Rates of Cesarean Delivery -- United States, 1991

Cesarean deliveries have accounted for nearly 1 million of the approximately 4 million annual deliveries in the United States since 1986 (Table 1). The cesarean rate in the United States is the third highest among 21 reporting countries, exceeded only by Brazil and Puerto Rico (1). This report presents data on cesarean deliveries from CDC's National Hospital Discharge Survey (NHDS) for 1991 and compares these data with previous years.

Data on discharges from short-stay, nonfederal hospitals have been collected annually since 1965 in the NHDS, conducted by CDC's National Center for Health Statistics. For 1991, medical and demographic information were abstracted from a sample of 274,000 inpatients discharged from 484 participating hospitals. The 1991 cesareans and vaginal births after a prior cesarean (VBAC) presented in this report are based on weighted national estimates from the NHDS sample of approximately 31,000 (11%) women discharged after delivery. The estimated numbers of live births by type of delivery were calculated by applying cesarean rates from the NHDS to live births from national vital registration data. Therefore, estimates of the number of cesareans in this report will not agree with previously published data based solely on the NHDS (2). Stated differences in this analysis are significant at the 95% confidence level, based on the two-tailed t-test with a critical value of 1.96.

In 1991, there were 23.5 cesareans per 100 deliveries, the same rate as in 1990 and similar to rates during 1986-1989 (Table 1). The primary cesarean rate (i.e., number of first cesareans per 100 deliveries to women who had no previous cesareans) for 1986- 1991 also was stable, ranging from 16.8 to 17.5. In 1991, the cesarean rate in the South was 27.6, significantly (p<0.05) higher than the rates for the West (19.8), Midwest (21.8), and Northeast (22.6). Rates were higher for mothers aged greater than or equal to 30 years than for younger women; in proprietary hospitals than in nonprofit or government hospitals; in hospitals with fewer than 300 beds than in larger hospitals; and for deliveries for which Blue Cross/Blue Shield * and other private insurance is the expected source of payment than for other sources of payment (Table 2). The same pattern characterized primary cesarean deliveries.

Since the early 1970s, the number and percentage of births to older women increased; however, if the age distribution of mothers in 1991 had remained the same as in 1986, the overall cesarean rate in 1991 would have been 23.3, essentially the same as the 23.5 observed.

Based on the NHDS, of the approximately 4,111,000 live births in 1991, an estimated 966,000 (23.5%) were by cesarean delivery. Of these, an estimated 338,000 (35.0%) births were repeat cesareans, and 628,000 (65.0%) were primary cesareans. Since 1986, approximately 600,000 primary cesareans have been performed annually. In 1986, 8.5% of women who had a previous cesarean delivered vaginally, compared with 24.2% in 1991. Of all cesareans in 1991, 35.0% were associated with a previous cesarean, 30.4% with dystocia (i.e., failure of labor to progress), 11.7% with breech presentation, 9.2% with fetal distress, and 13.7% with all other specified complications.

The average hospital stay for all deliveries in 1991 was 2.8 days. In comparison, the hospital stay for a primary cesarean delivery was 4.5 days, and for a repeat cesarean, 4.2 days -- nearly twice the duration for VBAC deliveries (2.2 days) or for vaginal deliveries that were not VBACs (2.3 days). In 1986, the average hospital stay for all deliveries was 3.2 days, for primary cesareans 5.2 days, for repeat cesareans 4.7 days, and for VBAC and non-VBAC vaginal deliveries 2.7 and 2.6 days, respectively.

Reported by: Office of Vital and Health Statistics Systems, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The cesarean rate in the United States steadily increased from 1965 through 1986; however, the findings in this report indicate that rates have been stable since 1986 (3). Because there is little evidence that maternal and child health status has improved during this time and because cesareans are associated with an increased risk for complications of childbirth, a national health objective for the year 2000 (4) is to reduce the overall cesarean rate to 15 or fewer per 100 deliveries and the primary cesarean rate to 12 or fewer per 100 deliveries (objective 14.8).

Postpartum complications -- including urinary tract and wound infections -- may account in part for the longer hospital stays for cesarean deliveries than for vaginal births (5). Moreover, the prolonged hospital stays for cesarean deliveries substantially increase health-care costs. For example, in 1991, the average costs for cesarean and vaginal deliveries were $7826 and $4720, respectively. The additional cost for each cesarean delivery includes $611 for physician fees and $2495 for hospital charges (6). If the cesarean rate in 1991 had been 15 (the year 2000 objective) instead of 23.5, the number of cesarean births would have decreased by 349,000 (617,000 versus 966,000), resulting in a savings of more than $1 billion in physician fees and hospital charges.

Despite the steady increase in VBAC rates since 1986, several factors may impede progress toward the year 2000 national health objectives for cesarean delivery. For example, VBAC rates substantially reflect the number of women offered trial of labor, which has been increasingly encouraged since 1982 (7). Of women who are offered a trial of labor, 50%-70% could deliver vaginally (7) -- a level already achieved by many hospitals (8). Trial of labor was routinely offered in 46% of hospitals surveyed in 1984 (the most recent year for which national data are available) (9) when the VBAC rate (according to NHDS data) was 5.7%. The year 2000 objective specifies a VBAC rate of 35%, based on all women who had a prior cesarean, regardless of whether a trial of labor was attempted. To reach the overall cesarean rate goal, however, increases in the VBAC rate will need to be combined with a substantial reduction in the primary rate.

One hospital succeeded in reducing the rate of cesarean delivery by applying objective criteria for the four most common indications for cesarean delivery, by requiring a second opinion, and by instituting a peer-review process (10). Other recommendations for decreasing cesarean delivery rates include eliminating incentives for physicians and hospitals by equalizing reimbursement for vaginal and cesarean deliveries; public dissemination of physician- and hospital-specific cesarean delivery rates to increase public awareness of differences in practices; and addressing malpractice concerns, which may be an important factor in maintaining the high rates of cesarean delivery (4).

References

1. Notzon FC. International differences in the use of obstetric interventions. JAMA 1990; 263:3286-91.

2. Graves EJ, NCHS. 1991 Summary: National Hospital Discharge Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993. (Advance data no. 227).

3. Taffel SM, Placek PJ, Kosary CL. U.S. cesarean section rates, 1990: an update. Birth 1992;19:21-2.

4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

5. Danforth DN. Cesarean section. JAMA 1985;253:811-8.

6. Hospital Insurance Association of America. Table 4.15: cost of maternity care, physicians' fees, and hospital charges, by census region, based on Consumer Price Index (1991). In: 1992 Source book of health insurance data. Washington, DC: Hospital Insurance Association of America, 1992.

7. Committee on Obstetrics. ACOG committee opinion no. 64: guidelines for vaginal delivery after a previous cesarean birth. Washington, DC: American College of Obstetricians and Gynecologists, 1988.

8. Rosen MG, Dickinson JC. Vaginal birth after cesarean: a meta-analysis of indicators for success. Obstet Gynecol 1990;76:865-9.

9. Shiono PH, Fielden JG, McNellis D, Rhoads GG, Pearse WH. Recent trends in cesarean birth and trial of labor rates in the United States. JAMA 1987;257:494-7.

10. Myers SA, Gleicher N. A successful program to lower cesarean-section rates. N Engl J Med 1988;319:1511-6.

• Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

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