Cesarean reduction efforts undercut by not attempting vaginal birth

Cesarean birth (CB) is likely overused¹ as no evidence of benefit to newborn morbidity or mortality and increasing maternal morbidity and mortality have spurred national and global efforts to reduce its use.^{2, 3} The increasing risks to the birthing person are “a significant maternal health safety issue.”⁴ While potentially lifesaving, CB does have both short- and long-term risks for both mother and newborn.^5-7 In the United States (US), the CB rate has risen from 16.5% in 1980,⁸ to 20.7% in 1996,⁹ to >30% from 2005 to the present¹⁰ with a rate of 32.2% reported for 2022 and the first quarter of 2023.¹¹ Since 2012, labor management guidelines¹ have been a core tool designed to help lower the CB rate in the United States. In January 2024, the American College of Obstetrics and Gynecology (ACOG) reaffirmed labor management guidelines as the principal mechanism for reducing CB.²

And yet, publicly available data¹² show that 72% of all CB between 2016 and 2021 in the United States occurred among women and birthing people with no trial of labor in pursuit of vaginal birth. Because the ACOG guidelines by definition only reduce CB among individuals who labor, they necessarily exclude the majority of CBs. As such, the ability of these guidelines to reduce CBs is significantly diminished.

The purpose of this commentary is to describe the disconnect between where cesarean reduction efforts are focused and where the majority of cesareans are actually occurring in the United States. Next, I propose a strategy for collecting and reporting data that would enable a more thorough analysis of this disconnect and that might also indicate ways to eliminate it. I close with some reflections on associated issues surrounding the provision of maternity care in the United States today.

Centers for Disease Control and Prevention (CDC) national vital statistics natality records distinguish between two clinical circumstances for CB: (i) CB that interrupts labor and (ii) CB without a trial of labor. The CDC data for the 6 years between 2016 and 2021¹² indicate that of the 21,821,747 women who gave birth, 21,727,755 (99.6%) have data on whether vaginal birth was attempted or not. Most women (77%, n = 16,757,753) attempted a vaginal birth (the labor group), while 23% (n = 4,970,002) did not attempt a vaginal birth (the no-labor group). Figure 1 shows the percentage of the population in each group.

Of the 21,727,755 women who gave birth between 2016 and 2021, 6,847,320 did so by cesarean, with 72% of CBs occurring in the group of women who did not attempt a vaginal birth (no labor, n = 4,970,002). This means that only 28% of CBs (n = 2,153,252) occurred in the group that attempted a vaginal birth (the labor group)—the group for which labor management guidelines to prevent unnecessary cesareans could have been helpful.

Figure 2 adds the percentage of cesarean births to the distribution displayed in Figure 1.

These data indicate a disconnect between the population targeted in cesarean reduction efforts and the population in which the majority of CBs actually occurs. Current reduction efforts target the 77% of the population that labors in attempting vaginal birth, but CBs in this population contribute only 28% of cesareans. In contrast, 72% of cesareans occur in the 23% of the population not attempting vaginal birth. Current efforts to reduce CB are inadequate as they pertain to only a fraction of the birthing population at risk for a surgical delivery.

The actual cesarean rate reflects a response to more than maternal and newborn health. In fact, the CB rate in the United States reflects multiple competing interests: maternal and newborn health, patient expectations and preferences,^{15, 16} practitioner skills,^{17, 18} culture of institutions, “facility level practices, communication between patient and health care professional,”¹⁹ legal and financial liability for practitioners and systems providing care, and long-standing but only recently recognized systemic racism.^20-23

Indications for cesarean performed without attempting vaginal birth have broadened in recent years to reflect, among other issues, the changed perception of the safety of CB¹ in the United States. Primary cesareans for maternal request²⁴ reflect support for maternal autonomy allowing convenience or previous birth trauma to influence mode and timing of delivery. Cesareans for breech presenting fetuses and for non-singletons reflect the shifting skill sets of practitioners providing maternity care, as well as evidence of both benefits and harms.^{18, 25-28} Gauging chances of vaginal birth to avoid intrapartum cesarean after a long labor and the use of imaging to predict macrosomia^{25, 29} also influence rates of surgical birth. In fact, fully half of all cesareans in multiparas without a history of cesarean and a quarter of all cesareans in nulliparas carrying singletons to term are performed without any attempt at vaginal birth.²⁵ The indications noted are major contributors to CB and should be addressed through policies and recommendations aimed at reducing cesareans in this group as well. The data needed to determine the prevalence of each indication for cesarean without attempted vaginal birth could be captured by means of small changes or additions in data collection; these data could guide the development of additional CB reduction strategies. Such strategies should include culturally and linguistically concordant doula care, midwifery care, and person-centered shared decision-making processes around mode of delivery as these have all been shown to reduce CB rates.³⁰

Cesarean reduction efforts to mitigate excessively high CB rates would benefit from more detailed data on the prevalence of and indication for cesareans that either happen during labor or that occur without any attempt at vaginal birth. Additional strategies for lowering CB among individuals represented in the group with no labor are also urgently needed. Tracking as a reportable measure both prevalence and indication for these is a critical a first step.