The Carbon Footprint of a Cesarean Section: A Study on Real‐Time, Prospectively Collected Data of Disposables, Energy, and Reusables

ABSTRACT

Aim

The healthcare sector, particularly operating rooms, is a major source of greenhouse gas emissions. To reduce this impact, it is important to assess the carbon footprint of medical procedures. The aim of this study was to assess the carbon footprint of a cesarean section, focusing on CO₂‐equivalent (CO₂eq) emissions from disposable products, reusable products, and HVAC energy use.

Methods

A prospective observational study was conducted in a Dutch academic hospital (Feb–Jun 2025). For 50 C‐sections, data on type, material, and weight of disposable and reusable products were collected. CO₂eq emissions were estimated using predefined product groups linked to life cycle assessment (LCA) data. HVAC energy use was calculated from procedure time and corresponding LCA data.

Results

The mean CO₂eq emission of a C‐section was 33.5 [SD 2.2] kg CO₂eq. Disposable products accounted for the largest share, with a mean contribution of 27.7 [SD 1.5] kg CO₂eq. Among disposable the surgical drapes, sterile gauze pads, and surgical gowns were the highest emitting categories. Energy use during the procedure contributed an average of 3.4 [SD 0.9] kg CO₂eq, while reusable products accounted for 2.4 [SD 0.1] kg CO₂eq. The mean CO₂eq emissions of planned and unplanned (urgency Levels S2 and S3) C‐sections were comparable.

Conclusion

The CO₂ emissions of a C‐section are substantial; disposable products were the highest contributors. Emission reduction could be achieved by minimizing unnecessary utilization of disposables, replacing disposables with reusable items, or by reducing the number of C‐sections performed.

1. Introduction

In 2024, global temperatures reached an unprecedented level, marking the first time in which the 1.5°C threshold above pre‐industrial levels was surpassed over the course of an entire year [1]. The Lancet Countdown report highlighted the consequences of temperature rise on public health, including an increase in heat‐related mortality and increased climate suitability for various pathogens [2]. While climate change poses serious threats to public health, the healthcare sector itself contributes to the problem, accounting for roughly 5% of global greenhouse gas emissions [2].

In accordance with the Paris agreement's climate ambitions, leading parties in the healthcare sector have established their own targets [3]. For example, the National Health Service (NHS) England has set a target to achieve net zero emissions of services under their direct control by 2040 [4]. Similarly, Dutch parties in the healthcare sector, including university medical centers, signed a ‘Green Deal’ which aims to achieve 55% reduction in CO₂ emissions by 2030 [5]. In order to identify mitigation opportunities, the emissions associated with current medical procedures must be mapped. Surgical procedures are highlighted because of their significant contribution to hospital waste and their high energy use. These procedures account for an estimated 20%–30% of the total hospital waste generated, and consume three to six times more energy compared to a regular hospital department [6].

A surgical procedure of particular interest is the cesarean section (C‐section), due to its frequent performance. In 2021, 18.1% of the babies born in the Netherlands were delivered by C‐sections, representing a total of 31 013 deliveries [7] Globally, the C‐section rate differs widely, ranging from 12.8% in Iceland to 49.5% in Chile for nulliparous women. Given this high prevalence, the procedure is expected to contribute substantially to the healthcare sector's carbon footprint.

Two retrospective studies assessed the CO₂ equivalent (CO₂eq) emissions of a cesarean section. Both studies compared different birth modes and based their analysis on Life Cycle Assessment (LCA) methodology. The first study, conducted in the United States, included reusable and disposable materials, consumption of energy by heating, ventilation and air conditioning (HVAC) and machines, and waste processing. This study concluded that a cesarean section produced more than twice the CO₂eq emissions of vaginal births, with over 50% of the CO₂eq emission attributed to HVAC systems [8]. The second study, conducted in the United Kingdom and the Netherlands, analyzed the carbon footprint of both reusable and disposable materials, as well as energy consumption and waste processing associated with cesarean sections. The study reported that a single C‐section generated 33.0 kg CO₂ equivalent (kg CO₂eq) emissions, excluding the emissions of anesthesia. The main contributors to this carbon footprint were energy use and disposable materials [9].

While these studies provide valuable insights, certain factors such as the use of additional disposable items not included in standard procedure trays and differences between planned and unplanned C‐sections were not addressed. This was due to the retrospective design of both studies, which relied on existing data sets or estimations of product use. Real‐world data collected prospectively is needed to better understand the CO₂ emissions of surgical procedures and to assess the carbon footprint with greater accuracy.

Therefore, the aim of this study is to assess the carbon footprint of C‐sections based on real‐time, prospectively collected data of disposables, energy, and reusables. The secondary objectives are to evaluate the effect of the urgency level of the C‐section on its carbon footprint and to identify areas with the greatest potential for emission reduction. The carbon footprint of anesthesia was excluded from the scope.

2. Methods

2.1. Study Design and Study Population

A prospective observational study was conducted in an academic hospital in the Netherlands. All C‐sections were included if performed between February and June 2025 and if they met the eligibility criteria: planned C‐sections and those classified with urgency Levels S2 (procedure performed within 75 min) and S3 (procedure performed within 24 h), which started between 08.00 and 16.30 on Monday to Friday. C‐sections performed in highly acute settings (urgency Level S1) were excluded from the study. Additionally, C‐sections involving patients who required isolation measures were excluded.

Ethical approval was obtained by the medical ethical review committee (METC Amsterdam UMC) of the hospital under number: 2025.0465.

2.2. Data Collection

2.2.1. Data for Clinical Assessment

Data registered during the procedure were: the urgency level of the C‐section (S2, S3, planned); OR‐time (duration of the procedure from the patient's arrival in the operating room to their departure); the number of attendees in the operating room; the use of disposables (type, material, and weight); the use of reusable instruments and linen (type, material, and weight). Use of disposables and reusables was registered by tallying. The collection of this data was sufficient to translate the carbon footprint of a C‐section into three main categories: disposables, reusables, and energy.

The scope was focused on the surgical part of the procedure. Therefore, data was not registered on pharmaceuticals; disposables, and reusables used in the nursery room for the neonate; disposables and reusables used by the anesthesiology team; energy used by lighting and operating room equipment; and travel by patients and staff (Figure 1).

FIGURE 1.

Scope of the study: The components within the dashed line are included in the analysis.

2.2.2. Data for Carbon Footprint Assessment

The disposable products (excluding packaging) were assigned to previously determined categories [10] (Table S2) with corresponding CO₂ equivalents based on a peer reviewed LCA study conducted at the same academic center concerning minimally invasive gynecology procedures [11]. The CO₂eq values of reusable textiles, energy, washing, and sterilization were directly retrieved from the same LCA study. The equivalents accounted for CO₂eq emissions across the entire lifecycle: production, transportation, and waste processing. The “energy” subcategory refers to energy from electricity, heating, cooling, and steam used for heating, ventilation and air conditioning (HVAC). The CO₂eq corresponding to the duration of the procedure (per minute of duration) is composed of these elements [11]. The CO₂eq of stainless steel and packaging materials were calculated by using the ReCipe 2016 Midpoint (H) impact assessment method, utilizing background inventory data derived from the Ecoinvent 3.10 database.

2.3. Outcomes

The primary outcome of this study was the mean carbon footprint of a C‐section, expressed in kilogram CO₂ equivalents (kg CO₂eq). Secondary outcomes were the carbon footprint per subcategory: disposables, reusables, and energy each expressed in kg CO₂eq, and the carbon footprint per different urgency level.

2.4. Statistical Analysis (Environmental Impact Assessment)

Results were reported with descriptive statistics. To calculate the CO₂eq emissions of disposables and reusables, the weight of the product was multiplied by the corresponding CO₂eq value. To calculate the CO₂eq emission of instrument tray sterilization, the tray size was expressed in DIN. Subsequently, it was multiplied by the CO₂eq of sterilization [11]. The CO₂eq emissions of energy use (electricity, heating, cooling, and steam) for HVAC was calculated by multiplying the duration of the procedure by the corresponding CO₂ equivalent. The total impact of a C‐section was calculated by combining the CO₂eq emissions of energy, disposables, and reusables.

3. Results

Between February and June 2025, 50 C‐sections were included (Figure 2). Seventy percent (n = 35) of the C‐sections were planned, 14% (n = 7) had an S3 urgency level, and 16% (n = 8) had an urgency level of S2. Two out of 50 surgeries were for twin pregnancies. Three C‐sections were combined with a permanent contraception procedure. In 98% (n = 49) of the cases the C‐section was performed with a Pfannenstiel incision and in 2% (n = 1) with a midline incision. Spinal anesthesia was used for 94% (n = 47) of the C‐sections; the remaining 6% (n = 3) were performed under general anesthesia. The mean time of the procedure was 89 [SD 26] minutes for S2 and S3 C‐sections and 87 [SD 22] minutes for planned C‐sections (Table 1).

FIGURE 2.

Flowchart for inclusion of C‐sections.

TABLE 1.

Baseline characteristics.

	Not planned (S2/S3)	Planned	Total
N (%)	15 (30)	35 (70)	50 (100)
Mean time of procedure in minutes [SD]	89 [26]	87 [22]	88 [23]

3.1. Primary Outcome

The mean carbon footprint of a C‐section was 33.5 [SD 2.2] kg CO₂eq, with the minimum being 30.5 kg CO₂eq and the maximum being 40.5 kg CO₂eq. Disposables contributed most, accounting for 27.7 [SD 1.5] kg CO₂eq. Energy use for HVAC accounted for a mean emission of 3.4 [SD 0.9] kg CO₂eq and reusable products accounted for a mean emission of 2.4 [SD 0.1] kg CO₂eq (Figure 3).

FIGURE 3.

Total carbon footprint of a C‐section categorized in disposables, reusables, and energy.

3.1.1. CO₂eq Emission of a Cesarean Section per Category

The mean use of all individual products or services within the three categories, with corresponding CO₂eq values, are presented in Table 2.

TABLE 2.

CO₂eq emissions of disposables, reusables, and energy.

Product/product group	Kg CO2eq of product	Mean product use [SD]	Kg CO2eq * mean product use [SD]
Disposables a
Procedure tray b	21.37	1.0 [0.0]	21.4 [0.0]
Upholstery OR table b	0.73	1.0 [0.0]	0.7 [0.0]
Standard extra b	1.27	1.0 [0.0]	1.3 [0.0]
Sterile gloves	0.17	4.0 [0.8]	0.7 [0.1]
Methylene blue b	0.74	0.1 [0.3]	0.1 [0.2]
Arterial and venous blood sample b	0.07	0.2 [0.4]	0.01 [0.0]
Instrument tray b	0.52	1.0 [0.0]	0.5 [0.0]
Cellulose underpad	0.14	0.3 [0.6]	0.0 [0.1]
Neonatal heat loss prevention suit	0.19	0.1 [0.2]	0.0 [0.0]
Kiwi	0.40	0.1 [0.3]	0.0 [0.1]
Surgical gown	1.11	1.9 [0.8]	2.1 [0.8]
Cleaning towel	0.10	0.0 [0.2]	0.0 [0.0]
Steri strip	0.01	0.1 [0.3]	0.0 [0.0]
EDTA blood collection tube	0.04	0.0 [0.1]	0.0 [0.0]
Marker	0.05	0.0 [0.2]	0.0 [0.0]
Suction tip and tube	0.11	0.0 [0.2]	0.0 [0.0]
Facemask	0.01	11.7 [1.5]	0.1 [0.0]
PA bottle	0.13	0.0 [0.1]	0.0 [0.0]
Needle	0.01	0.0 [0.1]	0.0 [0.0]
Syringe 10 mL	0.11	0.0 [0.1]	0.0 [0.0]
Bowl 1000 mL + 500 mL	0.40	0.1 [0.2]	0.0 [0.1]
Surgical drape baby bed	1.80	0.0 [0.2]	0.1 [0.4]
Kidney bowl	0.04	0.0 [0.1]	0.0 [0.0]
Adhesive tape	0.10	0.0 [0.1]	0.0 [0.0]
CTX 36 needle, vicryl suture	0.05	0.1 [0.3]	0.0 [0.0]
2–0 vicryl suture	0.05	0.0 [0.2]	0.0 [0.0]
Gauze pads round	0.38	0.1 [0.2]	0.0 [0.1]
Tachosyl	0.05	0.0 [0.1]	0.0 [0.0]
Umbilical cord clamp	0.02	0.1 [0.3]	0.0 [0.0]
Abdominal gauze pads	1.83	0.1 [0.4]	0.2 [0.7]
Suction tube	1.22	0.0 [0.1]	0.0 [0.2]
Sterile gloves (1 pair)	0.17	0.0 [0.1]	0.0 [0.0]
Fluid collection bag	0.26	1.0 [0.1]	0.3 [0.0]
Total disposables			27.7 [1.5]
Reusables
Instrumenttray b	1.34	1.0 [0.0]	1.3 [0.0]
Upholstery OR table	0.65	1.0 [0.0]	0.7 [0.0]
Clothing OR staff b	0.03	11.7 [1.53]	0.4 [0.1]
Tea towel	0.08	0.08 [0.34]	0.0 [0.0]
Operation gown patient	0.05	1.00 [0.00]	0.0 [0.0]
Total reusables			2.4 [0.1]

	Kg CO2eq per minute	Mean time [SD]	kg CO2eq*minutes
Energy
Time (minutes)	0.04	87.6 [23.0]	3.4 [0.9]
Total CO2‐eq emissions in mean kg CO2eq [SD]
			33.5 [2.2]

Note: For four C‐sections the number of attendants could not be assessed. Since this accounted for < 10% of the total inclusions, the median value was used. During one C‐section the use of additional disposables could not be observed. Consequently, the median from the other 49 inclusions was used.

^a Packaging of the disposables was included in the calculations.

^b These categories describe combinations of products. The content is described in Table S2.

3.1.1.1. Category Disposables

The largest contributor to the total CO₂eq emissions of a C‐section were disposable products (Figure 3). In total, 127 different disposable products were registered and divided into 24 categories (Table S1). The five disposable categories that contributed most to the emissions were highlighted in Figure 4. The category surgical drapes had the highest emission, namely 7.9 kg CO₂eq contributing for 24% to the total procedure's CO₂eq emissions. Sterile gauze pads were the second highest contributors being responsible for 13% of the total procedure's emissions, accounting for 4.3 kg CO₂eq. Surgical gowns also contributed for 13% to the total carbon footprint, and accounted for an emission of 4.2 kg CO₂eq. The category “Other” included all products that did not fit into any predefined category, a complete list of these products is provided in Table S2. Within this category, the highest contributor to CO₂eq emissions was blue wrap (sterile packaging material), accounting for 1% of the total procedures emissions, being 0.5 kg CO₂eq.

FIGURE 4.

Highest contributing categories to carbon footprint of disposables.

3.1.1.2. Category Energy

The mean procedure time was 87.6 [SD 23.0] minutes. Based on the pre‐calculated CO₂eq, the mean CO₂eq emission from energy use was 3.4 [SD 0.9] kg CO₂eq.

3.1.1.3. Category Reusables

Reusables contributed the least to the total emissions, accounting for 2.4 [SD 0.1] kg CO₂eq. Instrument sterilization was the largest contributor in this category with an emission of 1.0 [SD 0.0] kg CO₂eq, accounting for 3% of the procedure's total carbon footprint. The second largest contributor in this category was surgical table covers. The emission accounted for 2% of the total procedure's carbon footprint, producing 0.7 [SD 0.0] kg CO₂eq. The third highest contributor was the emission from clothing (including washing) of the OR staff, which accounted for 1% of the total procedure's carbon footprint, producing 0.4 [SD 0.1] kg CO₂eq.

3.1.2. CO₂eq Emissions of a Cesarean Section per Emergency Level

Of the 50 included C‐sections, 15 were unplanned and categorized as urgency Levels S2 or S3 the other 35 were planned procedures. The mean total CO₂eq emission for an entirely planned setting was 33.7 [SD 2.2] kg CO₂eq compared to 33.0 [SD1.9] kg CO₂eq for a more acute setting (S2/S3) (Figures 5 and 6). The disposables were responsible for a slightly higher emission in planned C‐sections, namely 27.9 [SD 1.6] kg CO₂e q, compared to 27.2 [SD 1.2] kg CO₂eq for more acute (S2/S3) C‐sections. The CO₂eq emissions of reusables and energy were similar across both categories. Specifically, for reusables, emissions were 2.4 [SD 0.1] kg CO₂eq for planned C‐sections and 2.4 [SD 0.0] kg CO₂eq for more acute C‐sections. For energy the CO₂eq emissions were 3.4 [SD 0.8] kg CO₂eq for planned C‐sections and 3.4 [SD 1.0] kg CO₂eq for unplanned C‐sections.

FIGURE 5.

Contributing factors to total carbon footprint planned C‐section.

FIGURE 6.

Contributing factors to total carbon footprint unplanned C‐section.

4. Discussion

The aim of this prospective observational study was to assess the carbon footprint of a cesarean section in terms of CO₂eq emissions of disposables, reusables and energy use. The findings of this study showed that the mean CO₂eq emission of a C‐section was 33.5 [SD 2.2] kg CO₂eq, with disposables contributing to 83% of the total carbon footprint. The mean CO₂eq emissions of planned and unplanned (more acute S2/S3) C‐sections, respectively 33.7 [SD 2.2] kg CO₂eq and 33.0 [SD 1.9] kg CO₂eq, were comparable.

The findings of the total carbon footprint of a C‐section were similar to Spil et al. [9] who reported a total carbon footprint of 33.0 kg CO₂eq for reusables (stainless steel, laundry), energy, and disposables (personal protective equipment and consumables). However, the distribution of emissions per category differed; a lower contribution of CO₂eq emissions from disposables was reported, namely 19.0 kg CO₂eq versus 27.7 kg CO₂eq in this study, and a 3.5 times higher energy consumption was reported of 12.0 kg CO₂eq versus 3.4 kg CO₂eq in this study [9]. This first difference can potentially be explained by the different study designs; Spil et al. estimated disposable emissions by a limited number of waste audits and based on expert opinion, in this study data was prospectively collected of 50 procedures which may have highlighted greater utilization of disposables leading to higher emissions. The second difference, the category energy, was partly explained due to the scope used for calculation energy consumption. Spil et al. included the energy consumption of lighting, operating room equipment, and of the recovery [9], this was not taken into consideration in this study.

Campion et al. assessed the CO₂eq emissions of a C‐section based on energy use, the production of disposable and reusable items, sterilization, and waste disposable, with anesthesia excluded from their analysis. The scope of their assessment covered activities occurring from the patient's arrival in the OR until their departure. The HVAC system accounted for over 50% of the total CO₂eq emissions, followed by energy consumption from machine and lighting. Regarding disposables, only custom trays were taken into account, which may explain the lower contribution of disposables to total CO₂eq emissions compared to our study [8]. However, the absence of detailed CO₂eq emission registration by Campion et al. limits the ability to perform a direct comparison of the results.

The annual number of C‐sections performed in the Netherlands exceeds 31 000 [7]. Given the CO₂eq emissions per procedure reported in this study, the total emissions associated with C‐sections performed in the Netherlands amount to over 1000 metric tons of CO₂eq. This is comparable to driving around the Earth 349 times in a passenger car (based on new passenger cars in the Netherlands in 2023) [12]. Within the Netherlands, the C‐section rate is 17.5%, which is relatively low compared to 12 other high income countries. For instance, the rate is 29.5% in the United States, 34.3% in Germany, and as high as 48.4% in Chile [13]. A major difference is observed in the percentage of patients undergoing a planned C‐section across countries; for example, 13.1% in the United States, 11.2% in Germany and Malta, compared to 4.6% in the Netherlands, and even as low as 2.8% in Iceland. According to Campion et al. a vaginal birth is about 50% more environmentally friendly in terms of CO₂eq emissions [8]. The significant variation in C‐section rates across countries highlights the potential for substantial environmental gains by reducing unnecessary procedures. However, vaginal births should also be monitored. Depending on labor analgesia used, the carbon footprint of vaginal births could be greater [9].

In addition to reducing the overall number of C‐sections, there is potential for lowering the carbon footprint within the procedure itself, particularly by targeting the impactful category disposables according to the “R‐ladder” strategy. This method describes 10 categories aimed at reducing usage of raw materials. The most effective category is referred to as “Refuse,” followed by “Rethink,” “Reduce,” and “Reuse.” [14] Interventions within the categories “refuse” and “reduce” include optimizing the content of disposable and reusable surgical trays. Replacing disposable products with high CO₂eq emissions, for example, surgical drapes and gowns, by reusable textile alternatives is a possible intervention in the category “reuse” [10].

4.1. Strengths and Limitations

Real‐time data collection within the prospective design of this study, combined with the substantial sample size, was a major strength, resulting in reliable and applicable data.

The study should also be interpreted in light of some limitations. The scope of this study was focused solely on the surgical component of the intervention. Therefore, we did not assess the CO₂eq emissions of disposables, reusables, and medication used for anesthetics. Parvatker et al. demonstrated that the contribution of anesthesia in general could be significant, with reported CO₂eq emissions ranging from 11 kg CO₂ eq to as high as 3000 kg CO₂eq [15] Spil et al. specifically assessed the CO₂eq of spinal anesthesia and reported an emission of 7.1 kg CO₂eq [9] In addition to anesthesia, Spil et al. assessed the CO₂eq emissions of hospital stay and complications. Combining these categories, they reported a total carbon footprint for a C‐section of 119.4 kg CO₂eq [9] In addition, the CO₂eq value of energy did not include energy use by lighting and operating room equipment. However, according to MacNeil et al. energy used by HVAC accounts for 90%–99% of the total energy used in an operating room [16]. Therefore, when interpreting the results of this study, it should be taken into consideration that the surgical scope is only a partial representation of the C‐section care pathway and the total CO₂eq emission of the procedure could be even higher. Further research using a similar research method with real‐time, prospectively collected data on the impact of the anesthesiologist's scope is recommended. Furthermore, the CO₂ equivalents were retrieved from a different study [11] Therefore, the reliability of this study is inherently dependent on the accuracy of the underlying LCA data. Lastly, this study was conducted in an academic center, which may limit generalizability to peripheral hospitals. However, since C‐section procedures are standardized, substantial differences are not anticipated.

Author Contributions

Elisabeth Colenbrander: data curation; formal analysis; investigation; visualization; writing – original draft preparation. Eva Cohen: methodology, writing – review and editing, formal analysis, investigation. Florine de Haes: formal analysis; methodology; resources; writing – review and editing. Niek Sperna Weiland: writing – review and editing, resources. Wouter Hehenkamp: writing – review and editing, resources, data curation. Dorien Salentijn: conceptualization, writing – review and editing, supervision, resources, project administration, methodology, visualization, writing – original draft.

Disclosure

The authors have nothing to report.

Ethics Statement

Ethical approval was obtained by the medical ethical review committee (METC Amsterdam UMC) of the hospital under number: 2025.0465.

Consent

No written consent has been obtained from the patients as there is no patient identifiable data included.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Content of product groups.

Table S2: Product categories disposables.

Data Availability Statement

The data that supports the findings of this study are available in the Supporting Information of this article (Table S1: Content of product groups, Table S2: Product categories disposables).