"A cesarean section is a major surgical procedure and should only be performed when medically necessary. When women are allowed to choose their method of delivery, it has a significant impact on the rate of cesarean births," says Kaire Sildver, a midwifery lecturer at the Tallinn Health Care College and Estonia's first midwife to hold a doctoral degree in medical science.

According to her, the World Health Organization and European professional associations currently recommend that cesarean sections make up 15 to 20 percent of all births.

Sildver examined how Estonia's and Finland's birth statistics compare with that recommendation in her recently defended doctoral dissertation. More specifically, she conducted a comparative analysis of the proportion of operative births in both countries from 1992 to 2023. To do so, she reviewed data from the medical birth registries of both nations, covering every birth over the 31-year period.

"Estonia has managed to maintain cesarean section rates more in line with Nordic trends, rather than following the example of southern countries, where this type of delivery is very common," Sildver points out.

Estonia's level Nordic

Operative obstetric care includes cesarean sections as well as assisted vaginal deliveries, such as vacuum and forceps births. Kaire Sildver focused her research on all such cases where medical intervention was required to deliver a baby. According to her, Estonia took much of its inspiration from Finland in this area over the past few decades.

"In Finland, the rate of such births stood at 15 percent in 1992 and increased only slightly over time," Sildver notes. Until 2019, the proportion of operative deliveries in Finland remained close to 16–17 percent. It has since risen to around 20 percent, possibly due to the COVID-19 pandemic or other contributing factors.

In contrast, Estonia lagged significantly behind Finland in 1992, following the restoration of independence. "We didn't have as many resources, which is why our cesarean section rate at the time was just 6 percent. That already fell short of the WHO's recommended rate, which was 15 percent back then," Sildver points out. She adds that a 6 percent rate is comparable to present-day levels in parts of Africa where access to obstetric care remains limited. The WHO has since revised its recommendation upward to 15–20 percent.

In the early 1990s, Estonia had limited equipment and was still relying on Soviet-era guidelines, but from that point on, local obstetric care began to improve rapidly, Sildver explains. Equipment, technology and clinical guidelines all saw major advancements. "Around 2007, the cesarean rate stabilized at around 19–20 percent, which has remained consistent to this day," the midwife notes.

According to Sildver, Estonia has since done a fairly good job of staying within the recommended range: in some years, cesarean sections account for 21 percent of births, in others 20 percent. "If we compare that with other European countries, the Nordic countries — Finland, Sweden, Norway, Denmark and Iceland — are all model examples when it comes to obstetric indicators," she says. The same, she adds, cannot be said of all European countries. For example, cesarean sections make up 44 percent of all births in Poland and 54 percent in Cyprus.

Sildver says such statistics depend, first and foremost, on whether women are allowed to choose their method of delivery. "Another very strong factor is money. If a country funds hospitals or doctors in a way that makes a cesarean section significantly more expensive than a vaginal birth, it becomes more financially advantageous for the hospital or doctor to perform more cesareans," she explains. The share of operative births also depends on nationally regulated clinical guidelines: how detailed and strict they are and how developed the midwifery system is in that country. According to Sildver, many studies have shown that access to high-quality midwifery care is one of the most important contributing factors.

Every hospital's statistics counts

In her doctoral dissertation, Kaire Sildver also examined the risk factors associated with operative deliveries. The first of these is the use of epidural anesthesia — a pain-relieving injection administered around the spinal cord to reduce labor pain. "Epidural use has become significantly more common, although in Finland it's used nearly twice as often as in Estonia," the midwife notes.

The second factor is maternal age, which continues to rise across Europe. "Older mothers tend to have more chronic health conditions and other risks, which in turn can increase the likelihood of both cesarean sections and operative vaginal deliveries," Sildver explains.

Based on her research findings, she also offered recommendations for the Estonian healthcare system on how to maintain its current high standards. "First and foremost, each hospital should monitor its own cesarean trends," she says. The WHO recommends categorizing cesarean births into ten groups according to the Robson classification system. Each group has its own benchmark rates set by the WHO. The Robson criteria can also be used to analyze operative vaginal deliveries.

"If we start exceeding the limits, we need to look inward: why is the cesarean rate rising?" the midwife points out. Perhaps first-time mothers need more support. Or perhaps the increase in repeat cesareans warrants further investigation. In any case, Sildver says, each hospital should analyze its own data in addition to relying on national statistics.

"Birth rates are falling across Europe, including in Estonia and Finland. From a public health policy standpoint, it's important to raise birth rates and the choice of delivery method plays a role in that," she adds. According to Sildver, every country should have a well-functioning Medical Birth Registry. High-quality registry data is essential for making evidence-based public health decisions.

This, in turn, would enable further development in both midwifery and the broader field of obstetric care, she says. However, analyzing individualized data has become increasingly difficult due to stricter access requirements and high associated costs. This negatively affects healthcare development and hampers cross-country comparisons and quality assessments. "Health policy decisions, clinical guidelines, data collection and analysis of operative delivery trends across countries all contribute to better health outcomes for mothers and newborns," Sildver concludes.

Kaire Sildver defended her dissertation, "Operative Deliveries in Estonia and Finland, 1992–2023," on November 24 at the University of Tartu. Her supervisors were Piret Veerus, senior researcher at the National Institute for Health Development; Katrin Lang, associate professor of epidemiology at the University of Tartu; and Mika Gissler, lead researcher at the Finnish Institute for Health and Welfare and Karolinska Institute in Sweden. The opponent was Professor Piotr Sieroszewski of the Medical University of Łódź.

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