What are some factors driving use of cesarean section in the United States?: A Listening to Mothers III Data Brief

The cesarean section rate has risen sharply over the last decade, stabilizing in recent years around one in three women. Although potential benefits of the procedure may outweigh possible harms in the presence of certain complications or risk factors, rates above 10 to 15% appear to do more harm than good. Cesareans also pose serious risks to women and babies in future pregnancies. Thirty-one percent of Listening to Mothers III survey participants gave birth by cesarean, including 15% with first (primary) cesareans and 16% with repeat cesareans. The survey explored possible drivers of high cesarean rates.

Learn more about Childbirth Connection’s Listening to Mothers III survey.

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SUMMARY OF KEY FINDINGS

“Maternal request” primary cesareans remain rare. Despite much media and professional attention to “maternal request” cesareans, only 1% of respondents who had a planned initial, or “primary,” cesarean did so with the understanding that there was no medical reason. About one mother in five (22%) reported asking their providers to schedule a cesarean before labor, and 87% of those did so believing that it would offer a health benefit to them or their babies, leaving about 2% overall who asked the provider to schedule a cesarean with no medical reason.

Many women report experiencing pressure from a care provider to have a cesarean.Overall, 13% of mothers reported experiencing pressure from a care provider to have a cesarean. However, this rose to 22% among women who had a repeat cesarean section, and 28% among both mothers who had a primary cesarean and those who had a vaginal birth after cesarean.

Discussion about giving birth after one or two prior cesareans steers many women toward repeat cesarean, even though research and professional guidelines support offering vaginal birth to nearly all such women. The survey looked at decision-making processes among women who had had one or two cesareans and whose care providers mentioned a possible repeat cesarean. Forty percent of women were presented with no information about why they should not have a repeat caesarean, while just 3% of women received no information about reasons to have a repeat cesarean. More than one in four of the women in this situation reported that the discussion had not been framed as a matter of choice. Among the 73% of care providers who expressed an opinion about the decision, 88% recommended repeat cesarean. Ultimately, 93% of the women in this group did have a repeat cesarean.

Discussion about giving birth when a baby might be getting large steers many women toward a primary cesarean, even though research and professional guidelines do not support use of cesarean section in this case. The survey looked at decision-making processes among women whose care providers discussed a planned initial or “primary” cesarean section (but not labor induction) because the baby might be getting quite large. One in five women (19%) were presented with no information about why they should not have an initial caesarean, while just 4% of women received no information about reasons to have a cesarean. Nearly four in ten of the women in this situation reported that the discussion had not been framed as a matter of choice. Among the 71% of care providers who expressed an opinion about the decision, 72% recommended a primary cesarean. Ultimately, 29% of women in this situation had a primary cesarean, versus the survey’s overall 19% primary cesarean rate.

Interventions in labor are closely linked with having unplanned cesarean. The phenomenon where one intervention increases the likelihood of others used to monitor, prevent, or treat side effects is known as the “cascade of intervention.” This cascade frequently ends in an unplanned cesarean section. Among first-time mothers with term births who experienced labor, those who had both labor induction and epidural analgesia were six times as likely to have a cesarean section (31%) as those who had neither intervention (5%).

 

A significant proportion of cesareans may be related to lack of access to vaginal birth after cesarean (VBAC). Of women with a previous cesarean, almost half (48%) were interested in the option of a VBAC, but 46% were denied that option. In 24%, the reason for the denial was unwillingness of the provider. In 15% the woman’s hospital did not allow VBACs.

Most survey participants were uninformed about potential harms of cesarean section. We explored respondents’ knowledge of two possible harms of cesarean section: breathing difficulties in newborns and placental problems in future pregnancies. In neither case did most cite the “correct” response, with “not sure” selected most often. Mothers who had a cesarean were no more likely to be correct about placental difficulties than mothers who did not, and much more likely than mothers with a vaginal birth to incorrectly agree that a cesarean lowers the likelihood of newborn breathing problems.