Low-Risk Cesarean Delivery in United States

United States

Nearly one-third of births in the United States were delivered by cesarean (C-section) in 2022. This surgical procedure removes the baby through an incision in the birthing parent’s abdomen. Many cesarean deliveries are unnecessary and have no health benefits for parents with low risk for complications based on their medical profile (e.g., singleton baby, head-first position, full-term baby at 37 or more weeks of gestation, first time giving birth). Variations in the style of practice among obstetricians and casual attitudes about surgery contribute to the overuse of this procedure. 

While cesarean deliveries are necessary in some situations, such as slow labor progression, fetal distress or health concerns for the woman, they can cause unnecessary short- and long-term side effects for parents and infants if performed without medical need. C-sections are associated with increased maternal mortality and morbidity compared with vaginal births and are associated with health risks for mother and infant, including:

• Surgical injuries. 
• Uterine lining infections (endometriosis) among women. 
• Postpartum hemorrhage among women. 
• Increased risk of complications in future pregnancies among women.
• Breathing problems among babies.
• Developing allergies or asthma later in life among babies.
• Delayed immune development among babies.

Surgical procedures are associated with prolonged admissions, making cesarean deliveries more costly than vaginal deliveries. A recent study found that the average spending per C-section among those with employer-sponsored health insurance was $26,280, compared with $14,768 for a vaginal delivery. 

The prevalence of low-risk cesarean delivery is higher among:

• Women age 40 and older compared with younger women. The prevalence of low-risk cesarean delivery increases with each increase in age group.
• Non-Hispanic Black, Native Hawaiian and Pacific Islander and Asian women compared with women of other racial or ethnic groups.
• Women with underlying health conditions, such as diabetes, hypertension or obesity. 

After a woman has had a C-section, there is an 86% chance that any subsequent pregnancy will also be delivered by C-section. However, rates of women attempting vaginal birth after a cesarean (VBAC) are increasing nationwide. As of 2022, the annual VBAC rate was 14.6%.

The American College of Obstetricians and Gynecologists recommends that health care providers encourage women without an indication for a C-section to plan on having a vaginal delivery and that providers do not perform elective C-sections before 39 weeks of gestation. Efforts to support vaginal delivery after a cesarean can reduce birth-related morbidity. 

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 to physicians.
• Promoting informed patient-centered decision-making for maternity care through public reporting of C-section delivery rates and outcomes.

Studies show that having the continuous support of a doula throughout pregnancy and labor can reduce the incidence of low-risk C-sections. States can finance and support community-based doula practice through Medicaid policies. Recommendations include providing Medicaid reimbursement for doula services, setting reimbursement rates that adequately cover the costs, and creating fiscal incentives for quality care and performance in maternity care. 

Women can take proactive steps to reduce their risk of a C-section, such as staying physically active and talking with their health care provider about labor and birth preferences.

Healthy People 2030 has an objective to reduce cesarean births among low-risk women with no prior births. 

The Department of Health and Human Services aims to reduce the low-risk cesarean delivery rate by 25% by 2025.

American College of Nurse-Midwives. “Lowering Your Chance of Cesarean Birth.” Journal of Midwifery & Women’s Health 65, no. 5 (September 2020): 723–24. https://doi.org/10.1111/jmwh.13174.

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.

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Habak, Patricia J., and Martha Kole. “Vaginal Birth After Cesarean Delivery.” In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing, 2024. http://www.ncbi.nlm.nih.gov/books/NBK507844/.

“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, December 2020. https://aspe.hhs.gov/sites/default/files/private/aspe-files/264076/healthy-women-healthy-pregnancies-healthy-future-action-plan_0.pdf.

Kozhimannil, Katy Backes, Michael R. Law, and Beth A. Virnig. “Cesarean Delivery Rates Vary Tenfold among US Hospitals; Reducing Variation May Address Quality and Cost Issues.” Health Affairs 32, no. 3 (March 2013): 527–35. https://doi.org/10.1377/hlthaff.2012.1030.

Osterman, Michelle J. K. “Changes in Primary and Repeat Cesarean Delivery: United States 2016-2021.” Vital Statistics Rapid Release No. 21. Hyattsville, MD: National Center for Health Statistics, July 6, 2022. https://doi.org/10.15620/cdc:117432.

Osterman, Michelle J. K., Brady Hamilton, Joyce Martin, Anne Driscoll, and Claudia Valenzuela. “Births: Final Data for 2022.” National Center for Health Statistics (U.S.), April 4, 2024. https://doi.org/10.15620/cdc:145588.

Ouyang, Lijing, Shanna Cox, Cynthia Ferre, Likang Xu, William M. Sappenfield, and Wanda Barfield. “Variations in Low-Risk Cesarean Delivery Rates in the United States Using the Society for Maternal-Fetal Medicine Definition.” Obstetrics & Gynecology 139, no. 2 (February 2022): 235–43. https://doi.org/10.1097/AOG.0000000000004645.

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.