Health Indicator Report of Cesarean Delivery in Low Risk Women
The World Health Organization (WHO) defines normal birth as "...spontaneous in onset, low risk at the start of labor and remaining so throughout labor and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth, mother and infant are in good condition." The aim of the care in normal birth is "to achieve a healthy mother and child with the least possible level of intervention that is compatible with safety. In normal birth, there should be a valid reason to interfere with the natural process." In 1970, the United States had a cesarean delivery rate of 5%. This increased to 20.8% in 1997, and to 31.9% in 2018, when nearly one-third of all children in the U.S. were born by cesarean delivery. The increases are present in all age groups and for all races and ethnic origins, without identified concurrent sources of increased obstetrical risk. A controversial aspect of this discussion is cesarean delivery on maternal request (CDMR) at term for a singleton pregnancy in the absence of any medical or obstetrical indication. It is not possible to obtain a confident estimate of the rate of CDMR at this time. The increase in cesarean delivery is an issue of importance for all women, but even more so for first time mothers, as the trend is increasingly to schedule repeat cesareans for all subsequent births, once a woman has had one cesarean birth. This trend has implications not only for a woman's entire reproductive life, but also for infants and the entire health care system. Since a cesarean delivery entails major surgery for the mother, the following complications may occur (and may occur at a greater rate than for vaginal delivery): postpartum hemorrhage, infection, operative injury, thromboembolism, hysterectomy, anesthetic complications, placental problems in subsequent pregnancies (including placenta previa and accreta), postpartum depression, and increased risk of surgical complications in the presence of maternal obesity. Effects of cesarean delivery on the newborn may include difficulty with initiation of breastfeeding, prematurity and its sequelae, lacerations, and respiratory problems. Both mother and infant will experience longer and more costly hospital stays than after the normal vaginal delivery. Studies done over the past 35 years have supported the safety and advisability of VBAC (vaginal birth after previous cesarean) in certain groups of women: most women with one previous cesarean delivery with a low transverse uterine incision are candidates for a VBAC; these women should be counseled about their options, risks, and benefits, and offered a trial of labor after a previous cesarean (TOLAC). The risk of uterine rupture with TOLAC or VBAC in this group of candidates is 0.7-0.9%. The risk of uterine rupture doubles if the woman has had two or more prior cesarean deliveries.
Rate of Repeat Cesarean Among Low Risk Women, Utah, 2009-2018
NotesDue to data collection methodology, it is possible that Utah Vital Statistics data misclassified types of cesarean section prior to 2013. Interpret these data with caution. [[br]] [[br]]"Low risk" refers to women giving birth whose baby is term (37 weeks or greater), singleton (not a twin or other multiple-fetus pregnancy), and in the vertex or head down position. There is no comparable U.S. data for this measure since 2007, when the rate was 90.8%.
Data SourceUtah Birth Certificate Database, Office of Vital Records and Statistics, Utah Department of Health
Data Interpretation Issues"Low risk" refers to women giving birth whose baby is full term (37 weeks or greater), singleton (not a twin or other multiple-fetus pregnancy), and in the vertex or head down position. By framing the data in this way, eliminating higher risk pregnancies which are more likely to require cesarean delivery, we can more accurately reflect increases in cesarean rates for women who have the least medical likelihood of needing a surgical delivery. The CDC defines "low risk cesarean delivery" as a cesarean delivery among term (37 or more completed weeks), singleton, vertex (head first) births to women giving birth for the first time. This is a subset of the above definition. The newer 2003 birth certificate form was adopted for use in Utah beginning in 2009, which renders data from 2008 and earlier not comparable to data from 2009 and later.
DefinitionA cesarean delivery is a surgical procedure in which a fetus is delivered through an incision in the mother's abdomen and uterus.
NumeratorNumber of cesarean deliveries for low risk women (with full term, single, head down baby)
DenominatorNumber of live births to low risk women (with full term, single, head down baby)
Healthy People Objective MICH-7.1:Reduce cesarean births among low-risk women with no prior cesarean births
U.S. Target: 23.9 percent
State Target: 16.7 percent
Other ObjectivesHealthy People 2020 is a comprehensive set of health objectives developed by the U.S. Department of Health and Human Services (DHHS). Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For three decades, Healthy People has established benchmarks and monitored progress over time. Healthy People 2020 has two objectives related to cesarean birth. Objective MICH 7.1 aims to reduce the rate of cesarean birth among low risk women with no prior cesarean birth to 23.9%. Objective MICH 7.2 aims to reduce cesarean births among low risk women with a prior cesarean birth to 81.7%.
How Are We Doing?In Utah, the rate of cesarean birth among low risk women with no prior cesarean birth decreased from 10.3% in 2009 to 8.3% in 2018. The rate of cesarean birth among low risk women with a prior cesarean birth decreased from 81.5% in 2009 to 74% in 2018. Utah exceeds the Healthy People 2020 objectives on both measures.
How Do We Compare With the U.S.?The overall cesarean rate in the U.S. increased from 20.8% in 1997 to 31.9% in 2018. Similarly, the Utah overall cesarean rate increased from 15.9% in 1997 to 22.6% in 2018. The Utah rate of cesarean birth among low risk women with no prior cesarean birth was 8.3% in 2018. The U.S. rate of cesarean birth among low risk women with no prior cesarean birth was 25.9% in 2018. The Utah rate of cesarean birth among low risk women with a prior cesarean birth was 74.0% in 2018. The U.S. rate of cesarean birth among ALL women with a prior cesarean birth was 86.7% in 2018.
What Is Being Done?The Utah Department of Health Power Your Life program aims to improve the health of women before and between pregnancies, to ensure the best possible birth outcomes, regardless of the mode of delivery. This approach includes the promotion of healthy weight and lifestyle throughout a woman's life, and education about this beginning in the teen years. Reproductive Life Plans have been developed for both teens and young women, and may be found online at: [http://www.poweryourlife.org].
Evidence-based PracticesThe American College of Obstetricians and Gynecologists provides evidence based clinical guidance in Practice Bulletin No. 184, November 2017, Vaginal Birth After Cesarean Delivery.
Available ServicesEvidence based practice guidelines for safe reduction of primary cesarean delivery can be found at:[[br]] [https://www.cmqcc.org/VBirthToolkitResource]
Health Program InformationWomen are advised to seek information on benefits and risks of vaginal birth after cesarean delivery, known as VBAC. Uterine rupture (cited as the main risk with a VBAC) is uncommon, approximately 1%, in women who labor and deliver vaginally in pregnancies following a cesarean delivery with a low transverse uterine incision. A prior cesarean with a vertical incision into the uterus is considered unsafe for any subsequent vaginal delivery. This needs to be confirmed by a surgical report from the cesarean surgery. Women are urged to discuss their desires for a trial of labor and VBAC with their health care providers.
Page Content Updated On 10/23/2019, Published on 11/08/2019