Health Indicator Report of Cesarean Delivery
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%. By 2006, nearly one-third (31%) of all children in the U.S. were born by cesarean delivery. This represents a 50% increase during the decade from 1996-2006 (from 20.7% in 1996). 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 occur often 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 counselled 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. VBACs should take place in facilities with immediate access to surgical suites and operating room staff, obstetricians, pediatricians, and anesthesia services.
Rate of Primary Cesarean Among Low Risk Women, Utah, 2009-2015
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. No comparable data for the U.S. has been published.
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 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 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.
DefinitionDelivery of infant from surgical incision into abdomen and through uterus (womb), rather than vaginal birth.
NumeratorNumber of cesarean deliveries for low risk women (singleton pregnancy, vertex presentation, 37 weeks or greater gestation).
DenominatorNumber of live births to low risk women (singleton pregnancy, vertex presentation at 37 weeks or greater gestation).
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). It comprises ongoing initiatives pursued over the past 30 years with the goal being to improve the health of all Americans. Healthy People 2020 has two objectives related to cesarean birth. Objective MICH 7.1 aims to reduce the rate of cesarean birth in low risk women to a national target of 23.9%. The second Healthy People 2020 objective related to cesarean birth is MICH 7.2: reduce cesarean births among low-risk women giving birth with a prior cesarean section giving birth via repeat cesarean to the new national target of 81.7%.
How Do We Compare With the U.S.?Total cesarean rates in the U.S. declined in the late 1980s and until 1996, when they began to increase. Similarly, Utah's cesarean rates have increased since 1999. Utah's overall cesarean rate for all women giving birth in 2015 was 22.6%. In 2015, 76.5% of the total number of low risk, term vertex, singleton deliveries in Utah were repeat cesareans. As the Healthy People 2020 objectives were changed to include only low risk pregnancies, there is no current data available for the U.S. rate. The goals espoused by experts in this area are to reduce the number of cesarean births in women giving birth for the first time, and increasing the number of vaginal births after prior cesarean (VBAC).
What Is Being Done?The Utah Department of Health Office of Health Care Statistics publishes an annual Hospital Comparison Report on Maternity and Newborns to enable women and their families to become more knowledgeable about maternity care in hospitals within their communities. New Utah birth certificate forms began to be used in 2009, which will enable the Department to collect more detailed information about delivery procedures and outcomes. The Utah Department of Health is currently working 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]. Planned pregnancy and preconception care are also advised. Initiatives are ongoing to encourage all women of childbearing age to take a multivitamin with folic acid daily. Much work is being done to improve the rates of screening, diagnosis, and treatment of chronic diseases, both during and between pregnancies.
Evidence-based PracticesThe American College of Obstetricians and Gynecologists Practice Bulletin No. 115, August 2010, Vaginal Birth After Previous Cesarean Delivery.
Available ServicesEvidence based practice guidelines for safe reduction of primary cesarean delivery can be found at:[[br]] [https://www.cmqcc.org/projects/support-vaginal-birth-and-reduce-primary-cesareans-collaborative-and-toolkit]
Health Program InformationWomen are advised to seek information on benefits and risks of vaginal birth in pregnancies following a previous 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 where the uterus was entered from a low transverse uterine (not skin) 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 12/08/2016, Published on 12/16/2016