Low-risk Cesarean Delivery

Low-risk Cesarean Delivery in United States

United States

In 2020, 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 mother’s abdomen. Some women with no medical need for it will choose to deliver via C-section. Elective C-sections are not recommended by the American College of Obstetricians and Gynecologists (ACOG). Variations in practice patterns among hospitals nationwide may be one of the driving forces behind the overuse of this procedure.

Elective C-sections have been found to have higher rates of neonatal mortality compared with non-elective C-sections and vaginal births. Cesarean delivery is associated with health risks for babies and mothers, including increased likelihood of:

• Surgical injuries. 
• Uterine lining infections (endometriosis). 
• Postpartum hemorrhage. 
• Breathing problems among babies.
• Developing allergies or asthma later in life.
• Delayed immune development.

Cesarean delivery is much more costly than vaginal delivery, with the average total charges to employer-provided commercial health insurance being $51,125 per C-section versus $32,093 per vaginal delivery in 2010. Out-of-pocket costs for cesarean deliveries continue to rise, averaging at $5,161 in 2015.

Low-risk cesarean delivery rates increase with maternal age and differ by race and ethnicity. 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 pregnancies will also be delivered by C-section.

The ACOG Committee Opinion on Cesarean Delivery on Maternal Request recommends that health care providers encourage mothers without indications for C-section to plan on having a vaginal delivery and that providers not perform elective C-sections before 39 weeks of gestation. 

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 for 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.

Healthy People 2030 includes an objective to reduce cesarean births among low-risk women, both with and without a prior cesarean birth. The U.S. Department of Health and Human Services also has a goal to reduce the low-risk cesarean delivery rate by 25% in five years. 

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.” American Journal of Obstetrics & Gynecology, ACOG/SMFM Obstetric Care Consensus, 210, no. 3 (March 2014): 179–93. http://dx.doi.org/10.1016/j.ajog.2014.01.026.

Corry, Maureen P., Suzanne F. Delbanco, and Harold D. Miller. “The Cost of Having a Baby in the United States.” Truven Health Analytics for Childbirth Connection, Catalyst for Payment Reform, and the Center for Healthcare Quality and Payment Reform, January 2013. https://www.catalyze.org/wp-content/uploads/2017/04/2013-The-Cost-of-Having-a-Baby-in-the-United-States.pdf.

“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.

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.

Moniz, Michelle H., A. Mark Fendrick, Giselle E. Kolenic, Anca Tilea, Lindsay K. Admon, and Vanessa K. Dalton. “Out-Of-Pocket Spending For Maternity Care Among Women With Employer-Based Insurance, 2008–15.” Health Affairs 39, no. 1 (January 1, 2020): 18–23. https://doi.org/10.1377/hlthaff.2019.00296.

Osterman, Michelle, Brady Hamilton, Joyce Martin, Anne Driscoll, and Claudia Valenzuela. “Births: Final Data for 2020.” National Vital Statistics Reports 70, no. 17 (February 7, 2021). https://doi.org/10.15620/cdc:112078.

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.