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BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health www.birthbythenumbers.org With support from: The Transforming Birth Fund

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Page 1: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Myth and Reality Concerning Cesarean Section in the U.S.

Professor Gene Declercq, PhDBoston University School of Public Health

www.birthbythenumbers.org

With support from: The Transforming Birth Fund

Slides Updated through January 15,2015

Page 2: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13

%

Source: National Center for Health Statistics Annual Birth Reports

%

1,284,339cesareans

in 2013

If the 2013 cesarean rate was the same as in 1996, there would have been 475,000 fewer cesareans in the U.S. in ’13.

Page 3: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

Page 4: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

Page 5: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

US Cesarean Rates, 1989-2013

20

22

24

26

28

30

32

34

% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

Page 6: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Commonly Used Explanations for the High Cesarean Rate

• Mothers are getting older• More multiples being born• Maternal obesity increasing• Babies are getting bigger• Mothers are generally less healthy• Mothers are asking for it

Page 7: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Older Mothers? % Births to Mothers 30 +, U.S. 1990-2013

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Between 2003 & 2010 CS Rate increased by 20%

> 35> 35

>30

BirthByTheNumbers.org

From 2010-2013, CS rate unchanged

Page 8: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Total Cesarean Rates (per 100 births) by Age of Mother: United States, 1996 and 2013

14.517.4

20.623.8

27.431.6

21.8

27.631.3

35.5

41.6

49.6

0

10

20

30

40

50

60

<20 20-24 25-29 30-34 35-39 40-54

1996 2013

50% 59% 52% 49% 52% 57%

Source: National vital statistics system, NCHS, CDC.

Per

cent

Overall increase, 1996-2013: 58.0%

Page 9: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Multiple Births? Proportion of all babies in multiple births,

U.S., 1980-2013

19801982

19841986

19881990

19921994

19961998

20002002

20042006

20082010

20120.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

BirthByTheNumbers.orgSource: National Center for Health Statistics Annual Birth Reports

Page 10: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Cesarean Rates for Multiple Births, U.S. 1990-2013

56% 56%

60%

74%76%

50%

55%

60%

65%

70%

75%

80%

1990 1995 2000 2006 2013

BirthByTheNumbers.org

Page 11: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Are Babies Getting Bigger?% Singleton Babies by Birthweight, U. S., 1991-2013

11% 11% 10% 8% 8%

30% 30% 29%28% 28%

0%

10%

20%

30%

40%

50%

1991 1996 2001 2006 2013

3500-3999gms

4000+gms41% 41% 39%

36% 36%

BirthByTheNumbers.org

Page 12: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

% Cesareans in Singleton Births, U.S. by Birthweight, 1991-2013

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

1991 1996 2001 2006 2013

3500 - 3999gms

4000 - 4499gms

4500+gms53.6%

38.6%

31.3%

21.8%

27.8%

38.2%

BirthByTheNumbers.org

Page 13: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Mothers’ Health?Prepregnancy Obesity, U.S. 2003, 2006, 2009, 2011

2003 2006 2009 201110%

12%

14%

16%

18%

20%

22%

17.6%

19.5%

20.5% 20.3%

Sources: 2003-2009 -- S. Fisher. Is obesity still increasing among pregnant women?Preventive Medicine 2013; 56: 372-378; 2011 – CDC VitalStats.

Page 14: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Mothers’ Health?Cesarean Rate Singleton Births by Prepregnancy

Weight Range, U.S. 2013

Underwei

ght

Normal

Wei

ght

Ove

rwei

ght

Obes

e I

Obes

e II

Obes

e III

-10%

0%

10%

20%

30%

40%

50%

60%

22.3%27.1%

33.6%39.7%

45.4%

54.0%

Source: CDC VitalStats, 2013.

Page 15: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Mothers’ Health?Diabetes* & Hypertension*, 1992,2002,2013

1992 2002 20130%

1%

2%

3%

4%

5%

6%

7%

2.2%

3.2%

6.0%

3.4%

4.4%

6.4%Any Diabetes

Any Hypertension

* Either gestational or chronic condition

Source: CDC VitalStats, selected years.

Page 16: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Mothers’ Health?Cesarean Rates, Singleton Births, U.S.,

1990, 1996, 2004, 2013

1990 1996 2004 201330%

40%

50%

60%

70%

Prepregnancy DiabetesChronic Hypertension

Source: CDC VitalStats, selected years.

Page 17: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Mothers’ Health?Cesarean Rates, Singleton Births, U.S.,

1990, 1996, 2004, 2013

1990 1996 2004 201330%

40%

50%

60%

70%

Prepregnancy DiabetesChronic Hypertension

Source: CDC VitalStats, selected years.

Page 18: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Mothers asked for it

Have maternal request cesareans played a major

role in these increases?

Page 19: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

http://www.childbirthconnection.org

Asking Mothers about

Maternal Request Cesareans

Page 20: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Two Components to Maternal Request Primary Cesarean

1. Mother made request for planned cesarean before labor

Page 21: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Two Components to Maternal Request Primary Cesarean

1. Mother made request for planned cesarean before labor

2. Cesarean for no medical reason

Page 22: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Patient Choice Primary Cesareans• Combining reason for cesarean and timing of

decision found only about 1% of respondents had a planned primary cesarean for no medical reason.“I think that [cesarean] is… the best way … to give birth. It is a planned way, no hassle, no pain, the baby doesn’t struggle to come out, the baby is not pressed to come out …I think that … everybody should have the baby by cesarean section.” (quote from LtM2)Studies from England, Canada and U.S. states

confirm very low rates of maternal request cesareans

Page 23: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Pressure to Accept Interventions by Method of Delivery

Did you feel pressure from any health professional to have a cesarean? % yes

7%

28%

28%

22%

0% 5% 10% 15% 20% 25% 30%

Vaginal

VBAC

PrimaryCesarean

RepeatCesarean

Source: Declercq et al. 2013. Listening to Mothers III.BirthByTheNumbers.org

Page 24: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Commonly Used Explanations for the High Cesarean Rate

• Mothers are getting older

• More multiples being born

• Babies are getting bigger

• Maternal health is worse: obesity,

diabetes & hypertension

• Mothers are asking for it

Page 25: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Commonly Used Explanations for the High Cesarean Rate

• Mothers are getting older – NO

• More multiples being born

• Babies are getting bigger

• Maternal health is worse: obesity,

diabetes & hypertension

• Mothers are asking for it

Page 26: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Commonly Used Explanations for the High Cesarean Rate

• Mothers are getting older – NO

• More multiples being born– NO

• Babies are getting bigger

• Maternal health is worse: obesity,

diabetes & hypertension

• Mothers are asking for it

Page 27: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Commonly Used Explanations for the High Cesarean Rate

• Mothers are getting older– NO

• More multiples being born – NO

• Babies are getting bigger – NO !!

• Maternal health is worse: obesity,

diabetes & hypertension

• Mothers are asking for it

Page 28: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Commonly Used Explanations for the High Cesarean Rate

• Mothers are getting older– NO

• More multiples being born – NO

• Babies are getting bigger – NO !!

• Maternal health is worse: obesity,

diabetes & hypertension – Some

• Mothers are asking for it

Page 29: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Commonly Used Explanations for the High Cesarean Rate

• Mothers are getting older– NO

• More multiples being born – NO

• Babies are getting bigger – NO !!

• Maternal health is worse: obesity,

diabetes & hypertension – Some

• Mothers are asking for it – NO

Page 30: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

If the usual explanations for the rising cesarean

rate don’t account for the changes what does?

Page 31: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

If the usual explanations for the rising cesarean

rate don’t account for the changes what does?

Practice Changes

Page 32: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Leading Indications for Cesareans

34%

23%

17%

7%

5%

4%4%

3% 3%

Labor ArrestNonreassuring fetal trac-ingMalpresentationMultiple GestationMaternal-FetalMacrosomiaOther Obstet.PreeclampsiaMaternal Request

Source: ACOG & SMFM. Safe Prevention of Primary Cesarean Delivery. 3/2014.

Page 33: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications

20

30

40

50

60

70

1990 1996 2011

Prolonged Labor

Nonreassuring FetalTracing

Macrosomia

Twins

*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org

Page 34: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

20

22

24

26

28

30

32

34

% Tot US 23 22. 22. 22. 21. 21. 20. 20. 20. 21. 22. 23 24 26 28 29 30 31 32 32 33 33 33 33 33

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13

%

Source: National Center for Health Statistics Annual Birth Reports

%

Revisiting the trend in cesareans in the US for comparison

BirthByTheNumbers.org

Page 35: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications

30

40

50

60

70

1990 1996 2011

Prolonged Labor

Nonreassuring Fetal Tracing

Macrosomia

Twins

*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org

Page 36: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Cesarean Rates, Low Risk*, First-Time Mothers for Medical Risk Factors & Labor Complications

30

40

50

60

70

1990 1996 2011

Prolonged Labor

Nonreassrg Fetal Trace

Macrosomia

Twins

*Singleton, Vertex, Full Gestation Births BirthByTheNumbers.org

Page 37: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Women have not changed nearly as much as practice patterns have

BirthByTheNumbers.org

Page 38: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Any other evidence that this is about a culture of

practice?

BirthByTheNumbers.org

Page 39: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Let’s look at variation.

If the practice of maternity care is evidence based, then differences in rates should be based primarily on different risk profiles of mothers.

BirthByTheNumbers.org

Page 40: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Page 41: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

MT

WY

ID

WA

OR

NV

UT

CA

AZ

ND

SD

NE

CO

NM

TX

OK

KS

AR

LA

MO

IA

MN

WI

IL IN

KY

TN

MS AL GA

FL

SC

NC

VAWV

OH

MINY

PA

MDDE

NJ

CTRI

MA

ME

VTNH

AK

HI

31.6%+

22.6-31.5%

DC

Cesarean Delivery Rates1, 2012

1Percentage of all live births by cesarean delivery

Source: Martin J, et al. Births Final Data 2012. National Vital Statistics System, 2014. BirthByTheNumbers.org

Page 42: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

MT

WY

ID

WA

OR

NV

UT

CA

AZ

ND

SD

NE

CO

NM

TX

OK

KS

AR

LA

MO

IA

MN

WI

IL IN

KY

TN

MS AL GA

FL

SC

NC

VAWV

OH

MI

NY

PA

MDDE

NJ

CTRI

MA

ME

VTNH

AK

HI

DC

1960 Electoral College Map

Nixon 219

Harry Byrd 15

Kennedy 303

BirthByTheNumbers.org

Page 43: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

JFK 1960 Vote and 2012 Cesarean Rates

20% 25% 30% 35% 40% 45%35

40

45

50

55

60

65

r = +.28

2012 Cesarean Rate

JFK

% V

ote

Each dot represents a U.S. state

Page 44: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

BirthByTheNumbers.org

Variation is not just at the state level but at the hospital level as well

Page 45: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

% Cesarean Deliveries by Hospital for ALL MA Births, 2004-2006

N = 49 Mean =31.2 σ2 =29.6

41.9

21.1

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

Hospital Rank

%CSAll 49 Hospitals

Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817

BirthByTheNumbers.org

Page 46: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

All Hospitals

10.3

35.0

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

Hospital Rank

%CS

% Cesarean Deliveries by Hospital for NTVS, Spontaneous Labor, BWT 2500-4000g Births

N = 49 Mean =21.1 σ2 =37.1

Source: Caceres I, et al. Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact. PLOS One.2013; 8 (3): e57817 BirthByTheNumbers.org

Page 47: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

How does a culture of intervention get manifested

in a hospital setting?

BirthByTheNumbers.org

Page 48: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

How does a culture of intervention get manifested

in a hospital setting?

Consider the Cascade of Interventions

BirthByTheNumbers.org

Page 49: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

InductionNo

53%

EpiduralNo

39%

EpiduralYes61%

InductionYes47%

EpiduralNo

22%

EpiduralYes78%

First-time mothers with term births (37-41 weeks’ gestation) who experienced labor

Cesarean Yes

20%

Cesarean Yes

5%

Cesarean Yes

31%

Cesarean Yes

19%In this group, which included 85% of first-time mothers, the overall epidural rate was 69% and overall cesarean rate was 21%.

Cascade of interventions in first-time mothers with term births who experienced labor

Base: first-time mothers with term births who experienced labor n=750

BirthByTheNumbers.org

Page 50: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

What about Vaginal Birth After Cesarean

(VBAC) ?

BirthByTheNumbers.org

Page 51: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

VBAC Rates*, U.S.,1990-2011

5%

10%

15%

20%

25%

30%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Source: NCHS Vital Stats. http://www.cdc.gov/nchs/VitalStats.htm

* Number of VBACs among women with prior cesarean

NOTE: Rates for 2005-2011 are unofficial

BirthByTheNumbers.org

Page 52: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

% VBAC Lower Risk* Mothers, U.S., Monthly Rates, 1990-2012

6%

9%

12%

15%

18%

21%

24%

27%

30%

33%

* Full-gestation(37+ weeks), vertex presentation, singleton births

Sachs, NEJM 1/99

ACOG New VBAC Guidelines 10/98 & 7/99

Lydon-Rochelle & Greene 7/01

LandonNEJM 12/04Flamm

Studies1988,’90, ‘94

McMahon NEJM 9/96

ACOG guidelines encourage VBAC, 1/82 10/88 Reaffirmed 1991

Revised ACOG Guide-

lines 8/10

BirthByTheNumbers.org

Page 53: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

VBAC Rates Industrialized Countries, 2010

MaltaIcelandFinland

NetherlandsNorway

GermanyFrance

BelgiumDenmark

EnglandEstonia

LuxembourgCzech Republic

SloveniaScotland

LithuaniaItalyU.S.

LatviaCyprus

0 10 20 30 40 50 60 70 8074

5252

4746

363534

333029

2828

2121

1110

97

6

Source: Adapted from Peristats & US Data

VBAC % = VBACS Women w/ Prior CS

BirthByTheNumbers.org

Page 54: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

August, 2010

BirthByTheNumbers.org

Page 55: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Mother had cesarean in the past, and did not have the option of a VBAC for recent birth.

LTMI 2000-02

LTMII 2005

LTMIII2011-12

Did not have the option because caregiver was unwilling to do a VBAC

36% 45% 24%

Did not have the option because hospital was unwilling to allow a VBAC

12% 23% 15%

Medical reason unrelated to prior cesarean 38% 20% 45%

U.S. Mothers Report of Experience Seeking a VBAC, 2000, 2005, 2012

Source: Listening to Mothers 3. New VBAC Guidelines

BirthByTheNumbers.org

Page 56: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

So is a rising cesarean rate inevitable?

BirthByTheNumbers.org

Page 57: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

So is a rising cesarean rate inevitable?

ABSOLUTELY NOT

BirthByTheNumbers.org

Page 58: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

US Cesarean Rates, 1989-2012

20

22

24

26

28

30

32

34

% Tot US 23 22.722.622.321.821.220.820.720.821.222.0 23 24 26 28 29 30 31 32 32 33 33 33 33

'89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12

%

Source: National Center for Health Statistics Annual Birth Reports

%

BirthByTheNumbers.org

Page 59: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Trends in Cesarean Rates (per 1000 births), Comparison Countries, 1990-2011

50

100

150

200

250

300

350

400

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Sources: OECD Health Data 2013; WHO Health for All Database, 2014. BirthByTheNumbers.org

Page 60: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Trends in Caesarean Rates (per 1000 births), Comparison Countries, 1990-2011

50

100

150

200

250

300

350

400

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Sources: OECD Health Data 2013; WHO Health for All Database, 2014. BirthByTheNumbers.org

Page 61: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery

Safe Prevention of Primary Cesarean Delivery

Questioning the Rising Cesarean Rate

BirthByTheNumbers.org

Page 62: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Evidence Based Advocacy

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Page 63: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

Prematurity and Low Birthweight, U.S., 1990-2012

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

6

7

8

9

10

11

12

13

Prematurity

Low Birthweight

9.8%Decrease 2006-12

%

YearBirthByTheNumbers.org

Page 64: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

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Page 65: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

http://www.choicesinchildbirth.org/

Evidence Based Advocacy

BirthByTheNumbers.org

Page 66: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

https://www.childbirthconnection.org/

Evidence Based Advocacy

Page 67: BirthByTheNumbers.org Myth and Reality Concerning Cesarean Section in the U.S. Professor Gene Declercq, PhD Boston University School of Public Health

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