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On July 18, 1976, the Soviet naval vessel, Kiev, transited the Turkish Straits from the Black Sea to the Mediterranean, with Turkish consent. Questions have been raised concerning the international legality of this transit, and in light of earlier reaction to an alleged violation by the Soviet Union of the rules on the passage of submarines through the Turkish Straits it seems appropriate to examine the facts and the governing law.

OBJECTIVE: To generate a global reference for caesarean section (CS) rates at health facilities. DESIGN: Cross-sectional study. SETTING: Health facilities from 43 countries. POPULATION/SAMPLE: Thirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10,045,875 women giving birth from 43 countries for model testing. METHODS: We hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. MAIN OUTCOME MEASURES: Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. RESULTS: According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/). CONCLUSIONS: This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. TWEETABLE ABSTRACT: The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems.

ObjectiveTo generate a global reference for caesarean section (CS) rates at health facilities. DesignCross-sectional study. SettingHealth facilities from 43 countries. Population/SampleThirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10045875 women giving birth from 43 countries for model testing. MethodsWe hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. Main outcome measuresArea under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. ResultsAccording to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (). ConclusionsThis article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. Tweetable abstractThe C-Model provides a customized benchmark for caesarean section rates in health facilities and systems. Tweetable abstract The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems. ; NICHD NIH HHS ; World Health Organization ; Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Social Med, Av Bandeirantes, BR-3900 Ribeirao Preto, Brazil ; WHO, World Bank Special Programme Res Dev & Res Traini, UNDP UNFPA UNICEF WHO, Dept Reprod Hlth & Res, CH-1211 Geneva, Switzerland ; Univ Paris 05, Sorbonne Paris Cite, UMR 216, Inst Dev Res, Paris, France ; WHO Reg Off Amer, Women & Reprod Hlth CLAP WR, Latin Amer Ctr Perinatol, Montevideo, Uruguay ; Emory Univ, Rollins Sch Publ Hlth, Dept Epidemiol, Atlanta, GA 30322 USA ; Paris Descartes Univ, Ctr Epidemiol & Biostat, Obstetr Perinatal & Pediat Epidemiol Res Team, Inserm U1153, Paris, France ; Natl Inst Publ Hlth, Ctr Populat Hlth Res, Cuernavaca, Morelos, Mexico ; Univ Technol, Fac Hlth, Sydney, NSW, Australia ; Natl Ctr Child Hlth & Dev, Dept Hlth Policy, Tokyo, Japan ; Ctr Rosarino Estudios Perinat, Rosario, Argentina ; Lindsay Stewart R&D Ctr, Off Res & Clin Audit, Royal Coll Obstetricians & Gynaecologists, London, England ; London Sch Hyg & Trop Med, Dept Hlth Serv Res & Policy, London WC1, England ; Shanghai Jiao Tong Univ, Sch Med, Xinhua Hosp, Shanghai Key Lab Childrens Environ Hlth,Minist Ed, Shanghai 200030, Peoples R China ; Univ Estadual Campinas, Sch Med Sci, Dept Obstet & Gynaecol, Campinas, SP, Brazil ; Family Hlth Bur, Minist Hlth, Colombo, Sri Lanka ; Fiocruz MS, ENSP, BR-21045900 Rio De Janeiro, Brazil ; Natl Inst Hlth & Welf, Helsinki, Finland ; Univ Tokyo, Grad Sch Med, Dept Paediat, Tokyo, Japan ; Bayer Krankenhausgesellschaft, Bayer Arbeitsgemeinschaft Qualitatssicherun Stati, Munich, Germany ; Khon Kaen Univ, Fac Med, Dept Obstet & Gynecol, Khon, Kaen, Thailand ; Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Obstet & Gynaecol, BR-14049 Ribeirao Preto, Brazil ; Minist Sante, Direct Sante Famille, Ouagadougou, Burkina Faso ; Univ Washington, Inst Hlth Metr & Evaluat, Seattle, WA 98195 USA ; Univ Mongolia, Hlth Sci, Sch Publ Hlth, Ulaanbaatar, Mongol Peo Rep ; GLIDE Tech Cooperat & Res, Ribeirao Preto, SP, Brazil ; Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Paediat, BR-14049 Ribeirao Preto, SP, Brazil ; Univ Calif San Francisco, Dept Obstet & Gynaecol & Global Hlth Sci, San Francisco, CA 94143 USA ; Khon Kaen Univ, Fac Publ Hlth, Dept Biostat & Demog, Khon Kaen, Thailand ; Univ Fed Sao Paulo, Sch Med Sao Paulo, Dept Obstet, Sao Paulo, Brazil ; Inter Amer Dev Bank, Social Protect & Hlth Div, Mexico City, DF, Mexico ; Fortis Mem Res Inst, Gurgaon, Haryana, India ; Hosp Nacl Itaugua, Itaugua, Paraguay ; Univ Fed Sao Paulo, Sch Med Sao Paulo, Dept Obstet, Sao Paulo, Brazil ; NICHD NIH HHS: T32 HD052460 ; World Health Organization: 001 ; Web of Science

ObjectiveTo generate a global reference for caesarean section (CS) rates at health facilities. DesignCross-sectional study. SettingHealth facilities from 43 countries. Population/SampleThirty eight thousand three hundred and twenty-four women giving birth from 22 countries for model building and 10045875 women giving birth from 43 countries for model testing. MethodsWe hypothesised that mathematical models could determine the relationship between clinical-obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three-step approach to generate the global benchmark of CS rates at health facilities: creation of a multi-country reference population, building mathematical models, and testing these models. Main outcome measuresArea under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate. ResultsAccording to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C-Model, with summary estimates ranging from 0.832 to 0.844. The C-Model was able to generate expected CS rates adjusted for the case-mix of the obstetric population. We have also prepared an e-calculator to facilitate use of C-Model (). ConclusionsThis article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C-Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS. Tweetable abstractThe C-Model provides a customized benchmark for caesarean section rates in health facilities and systems. Tweetable abstract The C-Model provides a customized benchmark for caesarean section rates in health facilities and systems. ; NICHD NIH HHS ; World Health Organization ; Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Social Med, Av Bandeirantes, BR-3900 Ribeirao Preto, Brazil ; WHO, World Bank Special Programme Res Dev & Res Traini, UNDP UNFPA UNICEF WHO, Dept Reprod Hlth & Res, CH-1211 Geneva, Switzerland ; Univ Paris 05, Sorbonne Paris Cite, UMR 216, Inst Dev Res, Paris, France ; WHO Reg Off Amer, Women & Reprod Hlth CLAP WR, Latin Amer Ctr Perinatol, Montevideo, Uruguay ; Emory Univ, Rollins Sch Publ Hlth, Dept Epidemiol, Atlanta, GA 30322 USA ; Paris Descartes Univ, Ctr Epidemiol & Biostat, Obstetr Perinatal & Pediat Epidemiol Res Team, Inserm U1153, Paris, France ; Natl Inst Publ Hlth, Ctr Populat Hlth Res, Cuernavaca, Morelos, Mexico ; Univ Technol, Fac Hlth, Sydney, NSW, Australia ; Natl Ctr Child Hlth & Dev, Dept Hlth Policy, Tokyo, Japan ; Ctr Rosarino Estudios Perinat, Rosario, Argentina ; Lindsay Stewart R&D Ctr, Off Res & Clin Audit, Royal Coll Obstetricians & Gynaecologists, London, England ; London Sch Hyg & Trop Med, Dept Hlth Serv Res & Policy, London WC1, England ; Shanghai Jiao Tong Univ, Sch Med, Xinhua Hosp, Shanghai Key Lab Childrens Environ Hlth,Minist Ed, Shanghai 200030, Peoples R China ; Univ Estadual Campinas, Sch Med Sci, Dept Obstet & Gynaecol, Campinas, SP, Brazil ; Family Hlth Bur, Minist Hlth, Colombo, Sri Lanka ; Fiocruz MS, ENSP, BR-21045900 Rio De Janeiro, Brazil ; Natl Inst Hlth & Welf, Helsinki, Finland ; Univ Tokyo, Grad Sch Med, Dept Paediat, Tokyo, Japan ; Bayer Krankenhausgesellschaft, Bayer Arbeitsgemeinschaft Qualitatssicherun Stati, Munich, Germany ; Khon Kaen Univ, Fac Med, Dept Obstet & Gynecol, Khon, Kaen, Thailand ; Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Obstet & Gynaecol, BR-14049 Ribeirao Preto, Brazil ; Minist Sante, Direct Sante Famille, Ouagadougou, Burkina Faso ; Univ Washington, Inst Hlth Metr & Evaluat, Seattle, WA 98195 USA ; Univ Mongolia, Hlth Sci, Sch Publ Hlth, Ulaanbaatar, Mongol Peo Rep ; GLIDE Tech Cooperat & Res, Ribeirao Preto, SP, Brazil ; Univ Sao Paulo, Ribeirao Preto Med Sch, Dept Paediat, BR-14049 Ribeirao Preto, SP, Brazil ; Univ Calif San Francisco, Dept Obstet & Gynaecol & Global Hlth Sci, San Francisco, CA 94143 USA ; Khon Kaen Univ, Fac Publ Hlth, Dept Biostat & Demog, Khon Kaen, Thailand ; Univ Fed Sao Paulo, Sch Med Sao Paulo, Dept Obstet, Sao Paulo, Brazil ; Inter Amer Dev Bank, Social Protect & Hlth Div, Mexico City, DF, Mexico ; Fortis Mem Res Inst, Gurgaon, Haryana, India ; Hosp Nacl Itaugua, Itaugua, Paraguay ; Univ Fed Sao Paulo, Sch Med Sao Paulo, Dept Obstet, Sao Paulo, Brazil ; NICHD NIH HHS: T32 HD052460 ; World Health Organization: 001 ; Web of Science