What Should the Cesarean Rate Be?

Since the cesarean rate began rising in the late 1970s, the obstetric community has debated what the rate should be and even objected to trying to set a rate at all.^{6, 7} A guest post I did awhile back for Lamaze’s blog “Connecting the Dots” documents that yes, it is possible to establish an optimal rate, and that rate is at most 19 percent and probably more in the range of 10 to 15 percent.

Why am I bringing this up now? For two reasons:

First, the U.S. cesarean rate has stood at 32 to 33 percent, or one in three people delivering their babies via major surgery, since 2007.⁴

Second, those articles celebrating “Best Maternity Care” hospitals that have been popping up on the internet recently? US News & World Report, the source for that ranking, used 24 percent, the CDC’s Healthy People 2020 benchmark for cesareans in low-risk first births, to designate hospitals as “Excellent at minimizing avoidable c-sections.” Hardly. Twenty-four percent was merely 10 percent less than 27 percent, the rate in 2007, a number set in the, as it turned out, vain hope that this would be an achievable reduction by 2020. If you want to know what “excellent at minimizing avoidable c-sections” really looks like, a study of Medicaid recipients receiving midwifery care at freestanding birth centers reported a 14 percent rate in similar women with, I might add, excellent outcomes despite being a socially disadvantaged population.^{1, 4}

As for minimizing repeat cesareans, that wasn’t even a consideration. The US News ranking methodology described vaginal birth after cesarean as a “preference” that “some hospitals can accommodate” and defined “routinely offers to support VBAC” as achieving a measly 5.4 percent VBAC rate among all women with prior cesareans. If all women with no conditions precluding labor after a cesarean labored, rates in the mid 70 percents or higher would be readily achievable.²

So, we have a system in which roughly half the cesareans overall could have been avoided, the rate for low-risk first births remains one in four,³ efforts to bring down the cesarean rate have accomplished nothing, and we’re applauding hospitals that have managed to do just a tad better than the status quo for low-risk first births. Over the decades, the failure to address excessive cesarean rates has meant that millions of women have undergone cesarean surgery they didn’t really need at enormous cost to their health and wellbeing and that of their babies—not to mention the financial cost to themselves and the maternity care system.

Your Take-Away

Where does that leave you? For suggestions on what you can do to avoid a cesarean you don’t really need, see my two-part blog series: “Part 1: How Can You Avoid an Avoidable First Cesarean?” and “Part 2: How Can You Avoid an Avoidable Repeat Cesarean?”

References

1. Alliman J, Stapleton SR, Wright J, et al. Strong Start in birth centers: Socio-demographic characteristics, care processes, and outcomes for mothers and newborns. Birth 2019;46(2):234-43.
2. Guise JM, Eden K, Emeis C, et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) 2010(191):1-397.
3. Hamilton BE, Martin JA, Osterman MJ. Births: Provisional data for 2021. NVSS Vital Statistics Rapid Release 2022;Report No. 20.
4. Jolles DR, Langford R, Stapleton S, et al. Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014. Birth 2017;44(4):298-305.
5. Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2018. Natl Vital Stat Rep 2019;68(13):1-46.
6. Phelan JP. Cesarean birth-rate goal for 2000: 50%! OBG Management July 1994:6.
7. Sachs BP, Kobelin C, Castro MA, et al. The risks of lowering the cesarean-delivery rate. N Engl J Med 1999;340(1):54-7.