Myth and Reality Concerning
Cesarean Section in the U.S.
Professor Gene Declercq, PhD
Boston University School of Public Health
www.birthbythenumbers.org
With support from: The Transforming Birth Fund
Slides Updated through January 15,2015
BirthByTheNumbers.org
US Cesarean Rates, 1989-2013
34
32
30
% 28
% 26
1,284,339
cesareans
in 2013
24
22
20
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
If the 2013 cesarean rate was the same as in 1996, there
would have been 475,000 fewer cesareans in the U.S. in ’13.
Source: National Center for Health Statistics Annual Birth Reports
US Cesarean Rates, 1989-2013
34
32
30
% 28
% 26
24
22
20
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
Source: National Center for Health Statistics
Annual Birth Reports
BirthByTheNumbers.org
US Cesarean Rates, 1989-2013
34
32
30
% 28
% 26
24
22
20
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
Source: National Center for Health Statistics Annual
Birth Reports
BirthByTheNumbers.org
US Cesarean Rates, 1989-2013
34
32
30
% 28
% 26
24
22
20
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
Source: National Center for Health Statistics
Annual Birth Reports
BirthByTheNumbers.org
Commonly Used Explanations for
the High Cesarean Rate
•
•
•
•
•
•
Mothers are getting older
More multiples being born
Maternal obesity increasing
Babies are getting bigger
Mothers are generally less healthy
Mothers are asking for it
BirthByTheNumbers.org
Older Mothers?
% Births to Mothers 30 +, U.S. 1990-2013
45%
40%
>30
35%
30%
25%
20%
Between 2003 &
2010 CS Rate
increased by 20%
From 2010-2013,
CS rate unchanged
15%
10%
5%
> 35
> 35
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
0%
BirthByTheNumbers.org
Total Cesarean Rates (per 100 births) by Age
of Mother: United States, 1996 and 2013
Overall increase,
1996-2013: 58.0%
60
1996
50
2013
49.6
Percent
41.6
40
35.5
31.6
31.3
27.6
30
23.8
21.8
20
10
14.5
27.4
20.6
17.4
50%
59%
52%
49%
52%
57%
<20
20-24
25-29
30-34
35-39
40-54
0
Source: National vital statistics system, NCHS, CDC.
BirthByTheNumbers.org
Multiple Births?
Proportion of all babies in multiple births,
U.S., 1980-2013
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Source: National Center for Health Statistics Annual Birth Reports
BirthByTheNumbers.org
Cesarean Rates for Multiple Births, U.S.
1990-2013
80%
74%
75%
76%
70%
65%
60%
60%
56%
56%
1990
1995
55%
50%
2000
2006
2013
BirthByTheNumbers.org
Are Babies Getting Bigger?
% Singleton Babies by Birthweight, U. S., 1991-2013
3500-3999gms
4000+gms
50%
41%
40%
41%
39%
36%
36%
30%
30%
30%
29%
20%
28%
28%
10%
11%
11%
10%
8%
8%
1991
1996
2001
2006
2013
0%
BirthByTheNumbers.org
% Cesareans in Singleton Births,
U.S. by Birthweight, 1991-2013
55%
3500 - 3999gms
4000 - 4499gms
4500+gms
50%
45%
40%
53.6%
38.2%
38.6%
35%
30%
25%
31.3%
27.8%
20% 21.8%
15%
10%
1991
1996
2001
2006
2013
BirthByTheNumbers.org
Mothers’ Health?
Prepregnancy Obesity, U.S. 2003, 2006, 2009, 2011
22%
20.3%
2009
2011
19.5%
20%
18%
20.5%
17.6%
16%
14%
12%
10%
2003
2006
Sources: 2003-2009 -- S. Fisher. Is obesity still increasing among pregnant women?
Preventive Medicine 2013; 56: 372-378; 2011 – CDC VitalStats.
BirthByTheNumbers.org
Mothers’ Health?
Cesarean Rate Singleton Births by Prepregnancy
Weight Range, U.S. 2013
60%
54.0%
50%
45.4%
39.7%
40%
30%
33.6%
27.1%
22.3%
20%
10%
0%
Source: CDC VitalStats, 2013.
BirthByTheNumbers.org
Mothers’ Health?
Diabetes* & Hypertension*, 1992,2002,2013
7%
6%
Any Diabetes
6.4%
6.0%
Any Hypertension
5%
4.4%
4%
3.4%
3.2%
3%
2.2%
2%
1%
0%
1992
2002
* Either gestational or chronic condition
Source: CDC VitalStats, selected years.
2013
BirthByTheNumbers.org
Mothers’ Health?
Cesarean Rates, Singleton Births, U.S.,
1990, 1996, 2004, 2013
70%
60%
Prepregnancy Diabetes
Chronic Hypertension
50%
40%
30%
1990
1996
Source: CDC VitalStats, selected years.
2004
2013
BirthByTheNumbers.org
Mothers’ Health?
Cesarean Rates, Singleton Births, U.S.,
1990, 1996, 2004, 2013
70%
60%
Prepregnancy Diabetes
Chronic Hypertension
50%
40%
30%
1990
1996
Source: CDC VitalStats, selected years.
2004
2013
BirthByTheNumbers.org
Mothers asked for it
Have maternal request
cesareans played a major
role in these increases?
BirthByTheNumbers.org
Asking Mothers
about
Maternal Request
Cesareans
http://www.childbirthconnection.org
Two Components to Maternal
Request Primary Cesarean
1. Mother made request for planned
cesarean before labor
BirthByTheNumbers.org
Two Components to Maternal
Request Primary Cesarean
1. Mother made request for
planned cesarean before labor
2. Cesarean for no medical reason
BirthByTheNumbers.org
Patient Choice Primary Cesareans
• Combining reason for cesarean and timing of
decision found only about 1% of respondents had
a planned primary cesarean for no medical
reason.
“I think that [cesarean] is… the best way … to give
birth. It is a planned way, no hassle, no pain, the baby
doesn’t struggle to come out, the baby is not pressed
to come out …I think that … everybody should have
the baby by cesarean section.” (quote from LtM2)
Studies from England, Canada and U.S. states
confirm very low rates of maternal request
BirthByTheNumbers.org
cesareans
Pressure to Accept Interventions
by Method of Delivery
Did you feel pressure from any health professional to
have a cesarean? % yes
Repeat
Cesarean
22%
Primary
Cesarean
28%
VBAC
28%
Vaginal
7%
0%
5%
10%
15%
20%
Source: Declercq et al. 2013. Listening to Mothers III.
25%
30%
BirthByTheNumbers.org
Commonly Used Explanations for
the High Cesarean Rate
• Mothers are getting older
• More multiples being born
• Babies are getting bigger
• Maternal health is worse: obesity,
diabetes & hypertension
• Mothers are asking for it
BirthByTheNumbers.org
Commonly Used Explanations for
the High Cesarean Rate
• Mothers are getting older – NO
• More multiples being born
• Babies are getting bigger
• Maternal health is worse: obesity,
diabetes & hypertension
• Mothers are asking for it
BirthByTheNumbers.org
Commonly Used Explanations for
the High Cesarean Rate
• Mothers are getting older – NO
• More multiples being born– NO
• Babies are getting bigger
• Maternal health is worse: obesity,
diabetes & hypertension
• Mothers are asking for it
BirthByTheNumbers.org
Commonly Used Explanations for
the High Cesarean Rate
• Mothers are getting older– NO
• More multiples being born – NO
• Babies are getting bigger – NO !!
• Maternal health is worse: obesity,
diabetes & hypertension
• Mothers are asking for it
BirthByTheNumbers.org
Commonly Used Explanations for
the High Cesarean Rate
• Mothers are getting older– NO
• More multiples being born – NO
• Babies are getting bigger – NO !!
• Maternal health is worse: obesity,
diabetes & hypertension – Some
• Mothers are asking for it
BirthByTheNumbers.org
Commonly Used Explanations for
the High Cesarean Rate
• Mothers are getting older– NO
• More multiples being born – NO
• Babies are getting bigger – NO !!
• Maternal health is worse: obesity,
diabetes & hypertension – Some
• Mothers are asking for it – NO
BirthByTheNumbers.org
If the usual explanations
for the rising cesarean
rate don’t account for the
changes what does?
BirthByTheNumbers.org
If the usual explanations
for the rising cesarean
rate don’t account for the
changes what does?
Practice Changes
BirthByTheNumbers.org
Leading Indications for
Cesareans
3%
Labor Arrest
3%
4%
Nonreassuring fetal
tracing
Malpresentation
4%
5%
34%
Multiple Gestation
7%
Maternal-Fetal
Macrosomia
17%
Other Obstet.
23%
Preeclampsia
Maternal Request
Source: ACOG & SMFM. Safe Prevention
of Primary Cesarean Delivery. 3/2014.
BirthByTheNumbers.org
Cesarean Rates, Low Risk*, First-Time Mothers for
Medical Risk Factors & Labor Complications
Prolonged Labor
70
Nonreassuring Fetal
Tracing
Macrosomia
60
Twins
50
40
30
20
1990
*Singleton, Vertex, Full Gestation Births
1996
2011
BirthByTheNumbers.org
Revisiting the trend in cesareans
in the US for comparison
34
32
% 30
28
%
26
24
22
20
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13
% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33
Source: National Center for Health Statistics
Annual Birth Reports
BirthByTheNumbers.org
Cesarean Rates, Low Risk*, First-Time Mothers for
Medical Risk Factors & Labor Complications
Prolonged Labor
Nonreassuring Fetal Tracing
70
Macrosomia
Twins
60
50
40
30
1990
*Singleton, Vertex, Full Gestation Births
1996
2011
BirthByTheNumbers.org
Cesarean Rates, Low Risk*, First-Time Mothers for
Medical Risk Factors & Labor Complications
Prolonged Labor
Nonreassrg Fetal Trace
70
Macrosomia
Twins
60
50
40
30
1990
*Singleton, Vertex, Full Gestation Births
1996
2011
BirthByTheNumbers.org
Women have not changed nearly
as much as practice patterns have
BirthByTheNumbers.org
Any other evidence that
this is about a culture of
practice?
BirthByTheNumbers.org
Let’s look at variation.
If the practice of maternity care is
evidence based, then differences in
rates should be based primarily on
different risk profiles of mothers.
BirthByTheNumbers.org
BirthByTheNumbers.org
Cesarean Delivery Rates1, 2012
WA
MT
ME
ND
VT
NH
MN
OR
ID
WI
SD
PA
IA
NE
NV
IL
UT
CO
CT
MI
WY
IN
OH
WV
KS
CA
KY
MO
VA
OK
NM
TX
AR
LA
RI
NJ
DE
MD DC
NC
TN
AZ
MA
NY
SC
MS
GA
AL
AK
FL
HI
22.6-31.5%
31.6%+
1Percentage
of all live births by cesarean delivery
Source: Martin J, et al. Births Final Data 2012. National Vital Statistics System, 2014.
BirthByTheNumbers.org
1960 Electoral College Map
WA
MT
ME
ND
VT
NH
MN
OR
ID
WI
SD
WY
MI
IL
CO
OH
IN
WV
KS
CA
AZ
PA
IA
NE
NV
UT
NY
MO
KY
RI
NJ
DE
MD DC
NC
TN
OK
AR
NM
VA
MA
CT
SC
MS
AL
GA
TX
LA
FL
AK
HI
Nixon
Kennedy
219
303
Harry Byrd 15
BirthByTheNumbers.org
JFK 1960 Vote and
2012 Cesarean Rates
65
JFK % Vote
60
Each dot
represents a
U.S. state
r = +.28
55
50
45
40
35
20%
25%
30%
35%
2012 Cesarean Rate
40%
45%
BirthByTheNumbers.org
Variation is not just at the
state level but at the
hospital level as well
BirthByTheNumbers.org
% Cesarean Deliveries by Hospital
for ALL MA Births, 2004-2006
%CS
All 49 Hospitals
45
41.9
40
35
30
25
1
2
3
4
5
6
7
8
9
N = 49
Mean =31.2
σ2 =29.6
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
21.1
20
15
10
5
0
Hospital Rank
Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The
Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817
BirthByTheNumbers.org
% Cesarean Deliveries by Hospital for NTVS,
Spontaneous Labor, BWT 2500-4000g Births
All Hospitals
%CS
40
35.0
35
30
25
20
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
N = 49
Mean =21.1
σ2 =37.1
15
10.3
10
5
0
Hospital Rank
Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The
Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817
BirthByTheNumbers.org
How does a culture of
intervention get manifested
in a hospital setting?
BirthByTheNumbers.org
How does a culture of
intervention get manifested
in a hospital setting?
Consider the Cascade of
Interventions
BirthByTheNumbers.org
Cascade of interventions in first-time mothers
with term births who experienced labor
Base: first-time
mothers with term
births who
experienced labor
First-time mothers with term births (37-41
weeks’ gestation) who experienced labor
n=750
Induction
Yes
47%
Induction
No
53%
Epidural
No
39%
Epidural
Yes
61%
Epidural
No
22%
Epidural
Yes
78%
Cesarean
Yes
Cesarean
Yes
Cesarean
Yes
Cesarean
Yes
5%
20%
19%
31%
In this group, which included 85% of first-time mothers, the overall
epidural rate was 69% and overall cesarean rate was 21%.
BirthByTheNumbers.org
What about Vaginal
Birth After Cesarean
(VBAC) ?
BirthByTheNumbers.org
VBAC Rates*, U.S.,1990-2011
30%
25%
20%
NOTE: Rates
for 2005-2011
are unofficial
15%
10%
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
5%
* Number of VBACs among women with prior cesarean
Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm
BirthByTheNumbers.org
% VBAC Lower Risk* Mothers, U.S.,
Monthly Rates, 1990-2012
33%
30%
27%
24%
21%
18%
15%
12%
9%
6%
ACOG guidelines
encourage
VBAC, 1/82 10/88
Reaffirmed 1991
McMahon NEJM 9/96
Sachs, NEJM 1/99
Lydon-Rochelle
& Greene 7/01
Flamm
Studies
1988,’90, ‘94
ACOG New
VBAC Guidelines
10/98 & 7/99
Landon
NEJM 12/04
Revised
ACOG
Guidelines 8/10
0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 0 0 1 1 2 2
- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 9 l-9 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 l-0 n- 0 y-0 n- 0 y-0 n- 0 l-0 n- 1 l-1 n- 1 l-1 n- 1 l-1
n
l
l
u
u
u
u
u
u
u
u
u
u
u
u
u
u
u
u
u
u
u
u
u
Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja J Ja Ju Ja Ju Ja J Ja J Ja J Ja J
* Full-gestation(37+ weeks), vertex presentation, singleton births
BirthByTheNumbers.org
VBAC Rates Industrialized Countries, 2010
6
7
Cyprus
Latvia
U.S.
Italy
Lithuania
Scotland
Slovenia
Czech Republic
Luxembourg
Estonia
England
Denmark
Belgium
France
Germany
Norway
Netherlands
Finland
Iceland
Malta
0
VBAC % = VBACS
Women w/ Prior CS
9
10
11
10
21
21
20
28
28
29
30
33
34
35
36
30
Source: Adapted from Peristats & US Data
40
46
47
50
52
52
74
60
70
80
BirthByTheNumbers.org
August, 2010
BirthByTheNumbers.org
U.S. Mothers Report of Experience
Seeking a VBAC, 2000, 2005, 2012
Mother had cesarean in the past, and did
not have the option of a VBAC for recent
birth.
LTMI
2000-02
LTMII
2005
LTMIII
2011-12
Did not have the option because
caregiver was unwilling to do a
VBAC
36%
45%
24%
Did not have the option because
hospital was unwilling to allow a
VBAC
12%
23%
15%
Medical reason unrelated to
prior cesarean
38%
20%
45%
Source: Listening to Mothers 3.
New VBAC Guidelines
BirthByTheNumbers.org
So is a rising cesarean
rate inevitable?
BirthByTheNumbers.org
So is a rising cesarean
rate inevitable?
ABSOLUTELY NOT
BirthByTheNumbers.org
US Cesarean Rates, 1989-2012
34
32
30
%28
%
26
24
22
20
'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12
% Tot US 23 22.722.622.321.821.220.820.720.821.222.0 23 24 26 28 29 30 31 32 32 33 33 33 33
Source: National Center for Health Statistics
Annual Birth Reports
BirthByTheNumbers.org
Trends in Cesarean Rates (per 1000 births),
Comparison Countries, 1990-2011
400
350
300
250
200
150
100
20
10
20
08
20
06
20
04
Sources: OECD Health Data 2013; WHO Health
for All Database, 2014.
20
02
20
00
19
98
19
96
19
94
19
92
19
90
50
BirthByTheNumbers.org
Trends in Caesarean Rates (per 1000 births),
Comparison Countries, 1990-2011
400
350
300
250
200
150
100
20
10
20
08
20
06
Sources: OECD Health Data 2013; WHO Health
for All Database, 2014.
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
50
BirthByTheNumbers.org
Questioning the Rising Cesarean Rate
Safe Prevention of Primary Cesarean Delivery
www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_
Primary_Cesarean_Delivery
BirthByTheNumbers.org
Evidence Based
Advocacy
BirthByTheNumbers.org
Prematurity and Low Birthweight,
U.S., 1990-2012
13
Prematurity
12
9.8%
Decrease
2006-12
11
10
%
9
Low Birthweight
8
7
6
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
Year
BirthByTheNumbers.org
BirthByTheNumbers.org
Evidence Based Advocacy
http://www.choicesinchildbirth.org/
BirthByTheNumbers.org
Evidence Based Advocacy
https://www.childbirthconnection.org/
www.birthbythenumbers.org
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