risk of postpartum maternal death. Knowledge
of the causes of death associated with this excess risk
informs contemporary discussion about cesarean deliv-
ery on request and should inform preventive strategies.
(Obstet Gynecol 2006;108:541–8)
LEVEL OF EVIDENCE: II-2
during the past decades. In France, this rate increased
from 10.8 % in 1981 to 20.2 % in 2003,1,2representing
approximately 160,000 women having cesarean de-
livery each year. A concomitant increase in the
prevalence of situations where cesarean delivery is
indicated to prevent severe maternal or infant com-
plications is unlikely. It seems likely that the range of
indications for cesarean delivery has broadened con-
siderably, and that more cesarean deliveries are per-
formed with few or no medical indications. In France,
the recent rise in the global cesarean rate is explained
entirely by the rise in prepartum cesarean delivery.1
Recently, some professionals have gone so far as to
propose elective cesarean delivery as an acceptable
first-choice method of delivery for women with nor-
mal pregnancy.3This trend has prompted the emer-
gence of a controversial debate on the risks and
benefits associated with cesarean delivery.4
This study focuses on one of the potential risks of
cesarean delivery: maternal mortality. Although ma-
ternal death has become rare in high-resource coun-
tries, it remains a tragic event, and excess maternal
mortality risk would have a strong effect on the
balance between potential harms and benefits of
cesarean delivery. In addition, maternal mortality
rates have shown little improvement during the past
20 years in developed countries, and factors involved
continuous rise in the rate of cesarean delivery
has been reported in many developed countries
From the Institut National de la Sante et de la Recherche Medicale (INSERM),
Unite Mixte de Recherche S149, Institut Federatif de Recherche 69, Epidemi-
ological Research Unit on Perinatal and Women’s Health, Hopital Tenon, Paris,
France; and Universite Pierre et Marie Curie-Paris 6, Paris, France.
The National Perinatal Surveys and the Confidential Enquiry on Maternal
Deaths were partly funded by the French Ministry of Health.
The authors thank the national coordination of the French National Perinatal
Surveys for providing data, and the National Committee of Experts on Maternal
Corresponding author: Catherine Deneux-Tharaux, INSERM U149, Maternite
Hopital Tenon, 4 rue de la Chine, 75020 Paris, France; e-mail:
© 2006 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
VOL. 108, NO. 3, PART 1, SEPTEMBER 2006OBSTETRICS & GYNECOLOGY
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