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 .
19751980 19851990 1995 20002006
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
(46.8%) of very preterm singleton infants were delivered by cesarean. Ap-
proximately one third of singleton 34- to 36-week (late preterm) and 37-
to 39-week infants were delivered by cesarean compared with approximately
one quarter of singleton infants born at 40 weeks or greater.
In 2006, cesarean rates varied considerably by state, from a low of 21.5%
in Utah to a high of 37.4% in New Jersey (Fig. 7) . Although there is no
clear-cut regional pattern, cesarean rates tended to be higher in the South-
eastern states, selected Appalachian states, and some states on the Eastern
Seaboard. Cesarean rates were lower in the Western Mountain and Upper
Midwestern states. From 1996 to 2006, cesarean rates increased sharply in
all states [1,2].
Questions and controversy generated by the increasing trends
The increasing trend in cesareans has generated controversy in the med-
ical literature. Fundamental questions have been raised about the reasons
for the increasing trend. Is the increase the result of changes in physician
practice patterns regarding cesarean delivery, increases in maternal requests
for cesarean section, or some combination of the two? Is the overall increase
in the cesarean rate the result in part of increases in medically elective cesar-
eans? Has there been a change in the medical risk profile of expectant
mothers, such that more births are now at higher risk? And, finally, what
are the benefits and harms of cesarean delivery for mothers and neonates?
Fig. 7. Cesarean rates by state: United States, 2006. (Data from Preliminary data from the
National Vital Statistics System, NCHS, CDC.)
MACDORMAN et al
Trends in the medical risk profile of mothers
Studies examining changes in the medical risk profile of mothers over
time have found little evidence to suggest that the rising cesarean rates are
due to such changes [7–10]. Declercq and colleagues  used birth certificate
data to examine the medical risk profiles of women over time with regards to
age, race/ethnicity, parity, gestational age, and birthweight and for a wide
variety of medical risk factors and complications of labor or delivery.
They found that changing primary cesarean rates were not related to general
shifts in mothers’ medical risk profiles. Rather, cesarean rates associated
with virtually every demographic or medical risk factor reported on birth
certificates shifted in the same pattern as with the overall cesarean rates.
They concluded, ‘‘changes in obstetric practices were the major influence
on the shifting pattern of primary cesarean rates’’ . A related study
used multivariate logistic regression analysis to examine changes in primary
cesarean rates over time for NIR deliveries after controlling for parity;
birthweight; and maternal ethnicity, age, and education and found that
the odds of having a primary cesarean in 2001 were 50% higher than the
odds in 1996 . Similarly, Rhodes and colleagues  found that excess
weight gain during pregnancy and macrosomia did not explain the increase
in cesarean delivery as cesarean rates increased in all weight gain categories,
and the incidence of macrosomia actually declined from 1990 to 2000.
Recent studies also have suggested that prepregnancy obesity (a measure
primary cesarean rates [11,12]. (Information on maternal prepregnancy
weight and weight gain is being collected on the 2003 revision of the birth cer-
of obesity among United States women in all age groups increased, however,
during the 1990s , whereas cesarean rates fell from 1991 to 1996 and then
increased from 1996 to 2000. Conversely, obesity rates did not increase from
1999 to 2004 among United States women of reproductive age , whereas
the cesarean rate continued to climb; thus, changes in obesity do not seem
to be the primary driving force behind the increase in the cesarean rate.
Trends for women who have no indicated medical or obstetric risk
Studies estimating population-based trends in cesarean deliveries with no
reported medical indications generally have used birth certificate data, hos-
pital discharge data, or a combination of both. DeClercq and colleagues 
used United States birth certificate data to identify a group of women who
had NIR for cesarean delivery. These comprised full-term, singleton, vertex
presentation births with no medical risk factors or complications of labor or
delivery reported on the birth certificate and no prior cesarean. For this very
low-risk group, the rate of primary cesareans has been rising since 1991 and
especially rapidly since 1996 . When data from this study were updated to
CESAREAN BIRTH IN THE UNITED STATES
2003 , the overall primary cesarean rate for births to mothers who
had NIR was 6.9%, nearly twice the 3.7% in 1996. The rate for first-time
mothers was even higher, at 11.2% in 2003 (Fig. 8).
These results are comparable to those of other studies. Bailit and col-
leagues , using birth certificate data, estimated the primary cesarean
delivery rate among women who had no medical or obstetric indication
at approximately 7% in 2001. Two other recent studies used hospital
discharge data to estimate the cesarean rate among women who had no re-
ported medical or obstetric indication at 3% to 7% [17,18]. The methodol-
ogy for the hospital discharge studies is similar to that for the birth
certificate studies and involves identifying mothers who had low-risk births
(full term or singletons) and no International Classification of Disease codes
associated with labor or with complications of labor and delivery in their
hospital discharge records [17,18]. A study that identified the subset of
women who had NIR factors in birth certificate or hospital discharge
data found a lower rate of medically elective cesareans (1.4%), based on
1998 to 2003 data . Regardless of the exact level in a given year, all avail-
able studies document a recent rapid increase in cesarean delivery in low-
risk women who had no medical indications for cesarean delivery.
Data on physician intention for method of delivery is not reported in
birth certificate or hospital discharge data systems. Also, comparisons may
be limited by possible under-reporting of medical risks and complications
on birth certificates (see discussion later). Still, cesarean deliveries among
low-risk women who have no medical indications represent the best approx-
imation of a ‘‘medically elective’’ cesarean group possible from these large
Maternal opinions regarding cesarean delivery
The concept of maternal request cesarean has been defined variously in
the medical literature. In some cases, it is defined simply as ‘‘primary elective
19971998 1999 20002001 2002 2003
Fig. 8. Primary cesarean rates by parity for women who had NIR: United States, 1996–2003.
NIR indicates women who had full-term vertex singleton births, birthweight less than 4000 g,
and no reported medical risk factors or complications of labor or delivery. (Data from National
Vital Statistics System, NCHS, CDC.)
MACDORMAN et al
cesarean delivery in the absence of a medical or obstetric indication’’ [20,21].
This definition, however, does not take into account the complex and nu-
anced interaction between an obstetric care provider and a patient in deci-
sion making. A recent review of studies on decision making surrounding
cesarean delivery concluded, ‘‘the medical norms of health services . . .
seem to drive nonmedically indicated cesarean delivery rates,’’ and advo-
cated for more detailed studies that examined patient-practitioner interac-
tions within the context of care .
Despite widespread discussion in the medical literature about maternal
request cesareans, few United States studies have asked pregnant women di-
rectly about their preferences for delivery method. Listening to Mothers II
was a survey of 1573 mothers ages 18 to 45 who gave birth in a hospital
to a singleton, still living infant in 2005. Results were weighted to reflect
the national population . In this study, for a mother to have a maternal
request primary cesarean, she needed to meet two criteria: (1) have had the
cesarean for no medical reason and (2) have made the decision for herself,
before labor. Of the 252 mothers who had a primary cesarean in the survey,
three indicated there was no medical indication for the cesarean and of these
only one responded that she had made the decision to have a cesarean her-
self before beginning labor .
Results from the first Listening to Mothers survey, conducted in 2002,
found little interest in a future elective primary cesarean, with only 6% of
primiparous mothers interested in that option in the future . A British
national survey of mothers also found the phenomenon of maternal request
cesareans to be rare . Research from other countries with high cesarean
rates, notably Brazil  and Chile , has found that rather than the ce-
sarean rate being driven primarily by maternal demands, it is the interaction
between mothers and their providers that leads to the decision to perform
a cesarean without a clear medical indication. For example in Potter and
colleagues’ study in Brazil , more than 80% of primiparous mothers in
the study anticipated a vaginal birth 1 month before their due date, yet al-
most half of these mothers (66% in private hospitals) ended up with a cesar-
ean. Thus, although true maternal request cesareans doubtless occur, direct
surveys of women seem to indicate that they are not numerous enough to
account for the recent increase in the United States cesarean rate.
Neonatal and maternal outcomes by method of delivery
Several recent review articles have examined the risks and benefits of med-
ically elective cesarean versus vaginal delivery for the mother and infant
[28–33]. Severalof these reviewswereanoutcomeof theMarch 2006National
on Maternal Request [31–33]. The NIH panel, after a systematic review of the
est ; however, four findings were supported by at least a moderate level of
CESAREAN BIRTH IN THE UNITED STATES
of planned vaginal and unplanned cesarean delivery) was associated with: (1)
problems for infants; (3) greater complications in subsequent pregnancies,
including uterine rupture andplacentalimplantation problems,and(4)longer
maternal hospital stays . Several recent studies have corroborated these
findings [19,35–39]. The NIH panel further noted that studies on neonatal
and maternal mortality lacked statistical power and consistent methodologies
to reliably assess the effect of the planned delivery route . As maternal
and neonatal mortality are rare events for low-risk women in developed coun-
tries, very large sample sizes often are needed to detect statistically significant
Several studies published in 2006 and 2007, and thus not included in the
NIH conference and other reviews, may have the potential to shed further
light on these issues. MacDorman and colleagues  examined neonatal
mortality using linked birth and infant death certificate data for 1998 to
2001 from 5.7 million births with NIR for cesarean delivery. They found
that even in the most conservative model (excluding congenital anomalies
and Apgar scores less than 4 and adjusting for sociodemographic and med-
ical risk factors), the odds ratio for neonatal mortality for primary cesarean
delivery was 2.02 (1.60–2.55) compared with vaginal delivery.
The NIH conference advocated using an ‘‘intention-to-treat’’ methodol-
ogy to analyze outcome data by method of delivery . Using this method-
ology, emergency cesareans performed after a woman is in labor are
combined with vaginal births to create a ‘‘planned vaginal delivery’’ cate-
gory, because the original intention was evidently a vaginal delivery. The
‘‘planned cesarean’’ category includes only those deliveries where a cesarean
section was performed without labor. When the MacDorman and col-
leagues’  data were reanalyzed using this methodology, the neonatal
mortality rate for the cesarean without labor category was 1.73 compared
with 0.72 for the planned vaginal category. In the most conservative model
(excluding congenital anomalies and Apgar scores less than 4 and adjusting
for sociodemographic and medical risk factors), the odds ratio for neonatal
mortality for cesarean without labor was 1.69 (1.35–2.11) compared with
‘‘planned vaginal’’ delivery .
Although using different methodologies and not all using the intention-
to-treat framework, several other recent studies have examined maternal
or neonatal mortality in relation to method of delivery. Villar and co-
workers , in a Latin American study, found, for infants in cephalic pre-
sentations, an odds ratio of neonatal mortality for cesarean delivery of 1.9
(1.6–2.3) compared with vaginal deliveries. Betran and colleagues , in
a global study of the relationship between method of delivery and maternal
and neonatal mortality, found that for countries with overall cesarean rates
below 15%, higher cesarean rates were correlated with lower maternal mor-
tality. For countries with national cesarean rates above 15%, however,
MACDORMAN et al
‘‘higher cesarean rates are predominantly correlated with higher maternal
mortality. A similar pattern is found for infant and neonatal mortality.’’
These findings were corroborated by Villar and coworkers for Latin Amer-
ica . Other recent studies found increased risks for maternal mortality
for low-risk women delivered by cesarean [45,46], whereas an additional
study found substantial serious maternal morbidity associated with cesarean
section but no significant difference in maternal mortality .
Cesarean rates in the United States fell between 1991 and 1996 and then
began to rise rapidly. In 2006, nearly one third (31.1%) of United States
births were cesarean deliveries. Over the past decade, cesarean rates in-
creased sharply for women of all ages, all race/ethnic groups, all periods
of gestation and in all states. Cesarean rates were highest for women ages
35 and over, for non-Hispanic black women, and for preterm births. Sixty
percent of the increase in the cesarean rate from 1996 to 2004 was the result
of increases in the primary cesarean rate. Based on the trend in the repeat
cesarean rate, a first cesarean delivery now virtually guarantees that subse-
quent deliveries will be cesarean deliveries. Repeat cesarean deliveries are
associated with significantly higher maternal and neonatal morbidity and
mortality compared with cesarean or vaginal deliveries for women who do
not have a prior cesarean [34,36–38,47–48]. For example, in one study,
the odds ratios of having a life-threatening placenta accreta were 2.4 (1.3–
4.3) for a third cesarean and 9.0 (4.8–16.7) for a fourth cesarean compared
with a primary cesarean [47,48].
Primary cesarean rates also have increased rapidly for women who have
NIR for cesarean delivery, which is the closest approximation to a medically
elective cesarean group available from birth certificates. Although compar-
isons are limited by differences in methodology between various studies,
there seems to be more evidence now than at the time of the NIH conference
for an increased risk for maternal and neonatal mortality and morbidity for
medically elective cesareans compared with vaginal births. In addition, the
increase in the primary cesarean rate seems primarily the result of changes
in obstetric practice and not to changes in the medical risk profile of births
or increases in maternal request.
all births in the United States for a given year. Most demographic items and
under-reporting of medical risk factors and complications of labor and deliv-
ery on birth certificates [49–51]. Reporting a risk factor or complication
CESAREAN BIRTH IN THE UNITED STATES
aged. Also, there is no reason to suspect that the reporting of these variables
has changed systematically over the past decade, potentially biasing trend
analysis . Unfortunately, future research using birth certificate data to
identify NIR women will be further limited by differences in the specific risk
factor data collectedbetween the 1989 and 2003 revisions of the UnitedStates
Standard Certificate of Birth. Because of the staggered implementation of
the 2003 revision among states, both revisions are in use in different
states, making it difficult to construct national estimates for the NIR group
Discussions of the reasons for the growth in primary cesareans have cen-
tered on changing attitudes concerning cesareans among physicians and
mothers [53–56]. Leitch and Walker  related the rise in the cesarean
rate to a change in medical practice and concluded that although indications
for cesarean did not change much over time, ‘‘there has been a lowering in
the overall threshold concerning the decision to carry out a caesarean sec-
tion.’’ This, combined with the increase in medically elective cesareans,
probably accounts for much of the increase in the cesarean rate over the
past decade. A more detailed examination is needed of mother, insurer, hos-
pital, and provider attitudes toward medically elective cesareans and of the
nature of the interaction between mothers and their obstetric care providers
in decision making about the method of delivery. Research on the economic
implications of the rising cesarean rate for hospitals, providers, insurers, and
parents also is essential.
There are markedly different practice recommendations regarding cesar-
ean delivery from American and international obstetric groups. In discus-
sing the ethics of medically elective cesareans, the American College of
Obstetricians and Gynecologists states ,
In the absence of significant data on the risks and benefits of cesarean de-
livery.if the physician believes that cesarean delivery promotes the overall
health and welfare of the woman and her fetus more than vaginal birth, he
or she is ethically justified in performing a cesarean delivery.
In contrast, the International Federation of Gynecology and Obstetrics
At present, because hard evidence of net benefit does not exist, performing
cesarean section for non-medical reasons is not ethically justified.
In 2004, Queenan  noted that the underlying ‘‘question is not the
ethics of patient choice, but lack of scientific proof of risks and benefits.’’
It is hoped that with an increasing body of research on the harms and ben-
efits of medically elective cesarean versus vaginal delivery, decision making
regarding medically elective cesarean versus vaginal delivery will be increas-
ingly evidence based.
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