Changes in cesarean section rates before and during the COVID-19 pandemic in South Korea

To evaluate changes in cesarean section (CS) rates in South Korea before and during the coronavirus disease 2019 (COVID-19) pandemic.

This retrospective cohort study analyzed all deliveries recorded in the Korean National Health Insurance Service database (2015-2021). We compared CS rates between pre-pandemic (2015-2019) and pandemic (2020-2021) periods. Interrupted time-series analysis (ITSA) assessed temporal changes, stratified by parity. Sensitivity analyses evaluated a low-risk group, excluding major complications, and a term singleton nulliparous subgroup to assess changes in medical indications.

Of 2,255,524 deliveries, the overall CS rate increased from 45.7% to 56.8% (P<0.001). ITSA demonstrated a consistent pre-pandemic upward trend (relative risk [RR], 1.0023; 95% confidence interval [CI], 1.0022-1.0024) and a modest immediate increase at the onset of the pandemic (RR, 1.0097; 95% CI, 1.0011-1.0184), with no sustained slope changes. The low-risk CS rate rose from 29.5% to 42.0% (P<0.001), showing a similar immediate-onset increase (RR, 1.0087; 95% CI, 1.0005-1.017). The term singleton nulliparous rate increased from 43.1% to 56.4% (P<0.001), driven entirely by the pre-pandemic trend (RR, 1.0029; 95% CI, 1.0028-1.0030), with no statistically significant immediate pandemic effect (RR, 1.0089; 95% CI, 0.9994-1.0184).

The COVID-19 pandemic was associated with a brief, immediate rise in overall CS rates but did not alter the long-term upward trends. This suggests persistent structural factors - such as a medico-legal environment, obstetrician shortages, and evolving practice norms - primarily drive South Korea's rising CS rates, rather than immediate clinical disruptions.