In 2024–2025, at the Emergency Hospital in Târgu Mureș, 31 births in 100 were by caesarean. At Bucharest’s University Hospital, 79.

Who gives birth there explains little#

The data come from the public tables of the DRG (diagnosis-related groups) system, the case-based scheme through which Romania’s National Health Insurance House (CNAS) pays hospitals. Every hospital birth falls into a group: caesarean or vaginal, with or without complications. From these, each unit’s rate can be worked out year by year, from 2018 to September 2026. For 2020 the calculation gives the same rates as a published study, to one decimal: 52.9% nationally, 49.7% in state hospitals and 79.8% in private ones (the study counts 3,317 fewer births).

The same tables say how many newborns under 2,500 grams and under 1,500 grams pass through each hospital, how many births it has, and whether it is private or state-run. A 2006 Ministry of Health order lists which maternity units were level III (regional referral centres) or level II (the next tier down). A model using all these characteristics, fitted only on 2018–2023, tried to predict the 2024 and 2025 rate of every unit with at least 200 births a year and a 2021–2023 history (226 unit-years). It was off by 12.9 percentage points on average.

The unit’s own 2021–2023 rate, on its own, was off by 4.0 points. A model that uses the other maternity units of the same county instead of the level (Romania has 41 counties plus Bucharest) is off by 10.9 points, still almost three times as much. Both get the same national trend, extended from 2018–2023. In the first nine months of 2026, which neither model had seen, the gap holds: 10.8 points against 4.8.

This does not show that any caesareans were unnecessary. It shows that the difference between units does not show up in what these tables measure about their patients, and that it persists from one year to the next: each unit’s deviation from the county model in 2019–2020 and in 2024–2025 correlate at 0.84 across 107 units (0.82 when the model is fitted only on 2021–2023, outside both periods).

Private clinics: eight in ten, every year#

Private clinics in the tables handled 11.5 in 100 births in 2025. Their caesarean rate has stayed near 80% every year: 80.2% in 2018, 78.6% in 2025. The private–state split explains part of the map, but not all of it: among state units with at least 400 births in 2024–2025 the real rate runs from 8% to 98%. Once the predicted rate is taken away, the standard deviation between them is still about 16 points (13 with the county model), after removing the part due to chance.

Rising almost everywhere#

In state maternity units the rate rose from 50.6% in 2018 to 57.7% in 2025 and 59.0% in the first nine months of 2026. Of the 107 units with at least 400 births in both 2018–2019 and 2024–2025, 77 rose by more than two points and 14 fell by more than two points. The typical rise was 5.2 points.

Eurostat counts differently (all hospital operations reported by the country, divided by all live births), so it gives Romania 51.4 caesareans per 100 live births in 2023, fewer than the DRG tables. Even so, Romania ranks third of the 27 EU countries, after Cyprus (62.0) and Greece (57.9). In the Netherlands, the lowest, the rate is 15.9.

More and more caesareans “with catastrophic complications”#

The DRG system splits caesareans into three groups by the complications written in the patient’s file. The group “with catastrophic complications” is worth almost twice as much to the hospital as the one without severe complications (relative weight 2.31 against 1.22). In 2018, 37 in 100 caesareans were coded in it. In 2025, 66.

The same drift shows in vaginal births: those without any complication fell from 10 to seven in 100. These tables cannot tell whether women became sicker or whether the way diagnoses are written into files changed. That is why the complication groups are not used in the model to describe patients.

What these tables do not show#

The tables do not say how many women are having their first baby, how many had a caesarean before, how many carry twins or a baby lying bottom-first. These characteristics weigh heavily on how a baby is born, and the World Health Organization recommends comparing units on the Robson groups, built from them and from the length of the pregnancy. Romania does not publish Robson groups by maternity unit.

A previous caesarean raises the chance of another one, so a unit with a high rate for years may come to see more and more patients with a past caesarean. Part of what stays unexplained may come from that. Small town hospitals usually send high-risk pregnancies on to the county hospital, so a low rate there is not a mark of quality. Newborns are counted by weight on admission, so large units also count babies transferred in from elsewhere.

The WHO says that across a whole country, rates above 10% are not associated with further falls in maternal and newborn deaths, and also that this figure does not apply to any single unit. Romania’s 2019 clinical guideline describes when a caesarean is indicated. The decision for a particular birth is taken with the doctor following the pregnancy.