Trends in cesarean delivery among low-risk patients

There were countervailing trends in cesarean delivery among low-risk patients in the United States from 2000 to 2019, according to a recent study published in JAMA Network Open.

Cesarean delivery is a major clinical intervention when not clinically indicated, increasing the risk of adverse outcomes. Reducing cesarean births was defined as a primary objective inthe US Department of Health’s Healthy People 2030 campaign, aiming to reduce the rate of cesarean births by 2.6% in low-risk patients by 2030.

To determine temporal trends in cesarean deliveries among low-risk patients, investigators conducted a repeated cross-sectional analysis. Delivery hospitalizations for patients aged 15 to 39 years at low risk for cesarean delivery were evaluated. Data was collected from the US National Inpatient Sample, containing information on about 20% of all US hospitalizations.

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM criteria from the Society for Maternal-Fetal Medicine (SMFM) were used to identify delivery hospitalizations. According to SMFM guidelines, full term patients with singleton, vertex fetuses and no history of cesarean delivery are at low risk of cesarean delivery.

Further SMFM criteria for being low risk include having no absolute or relative contraindications to vaginal birth, or other conditions associated with increased cesarean delivery risk. Delivery hospitalizations associated with obesity, chronic hypertension, pregestational and gestational diabetes, preeclampsia, and postdates gestational agediagnoses were also excluded.

Data on demographic factors such as maternal age, year of delivery, payer, race and ethnicity, and median income quartile were included in the analysis. Race and ethnicity data was collected to account for disparities related to these factors. Hospital data collected included location and teaching status and geographic region.

Temporal trends in cesarean deliveries among low-risk individuals and trends in cesarean deliveries for nonreassuring fetal status, labor arrest, and obstructed labor were the primary measures of the study. When analyzing labor arrest, investigators analyzed trends during the latent, active, and second stages of labor.

There were 40,517,867 low-risk deliveries included in the analysis, 12.1% of which were cesarean deliveries. Patients who were older, had commercial insurance, and delivered at hospitals in the South were more likely to undergo cesarean delivery.

An increase in cesarean delivery rates from 9.7% to 13.9% was observed from 2000 to 2009, followed by a decrease from 13% to 11.1% from 2012 to 2019. In patients with a diagnosis of nonreasuring fetal status, rates of cesarean delivery were 3.4% in 2000 and 5.1% in 2019.

In 2000, cesarean deliveries were seen in 3.6% of patients with labor arrest. This rate peaked in 2009 at 4.8%, then decreased to 2.7% in 2019. This indicated a decrease in cesarean delivery rates among patients with labor arrest in the latter years of the study period. 

The rate of cesarean births with obstructed labor was 0.9% in 2008 and 0.3% in 2019. All 3 stages of labor arrest diagnoses saw decreases in the latter study period. The average annual percentage change was -7% for the latent phase from 2011 to 2015, -2.5% for the active phase from 2009 to 2019, and -3.1% for the second stage from 2008 to 2019.

Reference

Frappaolo AM, Logue TC, Goffman D, et al. Cesarean delivery trends among patients at low risk for cesarean delivery in the US, 2000-2019. JAMA Netw Open. 2023;6(3):e235428. doi:10.1001/jamanetworkopen.2023.5428