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Trends in Cesarean Delivery for Twin Births in the United States: 1995–2008

Lee, Henry C. MD, MS; Gould, Jeffrey B. MD, MPH; Boscardin, W. John PhD; El-Sayed, Yasser Y. MD; Blumenfeld, Yair J. MD

doi: 10.1097/AOG.0b013e3182318651
Original Research
Journal Club

OBJECTIVE: To estimate trends and risk factors for cesarean delivery for twins in the United States.

METHODS: This was a cross-sectional study in which we calculated cesarean delivery rates for twins from 1995 to 2008 using National Center for Health Statistics data. We compared cesarean delivery rates by year and for vertex compared with breech presentation. The order of presentation for a given twin pair could not be determined from the available records and therefore analysis was based on individual discrete twin data. Multivariable logistic regression was used to estimate independent risk factors, including year of birth and maternal factors, for cesarean delivery.

RESULTS: Cesarean delivery rates for twin births increased steadily from 53.4% to 75.0% in 2008. Rates rose for the breech twin category (81.5%–92.1%) and the vertex twin category (45.1%–68.2%). The relative increase in the cesarean delivery rate for preterm and term neonates was similar. After risk adjustment, there was an average increase noted in cesarean delivery of 5% each year during the study period (risk ratio 1.05, 95% confidence interval 1.04–1.05).

CONCLUSION: Cesarean delivery rates for twin births increased dramatically from 1995 to 2008. This increase is significantly higher than that which could be explained by an increase in cesarean delivery for breech presentation of either the presenting or second twin.


Cesarean delivery for twin births increased dramatically from 1995 to 2008, particularly in women with low medical risk profiles.

From the Departments of Pediatrics and Medicine and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California; and the Departments of Pediatrics and Obstetrics & Gynecology, Stanford University, Stanford, California.

Supported by National Institutes of Health/National Center for Research Resources/OD UCSF-CTSI Grant No. KL2 RR024130. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

Corresponding author: Henry C. Lee, MD, MS, Department of Pediatrics, Division of Neonatology, University of California, San Francisco, 533 Parnassus Avenue, Room U503, San Francisco, CA 94143-0734; 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.