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Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery

Main, Elliott K. MD; Morton, Christine H. PhD; Melsop, Kathryn MS; Hopkins, David PhD; Giuliani, Giovanna MBA, MPH; Gould, Jeffrey B. MD, MPH

doi: http://10.1097/AOG.0b013e31826fc13d
Current Commentary

Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

California Maternal Quality Care Collaborative and the Stanford University School of Medicine, Palo Alto, and the California Pacific Medical Center and the Pacific Business Group on Health, San Francisco, California.

Corresponding author: Christine H. Morton, PhD, Stanford University School of Medicine, Medical School Office Building, 1265 Welch Road MS5415, Palo Alto, CA 94305; e-mail:

Supported by a grant from the California HealthCare Foundation, based in Oakland, California.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2012 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.