Important Facts for Cesarean delivery among low risk women with no prior births

Definition

A cesarean delivery is a surgical procedure in which a fetus is delivered through an incision in the mother's abdomen and uterus.

Numerator

Number of cesarean deliveries among low risk women (with full term, single, head down baby) with no prior births

Denominator

Number of live births to low risk women (with full term, single, head down baby) with no prior births

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 that are more likely to require a cesarean delivery, we can more accurately reflect increases in cesarean rates for women who have the least medical likelihood of needing a surgical delivery.

Why Is This Important?

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 (head down, headfirst, and facing the mother's spine, with its chin tucked to its chest) 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 32.1% in 2022, 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. 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 the 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 a normal vaginal delivery.

Other Objectives

Healthy People 2030 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 2030 has one objective related to cesarean birth. Objective MICH-06 aims to reduce the rate of cesarean birth among low risk women with no prior births to 23.6%.

How Are We Doing?

In Utah, the rate of cesarean birth among low-risk women with no prior birth increased from 16.7% in 2013 to 19.6% in 2022, which is below the Healthy People 2030 objective.

How Do We Compare With the U.S.?

The Utah rate of cesarean birth among low risk women with no prior birth was 19.6% in 2022. The U.S. rate of cesarean birth among low risk women with no prior birth was 26.3% in 2022.

What Is Being Done?

The Utah Department of Health and Human Services Maternal and Infant Health Program educates women on health and pregnancy. [https://mihp.utah.gov/]

Evidence-based Practices

The American College of Obstetricians and Gynecologists published the "Safe Prevention of the Primary Cesarean Delivery" obstetric care consensus: [https://www.ajog.org/article/s0002-9378(14)00055-6/fulltext]

Health Program Information

Women 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 healthcare providers.