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Indications Contributing to the Increasing Cesarean Delivery Rate

Barber, Emma L. MD; Lundsberg, Lisbet S. PhD; Belanger, Kathleen PhD; Pettker, Christian M. MD; Funai, Edmund F. MD; Illuzzi, Jessica L. MD, MS

doi: 10.1097/AOG.0b013e31821e5f65
Original Research

OBJECTIVE: To examine physician-documented indications for cesarean delivery in order to investigate the specific factors contributing to the increasing cesarean delivery rate.

METHODS: We analyzed rates of primary and repeat cesarean delivery, including indications for the procedure, among 32,443 live births at a major academic hospital between 2003 and 2009. Time trends for each indication were modeled to estimate the absolute and cumulative annualized relative risk of cesarean by indication over time and the relative contribution of each indication to the overall increase in primary cesarean delivery rate.

RESULTS: The cesarean delivery rate increased from 26% to 36.5% between 2003 and 2009; 50.0% of the increase was attributable to an increase in primary cesarean delivery. Among the documented indications, nonreassuring fetal status, arrest of dilation, multiple gestation, preeclampsia, suspected macrosomia, and maternal request increased over time, whereas arrest of descent, malpresentation, maternal-fetal indications, and other obstetric indications (eg, cord prolapse, placenta previa) did not increase. The relative contributions of each indication to the total increase in primary cesarean rate were: nonreassuring fetal status (32%), labor arrest disorders (18%), multiple gestation (16%), suspected macrosomia (10%), preeclampsia (10%), maternal request (8%), maternal-fetal conditions (5%), and other obstetric conditions (1%).

CONCLUSION: Primary cesarean births accounted for 50% of the increasing cesarean rate. Among primary cesarean deliveries, more subjective indications (nonreassuring fetal status and arrest of dilation) contributed larger proportions than more objective indications (malpresentation, maternal-fetal, and obstetric conditions).


Subjective indications, such as nonreassuring fetal status and arrest of dilation, contribute the largest proportions to the increasing primary cesarean delivery rate.

From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, Connecticut.

Dr. Jessica Illuzzi received support from the NICHD as a Women's Reproductive Health Research Scholar (NIH K12 HD047018).

The authors thank Cheryl Raab, RNC for her assistance with data collection.

Presented at the annual meeting of the Society for Maternal-Fetal Medicine, February 7–12, 2011, San Francisco, California.

Corresponding author: Jessica L. Illuzzi, MD, MS, Department of Obstetrics and Gynecology, Yale School of Medicine, PO Box 208063, New Haven, CT 06520-8063; e-mail:

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

© 2011 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.