Cesarean birth in the United States: epidemiology, trends, and outcomes.
ABSTRACT The percentage of United States cesarean births increased from 20.7% in 1996 to 31.1% in 2006. Cesarean rates increased for women of all ages, race/ethnic groups, and gestational ages and in all states. Both primary and repeat cesareans have increased. Increases in primary cesareans in cases of "no indicated risk" have been more rapid than in the overall population and seem the result of changes in obstetric practice rather than changes in the medical risk profile or increases in "maternal request." Several studies note an increased risk for neonatal and maternal mortality for medically elective cesareans compared with vaginal births.
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ABSTRACT: How do malpractice lawsuits affect physician behavior? Despite the central im-portance of this question in understanding the design of malpractice law, empir-ical evidence on this question remains limited. In this paper, I study the impact of malpractice claims against obstetricians, a specialty that is regarded as par-ticularly subject to malpractice concerns, on their choice of whether to perform C-sections, a common procedure that is thought to be sensitive to physician incentives. I find that immediately after an adverse event (defined as an ob-stetrical procedure that ultimately leads to a malpractice claim), C-section rates jump discontinuously by 4%. The increase in C-section rates persists even 4.5 years after the adverse event. Several other findings provide support to the view that fear of litigation and damage to reputation explain the results, rather than a mere response to the negative outcome that brought about the malpractice claim. First, unsuccessful claims, which, at the time of the adverse event, are perceived as less harmful to physicians' reputation, do not lead to an increase in C-section rates. Second, the impact on C-section rates is larger for patients insured by a commercial insurance provider, for which reputational concerns are likely to be stronger, since they are less constrained in their choice of physicians. In addition, the impact is smaller for experienced physicians, but not for those with a prior history of litigation claims. I also find evidence of peer effects: fol-lowing an adverse event, a physician's colleagues also have higher C-section rates. Overall, this study shows that following an adverse event physicians adopt more conservative and costly treatment strategies and that their response is likely to be related to fear of litigation and damage to reputation.12/2010;
- The Obstetrician & Gynaecologist 10/2011; 13(4).
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ABSTRACT: Objective To evaluate the effectiveness of an intervention to adjust the indications for caesarean delivery in a Brazilian teaching hospital in accordance with a specific protocol. Methods The present before-and-after study was carried out in three stages. In stages 1 and 3, data were obtained for 160 cesarean deliveries that occurred between May 20 and July 10 in 2011 and 2012, respectively. For stage 2, the protocol was implemented for 12 months. The deliveries in stages 1 and 3 were classified as high or low risk, and as consistent or inconsistent clinical cases on the basis of the protocol. Results A total of 160 (61.1%; 95% confidence interval [CI] 55.2–67.0) of 262 deliveries in stage 1 were by cesarean, compared with 160 (71.4%; 95% CI 65.5–77.3) of 224 in stage 3 (P = 0.67). In stage 1, 125 (78.1%; 95% CI 71.7–84.5) showed indications consistent with the protocol, compared with 136 (85.0%; 95% CI 79.5–90.5) in stage 3 (P = 0.11). Among the low-risk cesarean deliveries, 27 (51.9%; 95% CI 38.3–65.5) of 52 were consistent with the protocol in stage 1, compared with 49 (72.1%; 95% CI 61.4–86.1) of 68 in stage 3 (P = 0.02). Conclusion The proposed intervention improved the suitability of indications for cesarean delivery among low-risk pregnancies only.International Journal of Gynecology & Obstetrics. 01/2014;
Cesarean Birth in the United States:
Epidemiology, Trends, and Outcomes
Marian F. MacDorman, PhDa,*,
Fay Menacker, DrPH, CPNPa,
Eugene Declercq, PhDb
aReproductive Statistics Branch, Division of Vital Statistics, National Center for Health
Statistics, Centers for Disease Control and Prevention, 3311 Toledo Road,
Room 7318, Hyattsville, MD 20782, USA
bDepartment of Maternal and Child Health, Boston University School of Public Health,
715 Albany Street, Boston, MA, USA
The percentage of all births in the United States that are cesarean deliv-
eries has increased substantially in recent years, from 20.7% in 1996 to an
all-time high of 31.1% in 2006 [1,2]. Cesarean delivery currently is the
most common major surgical procedure for women in the United States
 with more than 1.3 million cesareans performed annually . The cesar-
ean rate increased dramatically during the 1970s and early 1980s and began
to decline in the late 1980s (based on data from the National Hospital Dis-
charge Survey). Between 1989 and 1996 the total cesarean rate decreased as
a result of a decrease in the primary rate and an increase in the rate of vag-
inal birth after cesarean (VBAC). Since 1996, these trends have reversed,
and increases have been rapid and sustained for primary and repeat cesar-
eans over the past decade . This article examines recent trends in cesarean
delivery for the overall population and for women who have no reported
medical indications for cesarean delivery, and it examines neonatal out-
comes for primary cesarean births among low-risk women.
Data on cesarean delivery used in this article are based on the method of
delivery as reported on the more than 4 million birth certificates filed each
The findings and conclusions in this article are those of the authors and do not necessar-
ily represent the views of the Centers for Disease Control and Prevention.
* Corresponding author.
E-mail address: firstname.lastname@example.org (M.F. MacDorman).
0095-5108/08/$ - see front matter ? 2008 Elsevier Inc. All rights reserved.
Clin Perinatol 35 (2008) 293–307
year in the United States and compiled by the National Center for Health
Statistics (NCHS). Cesarean data became available from birth certificates
in 1989, and by 1991 all states and the District of Columbia were reporting
this information. Before 1989, data from the National Hospital Discharge
Survey were used to track trends in cesarean delivery.
Several measures of cesarean delivery are used and computed as follows.
The total cesarean rate is the percent of cesarean births of all births in a given
year. The primary rate is the percent of cesarean births among women in
a given year who have not had a previous cesarean delivery. The rate of re-
peat cesarean delivery is the percent of all cesarean births among women
who have had a previous cesarean. A related measure, the rate of VBAC,
is defined as the percent of vaginal births among women who have had a pre-
This article examines changes in cesarean rates among all United States
mothers by maternal age, race/ethnicity, gestational age, and state. Total
cesarean rates are examined from 1989 to 2006 whereas primary and repeat
cesarean rates are examined from 1989 to 2004. National estimates of pri-
mary and repeat cesarean rates for 2005 and 2006 are not available because
of a change in the wording and formatting of the question on prior cesar-
eans between the 1989 and the 2003 revisions of the United States Standard
Certificate of Birth. Because of the staggered implementation of the 2003 re-
vision among states, both revisions currently are in use in different states,
making national estimates of primary and repeat cesareans problematic,
although state-level estimates are available.
Cesarean rates also are examined for mothers who have ‘‘no indicated
risk’’ (NIR) for cesarean delivery. This is a subgroup of United States births
comprising the lowest-risk population identifiable from birth certificates:
mothers who have full-term, singleton, vertex presentation births and
none of the 16 medical risk factors (eg, diabetes, hypertension) or 15 labor
and delivery complications (eg, fetal distress, prolonged labor) reported on
birth certificates and no prior cesarean. Neonatal outcomes by method of
delivery for low-risk women also are examined and available literature is
The percentage of United States births delivered by cesarean has increased
by 50% in the past decade. In 2006, 31.1% of United States births were
delivered by cesarean compared with 20.7% in 1996 (Fig. 1). The pace of
the increase shows no signs of slowing, as increases are more rapid since
2000 [1,2]. The rapid increase in the cesarean rate reflects two concurrent
trends: an increase in the primary cesarean rate and a steep decline in the
VBAC rate (Fig. 2). The primary cesarean rate increased from 14.6% in
1996 to 20.6% in 2004. Sixty percent of the increase in the total cesarean
rate from 1996 to 2004 was the result of increases in primary cesareans. At
MACDORMAN et al
the same time, the VBAC rate decreased from 28.3% to 9.2%. A decrease in
the VBAC rate implies a corresponding increase in the repeat cesarean rate,
which reached almost 91% in 2004 . Thus, the adage, ‘‘once a cesarean, al-
ways a cesarean,’’ seems true for more than 90% of women in the United
National estimates of primary and repeat cesarean rates for 2005 and
2006 are not available because of a change in the wording and formatting
of the method of delivery item on the 2003 revision of the United States
Standard Certificate of Birth (used by 12 states in 2005) . An examination
of state-level data reveals, however, that primary and repeat cesarean
rates continued to increase in 2005 . The United States cesarean rate is
high compared with that in many industrialized countries (Fig. 3); most
developed countries, however, also have experienced increases over the
past decade .
Fig. 1. Total cesarean delivery rate: United States, 1970–2006. (Data from Data for 1970–1988
are from the National Hospital Discharge Survey. Data for 1989–2006 are from the National
Vital Statistics System, NCHS, Centers for Disease Control and Prevention [CDC]. Data for
2006 are preliminary.)
Fig. 2. Total cesarean delivery rate, United States, 1989–2006, and primary cesarean and
VBAC Rates, 1989–2004. (Data from National Vital Statistics System, NCHS, CDC. Data
for 2006 are preliminary.)
CESAREAN BIRTH IN THE UNITED STATES
Variations by maternal age, race/ethnicity, gestational age, and state
Cesarean rates increase with increasing maternal age (Fig. 4). In 2006,
nearly half (47.6%) of births among women ages 40 and over were delivered
by cesarean compared with 22.2% of teen births. The higher rates for older
mothers may be related to patient/practitioner concerns, increased rates of
multiple births, and other biologic factors . Still, for each maternal age
group, cesarean rates increased sharply (by 45%–53%) from 1996 to 2006.
In 2006, cesarean rates were highest for non-Hispanic black women
(33.1%), followed by non-Hispanic white (31.3%), Asian or Pacific Islander
(30.6%), Hispanic (29.7%), and Native American women (27.4%) (Fig. 5).
10% 15%20% 25% 30%35%40%45%
Fig. 3. Cesarean rates in industrialized countries, 2003–2006. (Data from Organization for Eco-
nomic Cooperation and Development health data 2007; United States birth data for 2006 are
Fig. 4. Cesarean rates by age of mother: United States, 1996 and 2006. (Data from National
Vital Statistics System, NCHS, CDC. Data for 2006 are preliminary.)
MACDORMAN et al
Cesarean rates increased rapidly from 1996 to 2006 for women of all race
and ethnic groups. Increases were largest for Asian or Pacific Islander
women (65%), followed by non-Hispanic black (53%), Native American
(51%), non-Hispanic white (50%), and Hispanic women (49%).
Cesarean rates increased for births at all gestational ages between 1996
and 2005 (detailed data on cesarean delivery by gestational age for 2006
are not yet available) . When only singleton births were examined (births
in plural deliveries are more likely to be delivered by cesarean section), the
trend was similar. The average annual increase in the cesarean rate at each
gestational age category from 1997 to 1999 was 1% to 3%, compared with
an average annual increase of 4% to 6% from 2000 to 2005. Between 1996
and 2005, cesarean rates rose by 33% to 50% for each gestational age cat-
egory, including very preterm infants (!32 weeks of gestation) (Fig. 6).
Cesarean rates were highest for very preterm infants. In 2005, nearly half
Fig. 5. Cesarean rates by race and Hispanic origin of mother: United States, 1996 and 2006.
(Data from National Vital Statistics System, NCHS, CDC. Data for 2006 are preliminary.)
Fig. 6. Cesarean rates by gestational age, singleton births: United States, 1996–2005. (Data
from National Vital Statistics System, NCHS, CDC.)
CESAREAN BIRTH IN THE UNITED STATES