Despite ongoing efforts to lower the skyrocketing rate of cesarean deliveries in the United States, the rate of cesareans may in fact be a little too low worldwide.

That’s the conclusion of researchers who conducted two studies looking at overall health data from 194 countries.The combined results of the studies were published today in the Journal of the American Medical Association.

The researchers estimated that there were almost 23 million cesarean deliveries worldwide in 2012. That’s 19.4 cesareans for every 100 live births.

Researchers concluded the 19 percent was the optimum level for the overall health and safety of mothers and babies of any particular region.

The recommendation is above the 10 to 15 percent the World Health Organization (WHO) has set as a global goal. The researchers noted a 10 percent cesarean rate on average yields a mortality rate of 180 per 100,000 births. A 19 percent rate produces a mortality rate under 100 for 100,000 births.

“That’s a pretty dramatic difference,” said Dr. Alex B. Haynes, a study co-author and associate director of the safe surgery program at Ariadne Labs in Boston.

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A Deeper Look at the Numbers

Haynes told Healthline his team became interested in the cesarean rates while looking at the role of surgical care and overall health outcomes.

They noticed that cesarean deliveries account for 30 to 40 percent of all surgeries in some countries. Cesareans are the most common surgery in the United States, accounting for more than 30 percent of all births.

The research team collected health data from all 194 WHO member states to estimate cesarean delivery rates. The rates from country to country varied widely. Some developed nations, including the United States, had rates above the 19 percent. Others didn’t. Some developing nations, Haynes said, have high rates of cesarean deliveries while others don’t. In those nations, lack of access to healthcare was a major reason.

Haynes said the team concluded countries that increase their cesarean rates from 0 to 7 percent show a marked decline in mortality rates per live birth. From 7 to 19 percent there is still a decline but not as great. After 19 percent, he said, there isn’t much advantage.

“C-sections are really an important procedure when they’re needed for the health and safety of the mother and baby,” Haynes told Healthline. “However, they are still an invasive surgical procedure.”

Read More: Why Are Cesareans Performed? »

An Overall Look at Health Services

The debate over cesarean deliveries has intensified in recent years. The procedure is used when problems develop with fetal health, the mother’s health, the fetus’ positioning, the umbilical cord and other situations.

The surgery, however, can also cause infection, bleeding, and other complications.

Pragmatists recommend doing cesarean delivery when it is medically necessary, but not just because it’s convenient.

Haynes said the 19 percent rate might not be optimal for every country. It depends on their healthcare system.

For cesarean deliveries to be successful, a facility needs to be sanitized and it needs to have resources such as clean water. Facilities also need to be close enough that pregnant women in labor can reach it in an emergency.  

Haynes said the 19 percent is not so much a facility-by-facility guideline, but rather a target for countries to set policies in line with the status of their healthcare system.

Read More: First-Time C-Sections Can Lead to Greater Health Complications »