High Primary Cesarean Section Rates: Strategies for Improvement

Approximately one in three women giving birth in the United States will undergo cesarean delivery.1 Certain high-risk pregnancy conditions, such as placenta previa, may warrant a cesarean delivery, but most low-risk pregnancies are candidates for a vaginal birth. Low risk can be defined as nulliparous, term, singleton, and vertex (NTSV). As of 2020, the Centers for Disease Control and Prevention (CDC) ranked Florida, Mississippi, and Louisiana as the three states with the highest overall cesarean delivery rate, at 35.9%, 38.2%, and 36.8%, respectively.2 (See Figure 1.) According to the Maternal Safety Foundation, Florida’s 2017 NTSV cesarean section rate was 31%, the highest in the nation.3 Rising health care costs, increasing placenta accreta spectrum cases, factors affecting breastfeeding and bonding, and the current opioid use crisis all indicate a need to address these high rates. Compared to a vaginal delivery, cesarean delivery poses greater maternal and neonatal risks. These include a higher risk of maternal mortality, hemorrhage, infection, thromboembolism, amniotic fluid embolism, neonatal respiratory distress syndrome, and other long-term sequalae such as chronic pelvic pain and abnormal placentation.4 This commentary will provide an update on evidence-based approaches to lowering cesarean rates among NTSV births. It will also discuss the influence of provider and hospital unit culture, as well as the potential application of perinatal collaborative best practices across state lines. The goal is to provide recommendations to help lower NTSV cesarean births.