Low-Risk Cesarean Delivery

Low-Risk Cesarean Delivery in United States

United States

In 2021, nearly one-third of births in the United States were delivered by cesarean (C-section), a surgical procedure that removes the baby through an incision in the woman’s abdomen. Cesarean deliveries are often unnecessary for women with low risk for complications based on their medical profile (e.g., singleton baby, head-first position, full-term baby at 37 or more weeks of gestation, woman’s first birth). While cesarean deliveries may be necessary in some situations, they can cause unnecessary short- and long-term side effects for women and babies if performed without medical need. Complications associated with cesarean delivery carry increased maternal mortality and morbidity compared with vaginal births. There are no health benefits for women when cesarean delivery is not medically necessary. 

Variations in the style of practice among obstetricians and casual attitudes about surgery contribute to the overuse of this procedure. The American College of Obstetricians and Gynecologists (ACOG) found that the most common reason for a first-time C-section is slow progression of labor. The ACOG recommends healthcare providers give low-risk women more time to deliver babies vaginally before assuming labor is stalled to reduce the low-risk cesarean delivery rate.

Cesarean delivery is associated with health risks for women and babies, including:

• Surgical injuries. 
• Uterine lining infections (endometriosis) among women. 
• Postpartum hemorrhage among women. 
• Increased risk of complications in future pregnancies among women.
• Breathing problems among babies.
• Developing allergies or asthma later in life among babies.
• Delayed immune development among babies.
• Neonatal mortality among babies born via elective C-section compared with non-elective C-section and vaginal birth.

Cesarean deliveries are more costly than vaginal deliveries because it is a surgical procedure associated with more prolonged admissions. A recent study found that, among those with employer-sponsored health insurance, the average spending per cesarean delivery was $17,004, compared with $12,235 for a vaginal delivery.

The prevalence of low-risk cesarean delivery is higher among:

• Women ages 40 and older compared with younger women. The prevalence of low-risk cesarean delivery increases with each increase in age group.
• Non-Hispanic Black women compared with women of other racial or ethnic groups.

Moreover, after a woman has had a C-section, there is a 91% likelihood that any subsequent pregnancy will also be delivered by C-section. However, rates of women attempting vaginal birth after a cesarean (VBAC) are increasing nationwide. As of 2021, the annual VBAC rate was 14.2%.

The ACOG Committee Opinion on Cesarean Delivery on Maternal Request recommends that health care providers encourage women without an indication for a C-section to plan on having a vaginal delivery and that providers not perform elective C-sections before 39 weeks of gestation. Efforts to support vaginal delivery after a cesarean can reduce birth-related morbidity. 

Some actions that could lead to a decrease in C-section rates include:

• Improving specialization and triage for maternity care.
• Improving data collection and measurement of maternity care quality.
• Using Medicaid policy to improve hospital management practices in labor and delivery units, such as creating audits and providing feedback to physicians.
• Enhancing patient-centered decision-making for maternity care through public reporting of C-section delivery rates and outcomes.
• Facilitating and supporting the use of supportive birth professionals (such as doulas) during labor and delivery to provide continuous one-on-one support.
• Encouraging patience among health care providers to allow women with low-risk pregnancies to spend more time in the first stage of labor.

Healthy People 2030 includes an objective to reduce cesarean births among low-risk women, both with and without a prior cesarean birth.

Additionally, the Department of Health and Human Services has a goal to reduce the low-risk cesarean delivery rate by 25% by 2025.

American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. “ACOG Committee Opinion No. 761: Cesarean Delivery on Maternal Request.” Obstetrics & Gynecology 133, no. 1 (January 2019). https://doi.org/10.1097/AOG.0000000000003006.

Caughey, Aaron B., Alison G. Cahill, Jeanne-Marie Guise, and Dwight J. Rouse. “Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery.” Obstetrics & Gynecology 123, no. 3 (March 2014): 693–711. https://doi.org/10.1097/01.AOG.0000444441.04111.1d.

Collier, Ai-ris Y., and Rose L. Molina. “Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions.” NeoReviews 20, no. 10 (October 1, 2019): e561–74. https://doi.org/10.1542/neo.20-10-e561.

“Healthy Women, Healthy Pregnancies, Healthy Futures: Action Plan to Improve Maternal Health in America.” Washington, D.C.: U.S. Department of Health and Human Services, 2020. https://aspe.hhs.gov/sites/default/files/private/aspe-files/264076/healthy-women-healthy-pregnancies-healthy-future-action-plan_0.pdf.

Kozhimannil, Katy Backes, Michael R. Law, and Beth A. Virnig. “Cesarean Delivery Rates Vary Tenfold among US Hospitals; Reducing Variation May Address Quality and Cost Issues.” Health Affairs 32, no. 3 (March 2013): 527–35. https://doi.org/10.1377/hlthaff.2012.1030.

MacDorman, Marian F., Eugene Declercq, Fay Menacker, and Michael H. Malloy. “Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an ‘Intention-to-Treat’ Model.” Birth 35, no. 1 (2008): 3–8. https://doi.org/10.1111/j.1523-536X.2007.00205.x.

Menacker, Fay, Eugene Declercq, and Marian F. MacDorman. “Cesarean Birth in the United States: Epidemiology, Trends, and Outcomes.” Clinics in Perinatology 35, no. 2 (June 2008): 293–307. https://doi.org/10.1016/j.clp.2008.03.007.

Osterman, Michelle J. K. “Recent Trends in Vaginal Birth After Cesarean Delivery: United States, 2016–2018.” NCHS Data Brief No. 359. Hyattsville, MD: National Center for Health Statistics, March 2020. https://www.cdc.gov/nchs/data/databriefs/db359-h.pdf.

Osterman, Michelle J. K., Brady E. Hamilton, Joyce A. Martin, Anne K. Driscoll, and Claudia P. Valenzuela. “Births: Final Data for 2021.” National Vital Statistics Reports 72, no. 1 (January 31, 2023). https://doi.org/10.15620/cdc:122047.

Sandall, Jane, Rachel M. Tribe, Lisa Avery, Glen Mola, Gerard H. A. Visser, Caroline S. E. Homer, Deena Gibbons, et al. “Short-Term and Long-Term Effects of Caesarean Section on the Health of Women and Children.” The Lancet 392, no. 10155 (October 2018): 1349–57. https://doi.org/10.1016/S0140-6736(18)31930-5.