CESAREAN DELIVERY RATES IN THE UNITED STATES: The 1990s

doi:10.1016/S0889-8545(05)70074-7

Obstetrics and Gynecology Clinics of North America

Volume 26, Issue 2, 1 June 1999, Pages 275-286

https://doi.org/10.1016/S0889-8545(05)70074-7 Get rights and content

The rate of cesarean section (CS) in the United States has increased dramatically over the past 25 years. The US rate rose from 5.5% in 1970 to a high of 24.7% in 1988; the rate steadily decreased to 20.7% in 1996.4, 24 The increase in CSs has been the focus of considerable attention because of the increased maternal morbidity and cost associated with the procedure without apparent impact on infant mortality.⁶ In addition, the US rate is high compared with those of other industrialized nations.¹⁷ In 1990, in response to a growing concern about the high CS rate in the United States, the Department of Health and Human Services established the following Healthy People 2000 Objectives: decrease the CS rate to no more than 15 per 100 births; decrease the primary rate to 12 or fewer per 100 births; and increase the vaginal birth after CS (VBAC) rate to 35 or more per 100 births.²³ Although CS rates have steadily decreased since 1990, current trends indicate that the vast majority of states, and certainly the United States as a whole, are unlikely to meet these objectives.

This article describes the regional variation in CS rates in the United States. National data sources, standard definitions, and trends over time are described. New methodologies to adjust CS rates for case mix are presented. Finally, safe and effective strategies to reduce CS rates that have been reported from selected centers are summarized.

Section snippets

NATIONAL DATA SOURCES

The National Center for Health Statistics has two sources for national data on CS: (1) the National Hospital Discharge Survey and (2) birth certificates. Information dating back to 1965 is available from the National Hospital Discharge Survey. This is a nationally representative sample of patient discharge records of approximately 27,000 women annually who gave birth at participating hospitals. Although data from birth certificates provide considerably more detail on the demographic

DEFINITIONS

The US Department of Health and Human Services and the National Center for Health Statistics use standard definitions for computation of CS and VBAC rates.⁶ The formula for total CS rate is:

The primary CS rate relates the number of first CS births to the total number of births to women who have not had a previous CS:

The VBAC rate relates the number of vaginal births to women who have had a previous CS to the total number of women with previous CS.

Established data sources, such as vital records

CESAREAN RATE TRENDS OVER TIME

Total and primary CS delivery rates have steadily decreased from 1989 to 1996 (Fig. 1). The most recent published annual natality statistics are from 1996. The total CS rate in 1996 was 20.7% of live births, a 9.2% decline from the 1989 rate of 22.8%. The primary CS rate also decreased by 9.3%, from 16.1% in 1989 to 14.6% in 1996. The rate of VBAC increased dramatically between 1989 and 1996, from 18.9% to 28.3%.²⁴

Analysis of birth-certificate data from 1996 indicates that total CS rates were

REGIONAL VARIATION

Considerable variation exists in CS rates among regions in the United States and among states within those regions. The states with the higher CS rates are clustered in the southern and northeastern regions, whereas rates tend to be lower in the western and midwestern states (Fig. 2). Birth-certificate data from 1995 indicate a total CS rate of 22.8% in the South, 21.7% in the Northeast, 19.3% in the Midwest, and 19.1% in the West. Primary CS rates tend to parallel the total rates. VBAC seems

ADJUSTING FOR CASE MIX

Implicit in the comparison of the traditional, unadjusted CS rates among regions, states, institutions, or individual providers is the assumption that differences among the rates result from differences in management practices.¹⁵ Comparison of CS rates without adjusting for differences in the population may be invalid and is often unacceptable to hospitals and providers.2, 3, 7, 11, 15, 18 Some hospitals and providers may care for populations with a higher prevalence of risk factors that

STRATEGIES FOR REDUCING THE NUMBER OF CESAREAN BIRTHS

Regional variation in CS delivery rates and wide discrepancies among institutions and individual providers, even after adjusting for case mix, suggests that opportunity exists for safe reduction in CS rates. Numerous factors can influence clinicians' decisions to perform CSs. Practice patterns with respect to scheduled inductions of labor and timing of admission in spontaneous labor may influence rates. Patient and physician attitudes toward vaginal delivery after CS may vary. The training of

SUMMARY

The increase in CS rates in the United States in the 1970s and 1980s and the gradual decrease in the 1990s have been the focus of considerable attention because of the increased maternal morbidity and cost associated with the procedure without apparent impact on infant mortality. Focused efforts to reduce CS have resulted in a modest decrease the rate of primary CS and a marked increase in VBAC. Considerable variation in CS rates exists among regions in the United States and among states within

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American College of Obstetricians and Gynecologists

External Cephalic Version

(1997)

D.C. Aron et al.

Impact of risk-adjusting cesarean delivery rates when reporting hospital performance

JAMA

(1998)

Cited by (22)

Unforeseen consequences of the increasing rate of cesarean deliveries: Early placenta accreta and cesarean scar pregnancy. A review
2012, American Journal of Obstetrics and Gynecology
This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.
High caesarean rates in Madras (India): A population-based cross sectional study
2003, BJOG: An International Journal of Obstetrics and Gynaecology
To estimate the population caesarean section rate in urban India.
Population-based cross sectional study.
Madras City (Chennai), India.
Seven hundred and eighty resident women who delivered in Madras between June 1997 and May 1999.
Cluster sampling was done using streets as cluster units. Thirty clusters were selected from 1255 clusters by the probability proportion to size method and 26 women were selected randomly from each cluster.
Total and primary caesarean rates.
Total population caesarean section rate was 32.6% (95% CI 27–38) and primary caesarean section rate was 25% (95% CI 20–30). Total caesarean section rates in the public, charitable and private sectors were 20%, 38% and 47%, respectively. Private sector deliveries had an odds ratio of 2.4 (95% CI 1.5, 3.8) of a primary caesarean section delivery in comparison with the public sector after adjustment for parity, age at delivery of mother and educational status.
Forty-seven percent of births by caesarean section in the private sector is alarming and could implicate private sector care as the main contributing factor behind the high population caesarean section rates. Policymakers should urgently institute systems for accountability and ethical practice and regularly monitor all medical interventions, before large scale exploitation of the rural markets begins.
Mode of delivery and risk of respiratory diseases in newborns
2001, Obstetrics and Gynecology
Objective: To determine whether there is an increased incidence of persistent pulmonary hypertension in neonates delivered by cesarean, with or without labor, compared with those delivered vaginally.
Methods: We did a computerized retrospective review of 29,669 consecutive deliveries over 7 years (1992–1999). The incidences of persistent pulmonary hypertension of the newborn, transient tachypnea of the newborn, and respiratory distress syndrome (RDS) were tabulated for each delivery mode. Cases of persistent pulmonary hypertension were reviewed individually to determine delivery method and whether labor had occurred. The three groups defined were all cesarean deliveries, all elective cesareans, and all vaginal deliveries.
Results: Among 4301 cesareans done, 17 neonates had persistent pulmonary hypertension (four per 1000 live births). Among 1889 elective cesarean deliveries, seven neonates had persistent pulmonary hypertension (3.7 per 1000 live births). Among 21,017 vaginal deliveries, 17 neonates had persistent pulmonary hypertension (0.8 per 1000 live births). χ² analysis showed an odds ratio 4.6 and P < .001 for comparison of elective cesarean and vaginal delivery for that outcome.
Conclusion: The incidence of persistent pulmonary hypertension of the newborn was approximately 0.37% among neonates delivered by elective cesarean, almost fivefold higher than those delivered vaginally. The findings have implications for informed consent before cesarean and increased surveillance of neonates after cesarean.
Using active management of labor and vaginal birth after previous cesarean delivery to lower cesarean delivery rates: A 10-year experience
2001, American Journal of Obstetrics and Gynecology
Objective: Our objective was to analyze the statistics on cesarean delivery rates and the factors that have led to a reduction in these rates. Study Design: A retrospective analysis was done of delivery statistics from a 10-year period, January 1, 1989, to December 31, 1998. We investigated the changes made in the methods of delivery during the study period. The data were divided into 1-year periods and analyzed by χ² tables. Results: The overall cesarean delivery rate decreased from 16.59% to 10.92%; the primary cesarean delivery rate decreased from 9.22% to 7.11% and the repeated cesarean delivery rate from 7.37% to 3.81%. All these decreases were statistically significant. An increase in the rate of active management of labor by increasing oxytocin use and encouraging a trial of labor after previous cesarean delivery was also statistically significant. No changes in the outcome were observed in terms of neonatal morbidity and mortality rates. Conclusion: We found that our working plan for management of labor and delivery yielded and maintained a successful decline in the cesarean delivery rates without any negative effect on neonatal or maternal mortality rates. This low rate was maintained for a 10-year period. (Am J Obstet Gynecol 2001;184:1535-43.)
The knowledge, attitudes and behaviors of women applying to a family medicine center about cesarean section and curettage and their relationship with sociodemographic features
2014, Turkiye Klinikleri Jinekoloji Obstetrik
Caesarean section in uninsured women in the USA: Systematic review and meta-analysis
2019, BMJ Open

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: Address reprint requests to M. Kathryn Menard, MD, MPH, Department of Obstetrics and Gynecology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425–2233, e-mail: [email protected]

^*: Division of Maternal and Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina

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CESAREAN DELIVERY RATES IN THE UNITED STATES: The 1990s

Section snippets

NATIONAL DATA SOURCES

DEFINITIONS

CESAREAN RATE TRENDS OVER TIME

REGIONAL VARIATION

ADJUSTING FOR CASE MIX

STRATEGIES FOR REDUCING THE NUMBER OF CESAREAN BIRTHS

SUMMARY

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Ostet Gynecol

Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

External Cephalic Version

Impact of risk-adjusting cesarean delivery rates when reporting hospital performance

JAMA