Introduction:
Cesarean sections (CS) rates have increased worldwide, the optimal rate of CS has been long debated¹. Operative vaginal delivery (OVD) can provide a safe alternative in modern obstetric care². The rates of CS and OVD in Europe varied vary largely. CS rates in Europe (median rate 26.0% in 2019) in 2019 from 16.4% in Norway to 53.1% in Cyprus³. In Estonia, the share of CS was low, 6.4% in 1992⁴, in 2015 was 19.5%⁵. Today, Estonia is one of the safest countries in the Europe for giving birth³.

Aim:
Provide an overview of CS and OVD trends in Estonia.

Methods:
Data was obtained from the Estonian Medical Birth Registry (EMBR). EMBR was founded in 1992 and is a central digital registry collecting data about all births in Estonia. All births in the years 1992 – 2016 were included (n= 356 063). Trends of CS and OVD in total were analyzed. Incidence Rate Ratio (IRR) was calculated, and two time periods compared for total CS rates, adjusted by the mother’s age.

Results:
The annual number of births in Estonia decreased significantly, and the proportion of CS increased. The proportion of CS increased from 6.5% in 1992 to 20.9% in 2007 and remained stable thereafter. Mean age of mothers increased during the study period. The average annual increase in the number of CS between 1992 and 2009 is 6.5% (IRR 1.065, 95% CI 1.063–1.067), adjusted for the age of the mother, the number of CS increased by 3.6% per year (age-adjusted IRR 1.036, 95% Cl 1.034–1.038). In the years 2010 – 2016, the number of CS decreased slightly, but adjusting by mother’s age, the increase was ~3% per year. In 1992, 0.63% of all births were OVD but the proportion increased to 5.9% by 2016.

Conclusion:
In Estonia, the time trends of CS and OVD are similar, if the CS rate rises quickly, the OVD rate also rises. In order to improve the quality of maternity care, it is important to monitor the rates of operative delivery. The reasons for the increase of operative deliveries deserve detailed analyses.