Cesarean delivery is the most common major surgical procedure for women in the United States, with 1.4 million surgeries annually. In 2008, nearly one-third (32.3%) of US births were by cesarean delivery. Cesarean delivery rates have increased rapidly in the United States in recent years because of an increasing primary cesarean delivery rate and a declining vaginal birth after cesarean (VBAC) rate. In 2007, the VBAC rate was 8.3% in a 22-state reporting area. The US VBAC rate was lowest among 14 industrialized countries; 3 countries had VBAC rates greater than 50%.

BACKGROUND: After a gradual decline from 1990 to 2004, the percentage of births occurring at home in the United States increased by 5 percent in 2005 and that increase was sustained in 2006. The purpose of the study was to analyze trends and characteristics in home births in United States by race and ethnicity from 1990 to 2006. METHODS: U.S. birth certificate data on home births were analyzed and compared with hospital births for a variety of demographic and medical characteristics. RESULTS: From 1990 to 2006, both the number and percentage of home births increased for non-Hispanic white women, but declined for all other race and ethnic groups. In 2006, non-Hispanic white women were three to four times more likely to have a home birth than women of other race and ethnic groups. Home births were more likely than hospital births to occur to older, married women with singleton pregnancies and several previous children. For non-Hispanic white women, fewer home births than hospital births were born preterm, whereas for other race and ethnic groups a higher percentage of home births than hospital births were born preterm. For non-Hispanic white women, two-thirds of home births were delivered by midwives. In contrast, for other race and ethnic groups, most home births were delivered by either physicians or "other" attendants, suggesting that a higher proportion of these births may be unplanned home births because of emergency situations. CONCLUSIONS: Differences in the risk profile of home births by race and ethnicity are consistent with previous research, suggesting that, compared with non-Hispanic white women, a larger proportion of non-Hispanic black and Hispanic home births represent unplanned, emergency situations. (BIRTH 38:1 March 2011).

KEY FINDINGS: Data from the Natality Data File, National Vital Statistics System The cesarean rate rose by 53% from 1996 to 2007, reaching 32%, the highest rate ever reported in the United States. From 1996 to 2007, the cesarean rate increased for mothers in all age and racial and Hispanic origin groups. The pace of the increase accelerated from 2000 to 2007. Cesarean rates also increased for infants at all gestational ages; from 1996 to 2006 preterm infants had the highest rates. Cesarean rates increased for births to mothers in all U.S. states, and by more than 70% in six states from 1996 to 2007.

OBJECTIVES: This report presents 2006 data on new checkbox items exclusive to the 2003 U.S. Standard Certificate of Live Birth. Information is shown for checkboxes in the following categories: "risk factors in this pregnancy," "obstetric procedures," "characteristics of labor and delivery," "method of delivery," "abnormal conditions of the newborn," and "congenital anomalies of the newborn." These categories are included on both the 1989 and the 2003 U.S. Standard Certificates of Live Birth; however, many of the specific checkboxes were modified, or are new to the 2003 certificate. Data on selected new (not modified) checkboxes are presented in this report. METHODS: Descriptive statistics are presented on births occurring in 2006 to residents of the 19 states that had implemented the 2003 U.S. Standard Certificate of Live Birth as of January 1, 2006. RESULTS: There were 2,073,368 births to residents of the 19-state reporting area, representing 49 percent of 2006 U.S. births. The rate of prepregnancy diabetes was 6.8 per 1,000 births and gestational diabetes was 38.7; risk of both types of diabetes rose rapidly with advancing maternal age. Cervical cerclage was reported at a rate of 2.9 per 1,000. External cephalic version was used in 3.2 of every 1,000 births; its success rate decreased with increasing maternal age. Almost all attempts at forceps or vacuum delivery were successful. About 25 percent of women who had a cesarean delivery attempted a trial of labor. Fifteen percent of women received antibiotics during labor. Rates for antenatal steroids (8.4) and surfactant replacement therapy (3.2) decreased with increasing gestational age. Large differences by race and Hispanic origin were generally seen for the receipt of steroids and surfactant replacement therapy regardless of gestational age. Six percent of all infants were admitted to a neonatal intensive care unit (NICU).

To examine trends in repeat cesarean delivery, the characteristics of women who have repeat cesareans, and the risk of neonatal mortality for repeat cesarean birth compared to vaginal birth after cesarean (VBAC). Trends and characteristics of repeat cesareans were examined for: the period 1998-2002 for [1] all births, [2] low-risk births (singleton, term, vertex births) and [3] "no indicated risk" (NIR) births (singleton, term, vertex presentation births with no reported medical risks or complications). For low-risk and NIR births, neonatal mortality rates for repeat cesareans and VBACs were compared. Multivariate logistic regression was used to examine the risk of neonatal mortality for repeat cesareans and VBACs, after controlling for demographic and health factors. In 2002 the repeat cesarean rate was 87.4%, and varied little by maternal risk status or by demographic and health characteristics. From 1998-2002 rates increased by 20% for low risk and by 21% for NIR births, respectively. For low-risk women for the 1998-2002 birth cohorts, the adjusted odds ratio for neonatal mortality associated with repeat cesarean delivery (compared with VBAC) was 1.36 (95% C.I. 1.20-1.55). For NIR women, the adjusted odds ratio was 1.24 (0.99-1.55). The experience of a prior cesarean has apparently become a major indication for a repeat cesarean. Regardless of maternal risk status, almost 90% of women with a prior cesarean have a subsequent (i.e., repeat) cesarean delivery. This is the case even if there was no other reported medical indication. Our findings do not support the widely-held belief that neonatal mortality risk is significantly lower for repeat cesarean compared to VBAC delivery.

The rise in the rate of birhs by cesarean delivery has been accompanied by a decrease in the rate of vaginal delivery and in the use of forceps or vacuum extraction, methods that are used to assist vaginal delivery (i.e., assisted vaginal delivery). Between 1996 and 2006, birhs by cesarean delivery rose by 50 percent, from 20.7 to 31.1 percent. At the same time, the rate of assisted vaginal delivery declined from 11.8 to 6.6 percent and the rate of unassisted vaginal birhs fell from 67.5 to 62.3 percent. The pace of these changes accelerated between 2000 and 2006. | The decline in the rate of vaginal delivery (both assisted and unassisted) may reflect changes in obstetric training and practice patterns, as well as the continuing debate on the immediate and long-term risks and benefits of vaginal versus cesarean birh for both the mother and infant. | This analysis was prepared by Fay Menacker, DrPH, CPNP, and Joyce A. Martin, MPH, of the Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA.