The scandal of avoidable baby deaths in Shrewsbury, England, was partly caused by an obsession with natural birth, an independent inquiry found this week.

A 234-page report was deeply critical of the culture at Shrewsbury and Telford hospital NHS trust, where staff deliberately sought to keep caesarean section rates low.

In some cases women were denied caesarean sections when they should have been offered one. As a result, some were forced to endure extreme pain to try to achieve a vaginal birth, sometimes with harmful and even fatal consequences for their baby.

The culture in Shrewsbury originated from the “normal birth movement” during the 1980s, when concerns started to be raised about the increasing use of medical intervention in childbirth. Vaginal birth is a natural and physiological process. However, in certain circumstances, a caesarean section may be needed to protect the woman and the baby’s health.

A caesarean can be advised as a planned procedure or done in an emergency if it is thought a vaginal birth would be too risky. In these circumstances, underuse of caesarean sections, the likes of which occurred in Shrewsbury, contributes to an increased risk of poor outcomes.

At the same time, overuse, where the use of caesarean section has no medical indication, may lead to harm and a waste of resources. A caesarean section is a major operation that carries a number of risks, so it is usually only done if it is the safest option for the woman and their baby. Striking that balance when it comes to risk is why optimising the use of caesarean section is a global concern and a major public health challenge. Worldwide, the picture is a mixed bag with wildly different rates.

Overall, caesarean section rates continue to increase across high-income, middle-income and low-income countries. In a study published in the BMJ Global Health journal last year, the latest available data showed that 21.1% of women give birth by caesarean section worldwide. The proportion is about one in four in the UK.

However, averages range from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean. While in sub-Saharan Africa an average of 5% indicates underuse, the average of 42.8% in Latin America and the Caribbean is suggestive of overuse. Projections show that by 2030, 28.5% of women worldwide will give birth by caesarean section, ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia.

The variations show the challenge facing the world. In some areas, particularly poorer countries, women who would benefit from caesarean section are unable to have the procedure because of the financial and human resources required. At the same time, in other areas, rates are climbing extremely rapidly, prompting concerns over the health consequences of unnecessary or unsafely conducted operations.

In 1985, the World Health Organization (WHO) said countries should not have a caesarean rate higher than 10-15%. Today, those specific target rates have been dumped and the WHO does not recommend specific rates in populations or hospitals, reflecting the importance of focusing on a woman’s unique needs in pregnancy and childbirth.

More women than ever are giving birth in healthcare facilities, but in many parts of the world, the quality of care is poor, which has a negative effect on the health and wellbeing of the woman and their baby. It is vital all women are able to talk to health staff and be part of the decision-making on their birth, receiving adequate information on their mode of birth including the risks and benefits.