What has caused an increase in cesarean delivery (C-section) over time?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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From 1910-1928, the cesarean delivery rate at Chicago Lying-in Hospital increased from 0.6% to 3%. The cesarean delivery rate in the United States was 4.5% in 1965. According to the National Hospital Discharge Survey, the cesarean rate rose from 5.5% in 1970 to 24.1% in 1986. Fewer than 10% of mothers had a vaginal birth after a prior cesarean, and women spent an average of 5 days in the hospital for a cesarean delivery and only 2.6 days for a vaginal delivery.

It was predicted that if age-specific cesarean rates continued at the steady pattern of increase observed since 1970, 40% of births would be by cesarean in the year 2000. [19] Those predictions fell short, but not by much. The National Center for Health Statistics reported that the percentage of cesarean births in the United States increased from 20.7% in 1996 to 32.2% in 2014. [1, 20] Cesarean rates increased for women of all ages, races/ethnic groups, and gestational ages and in all states (see the image below). Both primary and repeat cesareans increased.

Cesarean delivery rates, United States. Cesarean delivery rates, United States.

Increases in the primary cesareans with no specified indication were faster than in the overall population and appear to be the result of changes in obstetric practice rather than changes in the medical risk profile or increases in maternal request. [21]

This has occurred despite several studies that note an increased risk for neonatal and maternal mortality for all cesarean deliveries as well as for medically elective cesareans compared with vaginal births. [22] The decrease in total and repeat cesarean delivery rates noted between 1990 and 2000 was due to a transient increase in the rate of vaginal births after cesarean delivery. [23]

The cesarean delivery rate has also increased throughout the world, but rates in certain parts of the world are still substantially lower than in the United States. The cesarean delivery rate is approximately 21.1% for the most developed regions of the globe, 14.3% for the less developed regions, and 2% for the least developed regions. [24]

In a 2006 publication reviewing cesarean delivery rates in South America, the median rate was 33% with rates fluctuating between 28% and 75% depending on public service versus a private provider. The authors conclude that higher rates of cesarean delivery do not necessarily indicate better perinatal care and can be associated with harm. [25]

Why the rate of cesarean delivery has increased so dramatically in the United States is not entirely clear. Some reasons that may account for the increase are repeat cesarean delivery, delay in childbirth and reduced parity, decrease in the rate of vaginal breech delivery, decreased perinatal mortality with cesarean delivery, nonreassuring fetal heart rate testing, and fear of malpractice litigation, as described in the following paragraphs.

In 1988, when the cesarean delivery rate peaked at 24.7%, 36.3% (351,000) of all cesarean deliveries were repeat procedures. Although reports concerning the safety of allowing vaginal birth after a cesarean delivery had been present since the 1960s, [26] by 1987, fewer than 10% of women with a prior cesarean delivery were attempting a vaginal delivery.

In 2003, the repeat cesarean delivery rate for all women was 89.4%; the rate for low-risk women was 88.7%. Today, low-risk women giving birth for the first time who have a cesarean delivery are more likely to have a subsequent cesarean delivery. [27]

In the past decade, an increase in the percentage of births to women aged 30-50 years has occurred despite a decrease in their relative size within the population. [28] The cesarean rate for mothers aged 40-54 years in 2007 was more than twice the cesarean rate for mothers younger than 20 years (48% and 23%, respectively). [28] The risk of having a cesarean delivery is higher in nulliparous patients, and, with increasing maternal age, the risk for cesarean delivery is increased secondary to medical complications such as diabetes and preeclampsia.

By 1985, almost 85% of all breech presentations (3% of term fetuses) were delivered by cesarean. In 2001, a multicenter and multinational prospective study determined that the safest mode of delivery for a breech presentation was cesarean delivery. [29] This study has been criticized for differences in the standards of care among the study centers that does not allow a standard recommendation. [30]

The most recent recommendation from the American College of Obstetricians and Gynecologists (ACOG) regarding breech delivery is that planned vaginal delivery may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. [31] This may lead to a small decrease in breech delivery rates, but the overwhelming majority of cases will probably continue to be delivered by elective cesarean.

A cluster-randomized controlled trial by Chaillet et al reported a significant but small reduction in the rate of cesarean delivery. The benefit was driven by the effect of the intervention in low-risk pregnancies. [32, 33]

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