Vital and

Health Statistics

Cesarean Delivery in

the United States, 1990

Series 21:

Data on Natality, Marriage, and Divorce

No, 51

An analysis of the demographic and maternal and infant health characteristics

associated with cesarean delivery from information deriied from live birth

certificates,

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyaftsvlle, Maryland

May 1994

DHHS Publication No. (PHS] 94-1929
Copyright information

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated,

Suggested citation

Tatfel SM. Ceaarean delivery in the United States, 1990. National Center for

Heaith Stetisfics. Vial Health Stat 21 (51). 1994.

Library of Congrees Cetakrglng-in-Publication Data

Taffel, Selma.

Cesarean delivery in the United States, 1990/ [S.M. Tafe~.

p. cm. — (Vital and health statistics. Series 21. Data on natality, marriage,

and divorce; no. 51) (DHHS publication ; no, (PHS) 94-1929)

“An analysis of the demographic and maternal and infant health

characteristics associated with cesarean delivery from information derived from

live birth certificates.”

“May 1994”

Includes bibliographical references.

ISBN 0-6406-0490-4

1. Cesarean sectio~United States+tatistics. 1.National Center for

Health Statistics (U.S.) Il. Title. 111.Series. National Vital Statistics System ; no.

51. HA2211 .A3 no. 5t

[RG761]

304.6’30973021 sAc20

[362.1 ‘96660973021]

DNLM/DLC

for Library of Congress 94-671

CIP

For sale by the U.S. Government Printing Office

Superintendent of Documents

Mail Stop: SSOP

Washington, DC 20402-9328
National Center for Health Statistics

Manning Feinleib, M. D., Dr.P.H., Db-ector

Jack R. Anderson, Deputy Director

Jacob J. Feldman, Ph. D., Associate Director for Analysis,

Epidemiology, and Health Promotion

Gail F. Fisher, Ph.D., Associate Director for Planning and

Extramural Programs

Peter L. Hurley, Associate Director for Wal and Health

Statistics Systems

Robert A. Israel, Associate Director for International

Statistics

Stephen E. Nieberding, Associate Director for

Management

Charles J. Rothwell, Associate Director for Data

Processing and Services

Monroe G. Sirken, Ph. D., Associate Director for Research

and Methodology

Division of Vital Statistics

Lester R. Curtin, Ph.D., Acting Director

James A. Weed, Ph. D., Deputy Director

Robert L. Heuser, M.A., Chiej Natality, Marriage, and

Divorce Statistics Branch

Joseph D. Farrell, Chiej Computer Applications Staff

Mabel G. Smith, ChieJ Statistical Resources Branch
Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Maternal characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OO.. 3

Region and State ofresidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

3

Race and age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

. . . . . . .

Hispanic origin and age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Live-birth order and age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

Educational attainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. O....O+

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

Weight gain during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . 5

Infant characteristic s........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Period ofgestation and birthweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7

Plurality ofbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7

Abnormal conditions ofthenewbom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Pregnancy and delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Medical risk factors ofpregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Complications of laborand delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...9

Obstetric procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...11

List ofdetailedtables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Appendix

Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Text figures

1. Age-adjusted cesarean rates by specified race of mothec Total of 49 reporting States and the District of Columbia,

1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2. Total cesarean rates by age of mother and live-birth orden Total of 49 reporting States and the District of Columbi~

1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

3. Total cesarean rates by birthweight and period of gestation: Total of 49 reporting States and the District of Columbia,

1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

...

[11
Symbols

--- Data not available

. . . Category not applicable

— Quantity zero

0.0 Quantity more than zero but less than

0.05

z Quantity more than zero but less than

500 where numbers are rounded to

thousands

* Figure does not meet standard of

reliability or precision

# Figure suppressed to comply with

confidentiality requirements
Cesarean Deliveryin the

UnitedStates, 1990

by Selma M. Taffel, Division of Vial Statistics

Introduction

In recent years cesarean delivery has become the most

frequently performed major operative procedure for women in

the childbearing ages. According to information derived horn

the National Hospital Discharge Survey (NHDS) conducted

annually by the National Center for Health Statistics, the

cesarean delivery rate (number of cesarean deliveries per 100

total deliveries) rose from 4.5 percent in 1965 to 24.1 percent

in 1986 and then stabilized at about this level through 1991

(l).

Beginning in 1989, method of delivery was included on

the U.S. Standard Certificate of Live Birth to complement the

information on cesarean delivery available from the NHDS. In

1990, 49 States and the District of Columbia included this

item on their birth certificates the birth certificate of Oklahoma did not request method of delivery in 1990 but this item

was added in 1991. This study uses information from 1990

certificates of live birth to describe maternal demographic

characteristics, predisposing medical risk factors, complications of labor and delivery, obstetric procedures, and infant

characteristics associated with cesarean delivery. Because the

number of births in Oklahoma in 1990 comprised only 1 percent of all births in the United States, the cesarean rates

presented in this report can be assumed to be representative of

the United States as a whole.

All data in this report are shown by race of the mother.

Although the information presented is based on counts of

births, many of the characteristics described refer to the

mother, for example, age and education. Therefore, for ease in

writing, the terms “mothers” and “women” are sometimes

used interchangeably with “births” or “infants.”
Highlights

Information from the live birth certificates of the 49 States

and the District of Columbia that reported method of delivery

indicates that in 1990, 914,096 births or 22.7 percent of the

4,110,563 births in these areas were by cesarean delivery. This

rate is five times as high as the cesarean rate in 1965

(4.5 percent). The primary cesarean rate (first cesareans per

100 live births to women who had no previous cesarean) in

1990 was 16.0, and the rate of vaginal births following a

previous cesarean delivery (VBAC) per 100 births to women

with a previous cesarean, 19.9.

The South region has the highest total and primary

cesarean rates, followed by the Northeast, Midwest, and West

regions. The South has the lowest VBAC rate and the Northeast the highest. There are substantial differences in State rates

within each region.

The overall cesarean rate was slightly higher for white

births than for black births (23.0 compared with 22.1) and a

similar racial differential is apparent for the majority of States.

By race, the highest cesarean rate was for Filipino mothers

(24.6 percent) and the lowest for Anerican Indian mothers

(17.5 percent). Mothers of Hispanic origin as a group were

slightly less likely to have a cesarean delivery (21.2 percent)

than non-Hispanic white (23.4 percent) or non-Hispanic black

mothers (22.1percent).

The risk of cesarean delivery is highly associated with

both maternal age and the live-birth order of the child. The

rate of cesarean delivery increases with mother’s age, from

16.6 percent for teenage girls to 32.3 percent for women in

their forties. Rates are highest for first births (24.7 percent)

and decline steadily for each additional birth order to 17.5 percent for fourth or higher order births. When age and birth

order are considered together, rates are highest for women

35–39 years of age having their first child (39.3 percent) and

women 40-49 years of age having their first (47.1 percent) or

second child (37.9 percent).

Married women are more likely to deliver by cesarean

than unmarried women (23.8 percent compared with 19.9 percent), and the increased risk is apparent for married women

less than 40 years of age.

Rates of cesarean delive~ rise rapidly with additional

educational attainment, and women with 12 or more years of

schooling are about 30 to 40 percent more likely to have a

cesarean delivery than women with less than 9 years of

schooling (23 to 25 percent compared with 18 percent). Much

of this differential in rates can be explained by the older ages

of women with higher levels of educational attainment.

The risk of a cesarean delivery generally increases with

added weight gain during pregnancy. However, for weight

gains of less than 36 pounds, rates of cesarean delivery are

about the same or lower than average, and the risk of a

cesarean delivery is substantially higher than average only

when weight gain is 46 pounds or more.

Period of gestation and birthweight are both closely

related to the risk of cesarean delivery. Rates are highest for

preterm births (less than 37 completed weeks of gestation),

28.7 percent, decline to a low of 18.8 percent for a gestational

age of 40 weeks, and then rise to 23.0 percent for postterm

births (gestations of 42 weeks or longer). Rates are particularly high when birthweight is less than 1,500 grams (5 pounds

8 ounces), 43.7 percent, decline to a low of 19.8 percent for

birthweights of 3,000-3,499 grams (6 pounds 10 ounces-7

pounds 11 ounces), and then rise to 37.3 percent for birthweights of 4,500 grams or more (9 pounds 15 ounces or

more).

The cesarean rate for plural births is more than twice that

of singleton births (55.7 percent compared with 21.9 percent);

54.7 percent of births in twin deliveries, 86.0 percent in triplet

deliveries, and 89.0 percent in quadruplet, quintuplet, and

other multiple deliveries are by cesarean.

The cesarean rate for six of the eight abnormal conditions

noted on birth certificates was 34 percent or higher. Similar

high rates of cesarean delivery were evident for mamy of the

medical risk factors of pregnancy, complications of labor and

delivery, and obstetric procedures included on birth certificates. However, there is generally little difference by race in

the incidence of cesarean delivery for these conditions and

procedures.
Maternal characteristics

Region and State of residence

Of the 4,110,563 births in 1990 in the 49 States and the

District of Columbia reporting method of delivery, 914,096

were cesarean deliveries (table 1). Method of delivery was not

recorded for 2 percent of the births in the reporting area.

Ahnost two-thirds (63 percent) of all cesareans were primary

or first cesareans, and slightly over one-third (37 percent) were

repeat cesareans. A relatively small number of births (84,299)

were vaginal births following a previous cesarean delivery

(VBAC). Table 1 presents the number of births in 1990 by

method of delivery for the total reporting area and for each

region and State where the mother resided.

The total cesarean rate for the reporting area in 1990 was

22.7, and the primary rate was 16.0. The VBAC rate was 19.9

(table 2). These rates are within 1 percentage point of those

derived from the 1990 NHDS (23.5 for the total cesarean rate,

16.8 for the primary rate, and 20.4 for the VBAC rate) (l).

There are distinct regional and State variations in total,

primary, and VBAC rates (table 2). The south region had the

highest total and primary cesarean rates, followed by the

northeast, midwest, and west regions. Consistent with its high

cesarean rate, the south had the lowest VBAC rate. The

highest YBAC rate was in the northeast, with the west and

midwest regions intermediary (table 2). Within each region,

State rates varied by as much as 7 percentage points for the

total cesarean rate, by 5 percentage points for the primary rate,

and by as much as 20 percentage points for the VBAC rate.

For the reporting area as a whole, the total cesarean rate

was slightly higher for white btis than for black births (23.0

compared with 22.1). While white rates exceeded black rates

in the northeast, midwest, and south regions by about 2 percentage points, rates were higher in the west for black births

by 3 percentage points. For the majority of reporting States,

white rates were higher than black rates. Racial differences in

primary rates follow the same pattern as noted for the total

cesarean rate, while VBAC rates are generally higher for black

births.

Race and age

Regardless of the mother’s race, cesarean rates increase

rapidly with age (table 3). For all races combined, the rate was

about twice as high for mothers 40-49 years of age (32.3) as

for teenage mothers (16.6). The age differential in rates is

particularly noticeable for Chinese, Filipino, and “Other”

Asian or Pacific Islander mothers, who were about 3 to 3%

times as likely to have a cesarean delivery if they were 40-49

years old at the time of birth than if they were less than 20

years of age. Hawaiian mothers in the oldest years of childbearing are about 2% times as likely as teenage mothers to

deliver by cesarean; the oldest white, black American Indian,

and Japanese mothers are about twice as likely as teenage

mothers to deliver by cesarean (table 3).

By race the highest cesarean rates were for Filipino

(24.6 percent), white (23.0 percent), and black mothers

(22.1 percent), and the lowest for American Indian (17.5 percent) and Hawaiian mothers (18.2 percent). Racial differences

in cesarean rates are affected by the proportion of births to

teenage and older mothers as well as by differences in

age-specific cesarean rates. If the age distribution of births for

specific racial groups were the same as for all births, then the

rates for white, Chinese, Japanese, Filipino, and “Other”

Asian or Pacilic Islander mothers would be reduced because

the proportion of births to older mothers is higher for these

groups than for the average of all racial groups combined. By

contrast, the rates for black American Indian, and Hawaiian

mothers would be raised because of the far higher proportion

of teenage births relative to all births for these races (table 3

and figure 1).

After differences in the age distributions of racial groups

are taken into account, black mothers have the highest risk of

a cesarean delivery (23.3 percent) followed by white mothers

(22.8 percent) and Filipino mothers (22.2 percent); the lowest

risk of cesarean delivery then is for “Other” Asian or Pacific

Islander mothers (17.8 percent) and American Indian and

Chinese mothers (each 18.0 percent).

Hispanic origin and age

Mothers of Hispanic origin as a group are somewhat less

likely to have a cesarean delivery (21.2 percent) than nonHispanic white (23.4 percent) or non-Hispanic black mothers

(22.1 percent) (table 4). However, more than one-third of

Cuban mothers (34.7 percent) delivered by cesarean in 1990, a

rate substantially higher than for other Hispanic groups. Rates

for the remaining Hispanic groups ranged fkom 20.3 percent

for Mexican mothers to 22.8 percent for “other” and unknown

Hispanic origin mothers. As was true for individual racial

groups, rates of cesarean delivery increased rapidly with

advancing age of mother for all Hispanic origin groups.

3
25 r ,... 23.3

20

15

10

5

17.8 18,0 18.0 18,5

22.2

18.9

Figure 1. Age-adjusted cesarean rates by specified race of mothec Total of 49 reporting States and the Dietriot of Columbia, 1990

As noted for racial differences in the risk of cesarean

delivery, variation in rates by Hispanic origin are affected by

differences in age-specific rates and to a lesser extent, in the

proportion of teenage and older mothers. For all maternal

ages, Cuban mothers had a higher rate of cesarean delivery

than any other Hispanic or non-Hispanic group, and this is

reflected in their relatively high overall rate of 34.7 percent.

Mter standardization for differences in the age at childbirth,

Cuban mothers still have by far the highest risk of cesarean

delivery (33.7 percent), followed by Puerto Rican mothers and

“other” and unknown Hispanic origin mothers (each 23.6 percent). The lowest risk is still for Mexican mothers (21.0 percent) and Central and South American mothers (21.1 percent).

Live-birth order and age

As noted earlier, the rate of cesarean delivery increases

with mother’s age and is particularly high for women in the

oldest years of childbearing. As shown in table 5, a rapid

increase in rates by maternal age is apparent for almost all

live-birth orders. However, live-birth order affects the rate of

cesarean delivery independent of maternal age (table 5 and

figure 2). The risk of a cesarean delivery is highest for mothers

having their first child regardless of age, and except for

teenage mothers, the risk drops rapidly with succeeding births.

This decline in cesarean rates as live-birth order increases for

women 20 years of age and older is evident for both white and

black mothers.

The highest cesarean rates for any age–birth order combination were for women 35–39 years of age having their first

birth (39.3 percent) and women 40-49 years of age having

their first (47.1 percent) or second child (37.9 percent); the

50-

40 -

UJ

5

z 30

0

0

ii

: 20

%

r

First

birth

Second

birth

Third

or higher

birth

10

t

o~~

Under 20-24 25-29 30-34 35-39 40-49

20

Maternal age in years

NOTE The total cesarean rate is the number of births by ce$arean p+r 100 told births.

Figure 2. Total cesarean rates by age of mother and live-birth

ordefi Total of 49 reporting States and the District of Columbia,

1990

lowest rates were for women in their twenties having a fourth

or higher order birth (15.8-15.9 percent), and for teenage

mothers having their second or third child (15.2 percent and

15.8 percent, respectively).

One explanation for the higher cesarean rates for finst

births is that women having a first child are more likely to

have 16 or more years of schooling than women having higher

order births. This level of educational attainment is associated

with the highest risk of a cesarean delivery (see section

“Educational attainment “).

4
The cesarean rate for first births to older women has

apparently been quite stable since 1975, and thus did not

contribute to the rapid rise in the overall cesarean rate during

this time period. Information derived from the birth certificates

of six States indicate that rates for first births to women 35

years and over ranged from 37 to 38 percent in the 1975–85

period (2). In 1990, the national cesarean rate for women in

this age group having a first birth was 40 percent.

Cesarean rates for women 35 years of age or older are

substantially higher for black than for white mothers for

similar birth order, with differences particularly noticeable for

mothers 4049 years of age. For this age group, the cesarean

rate for black mothers having their fourth or higher order birth

is 28.7, compared with 21.9 for white mothers of similar parity

(table 5).

For all age groups, total and primary cesarean rates are

almost identical for first order live births (table 5), an indication that most women delivering their first live-born infant by

cesarean have not had a previous cesarean delivery for a

pregnancy resulting in a fetal death. Primary rates for second

and higher order live births are generally only about one-third

the level for first order births, suggesting that the risk of

cesarean delivery is greatly lowered if a mother has had a

previous vaginal birth.

Marital status

In 1990, the cesarean rate was 20 percent higher for

married than for unmarried women (23.8 compared with

19.9 percent) (table 6). However, regardless of marital status,

the risk of a cesarean delivery increases rapidly with maternal

age.

The higher rate for married women reflects their slightly

higher cesarean rate for all age groups, except 40-49 years,

the far lower percentage of married mothers in their teenage

years when the risk of cesarean delivery is lowest and the

higher proportion of married women in the oldest years of

childbearing when the risk is highest.

The higher cesarean rate for married mothers may also be

a reflection of their generally higher level of educational

attainment, with its attendant increased risk of cesarean delivery (see following section). Also, married mothers are more

likely to have private insurance (68 percent) as the expected

source of payment for delivery than unmarried mothers (21 percent) (3). Women with private insurance are more likely to

have a cesarean delivery than women with government insurance or those with no insurance (l).

For similar ages, married black mothers are more likely

than married white mothers to have a cesarean delivery, and

the racial differential increases with age. However, racial

differences for unmarried mothers are minimal for each age

group and of no consistent pattern (table 6).

Educational attainment

The educational attainment of the mother is a commonly

used measure of the socioeconomic status of the family. In

1990, educational attainment was reported on the birth certificates of all States except Washington, by New York City (but

not the remainder of New York State), and by the District of

Columbia.

The rate of cesarean delivery increases with additional

years of schooling and women with 12 or more years of

schooling are 32 to 42 percent more likely to deliver by

cesarean than women with less than 9 years of schooling (23.1

to 24.9 percent compared with 17.5 percent). An increase in

the risk of cesarean delivery with added educational attainment can be seen for both white and black mothers. But an

independent effect of maternal age is again evident. For all

levels of education, the risk of a cesarean delivery rises with

advancing age, regardless of mother’s race (table 7).

The higher cesarean rates for women with at least a high

school education is partly explained by the generally older

ages of these mothers when the risk of cesarean delivery is

greatest. For example, the cesarean rate for women with 16 or

more years of education is 24.9 percen4 or 42 percent higher

than the rate for women with less than 9 years of schooling

(17.5 percent). But if both groups of women had the same age

distribution as all women giving birth in 1990, then the

cesarean rate for women with 16 or more years of schooling

would be only 16 percent higher than those with minimal

schooling. In other words, 57 percent of the difference in rates

can be explained by the older ages of women with the highest

level of education, and 43 percent by the fact that at each age

level cesarean rates are higher for women with 16 or more

years of schooling than for women with less than 9 years of

schooling.

An additional reason for the elevated risk of cesarean

delivery for women with higher levels of education is that

HMO and insurance coverage for delivery increases with

added years of schooling over 90 percent of mothers with 16

or more years of schooling had such coverage at the time of

delivery compared with about 40 percent of mothers with less

than 12 years of education (4). As noted in the section

“Marital status,” women who have insurance are more likely

to deliver by cesarean than women without insurarw coverage.

A recent study indicates that rates of primary cesarean

delivery vary directly with socioeconomic status, and that this

association cannot be completely explained by differences in

maternal age, parity, birthweigh~ race, ethnic group, or complications of pregnancy or childbirth (5).

Weight gain during pregnancy

From 1974 to 1989, the medical community recommended that a mother gain 22–27 pounds during the course of

a normal pregnancy (6,7). Guidelines for weight gain were

revised in 1990 to take into account the mother’s prepregnancy weight for height. For a mother of average size, the

recommended weight gain was 25–35 pounds, for smaller than

average women, 28-40 pounds, and for heavier women, no

less than 15 pounds. Teenage mothers and black mothers were

advised to gain at the upper end of these ranges (8).

This analysis of the risk of a cesarean delive~ by

mother’s weight gain is limited to singleton births. Mothers of

Wins, triplets, and other multiple births tend to gain more

5
during pregnancy than mothers of singletons (9), and they

have a far higher risk of a cesarean delivery (see section

“Plurality of birth”).

Cesarean rates generally rise with increased maternal

weight gain, increasing from 20.4percent for gains of 16-20

pounds to 28.4 percent for gains of 46 pounds or more. A

similar pattern is evident for all gestational ages and for all

birthweights. For weight gains of less than 36 pounds, rates of

cesarean delivery are about the same or lower than the overall

average of 22.0 percent (table 8).

For gestational ages of under 37 weeks, 37–39 weeks, and

40 weeks and over, cesarean rates for weight gains below 36

pounds are about the same or lower than the respective

averages for these gestational ages; for weight gains of 36-40

pounds, the cesarean rates are about 2 percentage points

higher than average; for weight gains of 41J15 pounds, about

3 percentage points higher than average; and for the highest

weight gains of 46 pounds or more, 6 to 7 percentage points

higher than average. Thus, regardless of gestation! age, the

risk of cesarean delivery is substantially higher only when

weight gain is 46 pounds or more.

Similarly, for birthweights of 2,500 grams (5 ]pounds 8

ounces) or more, cesarean rates substantially exceed the

average for the respective birthweight category only when

weight gain is more than 46 pounds (table 8). For example, for

birthweights of 2,500-3,499 grams (5 pounds 8 ounces–7

pounds 11 ounces, the birthweight of more than one-half of

the infants born in 1990), the cesarean rate exceeded the

average for these birthweights by more than 5 percentage

points only for weight gains of at least 46 pounds.

Previous research indicated that for one population of

women, only those who gained more weight than the 1990

Institute of Medicine recommendation for their weight and

height had an increased risk of cesarean delivery after ccmtrolling for fetal size (10).
Infant characteristics

Period of gestation and birthweight

Period of gestation is strongly associated with the risk of

a cesarean delivery, with rates highest for babies born preterrn

(less than 37 completed weeks of gestation)(table 9). The peak

rate for preterm births was for gestations of 28-31 weeks

(37.3 percent), with rates substantially lower for gestations of

under 28 weeks (30.0 percent) and for 36 weeks (25.5 percent). For births with gestational ages of 37 weeks or longer,

rates declined from 23.9 percent for gestations of 37–39 weeks

to a low of 18.8 percent for 40 weeks gestation and then

increased to 23.0 percent for postterm births (42 weeks gestation or longer). White mothers are more likely than black

mothers to have a cesarean delivery for gestational ages of less

than 40 weeks, but less likely to have a cesarean for longer

gestational periods.

Birthweight is also closely related to the risk of a cesarean

delivery, and newborns with the lowest and highest birthweight are the most likely to be delivered by cesarean

50r

10

t

Less 2,500- 3,000- 3,500- 4,000- 4,500

than 2,999 3,499 3,999 4,499 or more

2,500

Birthweightin grams

NOTE! The totsl cessrean rate is the number of birth-sby ceearean per 100 total births.

Figure 3. Total cesarean rates by birthweight and period of

gestation: Total of 49 reporting States and the District of

Columbia, 1990

(table 10). The cesarean rate for very low birthweight infants

(less than 1,500 grams or 3 pounds 4 ounces) was 43.7 percent, declining to 19.8 for birthweights of 3,000-3,499 grams

(6 pounds 10 ounce&7 pounds 11 ounces), and then increasing to 37.3 percent for babies weighing 4,500 grams (9 pounds

15 ounces) or more. This same pattern of the highest cesarean

rates at each end of the birthweight distribution is evident for

all periods of gestation (figure 3). The lowest cesarean rates

are for babies weighing 2,500-3,499 grams with gestational

ages of 40 weeks or more (18-19 percent).

The high cesarean rates for births of less than 40 weeks

gestation that weigh 4,500 grams or more probably reflect to

some extent births that are to diabetic mothers. Diabetes is

associated with a very high risk of cesarean delivery (see

section “Medical risk factors of pregnancy”) and babies of

diabetic mothers tend to be large for their gestational age

(11,12).

For equivalent birthweights up to 3,500 grams, white

mothers are more likely to deliver by cesarean than black

mothers but at higher birthweights, black mothers have a

higher rate of cesarean delivery.

Plurality of birth

According to information from the NHDS, the cesarean

rate for plural deliveries rose nearly fivefold between 1970 and

1990 (from 9 percent to 51 percent) (3,13). In 1990, the

cesarean rate for plural births derived from birth certificates

was more than twice that of singleton births (55.7 compared

with 21.9) (table 11). More than hrdf of the births in twin

deliveries (54.7 percent) were by cesarean and almost 9 in 10

births in triplet, quadruplet, or quintuplet deliveries (86.0 percent for triplet and 89.0 percent for quadruplet, quintuplet, and

other multiple deliveries, respectively). The cesarean rate was

7 percent higher for white than for black twin births and

16 percent higher for other multiple births.

There are many reasons for the far higher cesarean rates

for plural than for singleton births. Twins, triplets, and other

plural births are more likely than singleton births to have a low

or very low birthweight and to be delivered preterm (9,14),

conditions that are associated with a higher-than-average rate

of cesarean delivery. Mothers of plural births are more likely

to have certain medical risk factors and complications of labor

and delivery such as eckunpsia, abruptio placenta, placenta

previa, and breech/malpresentation (15,16) that are associated

with high rates of cesarean delivery (see sections that follow).

7
In addition, mothers of plural births tend to be older than

mothers of singletons. In 1990, 38 percent of the mothers of

twins and 54 percent of the mothers of triplets and other plural

births were 30 years or older compared with 30 percent of the

mothers of singletons. As noted previously, the rate of cesarean delivery increases with advancing age.

Abnormal conditions of the newborn

Table 12 presents cesarean rates for abnormal conditions

of the newborn for which information is available from birth

certificates. Definitions of these conditions are included in the

“Technical notes.” Hyaline membrane disease/respiratory distress syndrome (RDS) occurred in 6 of every 1,000 births in

1990; almost one-half of these births (48 percent) were delivered by cesarean. There is evidence that cesarean delivery

without labor increases the risk of this condition (17). Lending

credence to this hypothesis is the fact that triple the proportion

of newborns delivered by cesarean than delivered vaginally

had hyaline membrane disease/RDS (12 per 1,000 compared

with 4 per 1,000 births) (9).

Babies with meconium aspiration syndrome are also at

higher than average risk of a cesarean delivery. This syndrome

occurred in 3 of every 1,000 births in 1990, with one-third

(35 percent) of these births a cesarean delivery.

More than one-third of the births (36 percent) needing

assisted ventilation for up to 30 minutes after birth and almost

one-half of those (48 percent) needing assistance for 30 minutes or longer were by cesarean delivery. Assisted ventilation

of less than 30 minutes was performed in 13 of every 1,000

births, and assisted ventilation for 30 minutes or longer in 7 of

every 1,000 births.

Seizures occurred in only about 1 in every 1,000 births,

with one-third of these births (34 percent) a cesarean delivery.

Some research indicates that cesarean delivery is protective

against seizures (18) but this has been questioned (19).

Information from birth certificates indicates that the incidence

of seizures is 60 percent higher for newborns delivered by

cesarean than those delivered vaginally (1.3 compared with

0.8 per 1,000 births, respectively). Cesarean rates for these

abnormal conditions of the newborn were generally somewhat

higher for white mothers than for black mothers.
Pregnancy and delivery

Brief definitions of each of the medical risk factors,

complications of labor and delivery, and obstetric procedures

included in this report are presented in the “Technical notes.”

Medical risk factors of pregnancy

A number of medical risk factors of pregnancy are

associated with a much higher-than-average risk of cesarean

delivery (table 13). The cesarean rate was more than 40 percent for eclampsia (52.3), genital herpes (46.0), hydramnios/

oligohydramnios (45.6), pregnancy associated hypertension

(41.6), and chronic hypertension (41.4). Except for acute or

chronic lung disease, genital herpes, and hemoglobinopathy—

where rates are substantially higher for white than black

mothers-cesarean rates for the remaining 11 conditions studied are quite similar for white and black mothers.

Complications of labor and delivery

Many of the complications of labor and delivery for

which information is available from birth certificates are

associated with a greatly elevated risk of cesarean delivery

(table 13). Rates are particularly high (more than 50 percent)

for cephalopelvic disproportion (97.7 percent), breechl

malpresentation (84.5 percent), placenta previa (82.3 percent),

dysfunctional labor (65.2 percent), fetal distress (62.6), cord

prolapse (59.5 percent), abruptio placenta (57.7 percent), and

anesthetic complications (51.8 percent). As noted for medical

risk factors of pregnancy, rates of cesarean delivery are

generally quite similar for most complications for white and

black mothers.

Cesarean rates for several of these complications of labor

and delivery have risen sharply in the last 2 decades. Cesarean

rates for 1970 are available from the 1970 NHDS (13) and

these can be compared with the 1990 cesarean rates derived

from live-birth certiilcates. For example, between 1970 and

1990 the rate for premature rupture of membrane increased

from 13 to 29 percen~ for prolonged labor, from 23 to

40 percent; and for breech/malpresentation, from 15 to

85 percent.

Obstetric procedures

The use of electronic fetal monitoring (EFM) during labor

to assess fetal heart rate has grown rapidly since its introduction in 1960 (20). By 1980, 48 percent of mothers were

monitored (21) and by 1990, 73 percent (22). Past research

found that EFM was associated with a 30 percent or higher

risk for a primary cesarean delivery for monitored than for

nonmonitored births (20,23).

The overall cesarean rate of 21.7 percent for births with

EFM, derived from information entered on 1990 birth certificates (table 13), was slightly lower than the national average

of 22.7 for all births. The 1989 cesarean rate for EFM

(21.4 percent) was also lower than the 1989 overall cesarean

rate (22.8 percent) (24). There are several explanations for this

apparent inconsistency. Since the early 1980’s, the American

College of Obstetricians and Gynecologists (ACOG) has

repeatedly apprised its members on the appropriate use and

interpretation of EFM readings (25-27). ACOG guidelines

stress that fetal monitoring should be considered as only one

parameter of fetal well being. Additionally, EFM is more often

used for primary cesareans than for repeat cesareans (74 percent versus 60 percent), and the primary cesarean rate for

EFM of 16.2 percent is about the same as the primary rate of

16.0 for all births.

Induction and stimulation of labor were far less frequently

performed than EFM in 1990 (10 percent and 11 percent of all

births, respectively). The cesarean rates for induction of labor

(21.9 percent) and stimulation of labor (17.9 percent) were

both lower than the overall average of 22.7 percent. However,

both procedures are far more likely to precede a primary than

a repeat cesarean delivery. The primary cesarean rates for

induction of labor (20.5 percent) and for stimulation of labor

(16.5 percent) were both higher than the primary cesarean rate

of 16.0 percent for all births.

Amniocentesis and tocolysis are both tiequently performed during pregnancy (3 percent and 2 percent of women

in 1990, respectively) but more than one-half of the mothers in

1990 (52 percent) had ultrasound. Mothers who have amniocentesis, tocolysis, or ultrasound during pregnancy are all at

higher risk of a cesarean delivery (table 13). The cesarean rate

for mothers having amniocentesis was 36.0 percent, 31.1 percent for mothers having tocolysis, and 26.3 percent for mothers who had ultrasound. As was observed for medical risk

factors and complications of labor and delivery, rates by race

were fairly similar for four of the six obstetric procedures

analyzed.

9
Information now available on method of delivery from

birth certificates confirms past findings on the groups at

highest risk of cesarean delivery and greatly expands our

knowledge of the demographic and health characteristics

associated with cesarean delivery. Mothers who live in the

South, who are in the oldest years of childbearing, having their

first birth, married, or who have high educational attainment

are all at increased risk of a cesarean delivery. Very short

gestations, low or high birthweights, multiple delivery, the

presence of certain complications of pregnancy, labor andlor

delivery, abnormal conditions of the newborn, and the use of

some obstetric procedures are also associated with elevated

cesarean rates.

Several recent studies (28,29) have concluded that advanced

maternal age in and of itself may be an independent risk factor

for cesarean delivery, due to physician and patient concern

over pregnancy outcome for older women. Many of the

characteristics examined in this study are highly related to

maternal age (for example, marital status and educational

attainment). Therefore, for these variables, mother’s age is

also taken into account to determine if age itself is the

underlying reason for differences in rates of cesarean delivery.

The importance of the role of maternal age in the risk of

cesarean delivery is clearly demonstrated throughout this

report: Older mothers are more likely to deliver by cesarean

regardless of race, Hispanic origin, parity, marital status, or

educational attainment.

The overall rate of cesarean delivery is only slightly lower

for black than for white mothers (22.1 percent compared with

23.0 percent), despite the generally lower educational attainment of black mothers and the higher percentage who are

unmarned or in their teen years, all factors that tend to

substantially lower the risk of cesarean delivery. However,

there are many offsetting factors that tend to raise the cesarean

rate for black mothers. A relatively high proportion of black

births occur in the South, which has the highest cesarean rate

of all regions; the incidence of low and very low birthweight is

far higher for black births; and premature delivery is hvice as

frequent for black babies. Also, although rates of cesarean

delivery for most medical risk factors, complications of labor

and or delivery, and abnormal conditions of the infant are

about the same for both races, the incidence of a lnumber of

these conditions is substantially higher for black mothers and

babies, and that has the effect of increasing the overall

cesarean rate for black mothers.

A national health objective for the year 2000 is to reduce

the total cesarean rate to 15 or fewer per 100 deliveries (30).

In 1990, only 17 States had cesarean rates below 20 percent,

and only one (Alaska), a cesarean rate of 15 percent. With the

1989 revision of the standard certificate of live bir@ annual

data have become available that will enable medical and

health researchers to track State cesarerm rates, and to identify

geographic areas and subgroups where cesarean rates substantially exceed the national average.

10
References

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2.

3.

4.

5.

6.

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8.

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10.

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17.

Centers for Disease Control and Prevention. Morbidity and

mortality weekly repoti, vol 42 no 15. Washington: Public

Health Service. 1993.

Notzon F~ Bergsjo P, Cole S, et al. International collaborative

effort on birth weight, plurality, perinatal, and infant mortality.

IV. Differences in obstetrical delivery practice Norway, Scotland, and the United States. Acts Obstet Gyneccd Stand 70:451-

60.1991.

National Center for Health Statistics. Unpublished data from the

1990 National Hospital Discharge Survey.

National Center for Health Statistics. Unpublished data from the

1988 National Maternal and Infant Health Survey. 1991.

Gould JB, Davey B, and Stafford RS. Socioeconomic differences

in rates of cesarean section. NEJM 321(4)233-9. 1989.

American College of Obstetricians and Gynecologists. Standards for obstetric-gynecologic services. 4th ed. Chicago The

American College of Obstetricians and Gynecologists. 1974.

American College of Obstetricians and Gynecologists. Standards for obstetric-gynecologic services. 7th ed. Washingtorx

The American College of Obstetricians and Gynecologists.

1989.

Institute of Medicine—National Academy of Sciences. Subcommittee on nutritional status and weight gain during pregnancy.

Nutrition during pregnancy part I, weight gain, part II, nutrient

supplements. National Academy Press. Washington DC. 1990.

Unpublished data from the 1990 national vital registration

system.

Parker JD and Abrams B. Prenatal weight gain advice An

examination of the recent prenatal weight gain recommendations

of the Institute of Medicine. Obstetrics Gynecol 79(5), part

1:664-9.1992.

Lubchenco LO. The high risk infant. Philadelphia, London,

Toronto: WB Saunders. 1976.

Schaffer AJ, Avery MB. Diseases of the newborn. 4th ed.

Philadelphia, London, Toronto: WB Saunders. 1977.

Placek PJ, Taffel SM. The frequency of complications in cesarean and noncesarean deliveries, 1970 and 1978. Public Health

Reports 98(4):396-400. 1983.

Taffel SM. Health and demographic characteristics of twin

births: United States, 1988. National Center for Health Statistics.

Vital Health Stat 21(50). 1992.

TafYelSM, Lewis CT. The risk of twin delivery New information from the revised 1989 U.S. Certificate of Live Birth. Paper

presented at the annual meeting of the American Public Health

Association. Washington DC. 1992.

Unpublished data from the 1989 national vital registration

system.

Curet LB, Zachman AV, Rao ~ et al. Effect of mode of

delivery on incidence of respiratory distress syndrome. Int J

Gynecol Obstet 27:165–70. 1988.

18. Leveno KJ, Cunningham FG, Pritchard JA. Cesarean section

An answer to the House of Home. Am J Obstet Gynecol

153:83844.1985.

19. O’Dnscoll ~ Foley ~ MacDonald D, Stronge J. Cesarean

section and perinatal outcome: Response from the House of

Home. Am J Obstet Gynecol 158(3), part 1:449-52.1988.

20. Clark SL, Paul RH. Intrapartum fetal surveillance The role of

fetal scalp blood sampling. Am J Obstet Gynecol 153(7):717–

20.1985.

21. Placek PJ, Keppel KG, TatTel SM, LSS TL. Electronic fetal

monitoring in relation to cesarean section delivery, for live births

and stillbirths in the U.S., 1980. Public Health Reports 99(2>173-

83.1984.

22. National Center for Health Statistics. Advance report of maternal and infant health data from the birth certificate, 1990.

Monthly vital statistic repoti, vol 42 no 2, suppl. Hyattsville,

Maryland Public Health Service. 1993.

23. McCusker J, Harris DR, Hosmer DW. Association of electronic

fetal monitoring during labor with cesarcan section rate and with

neonatal morbidity and mortality. Am J Public Health

78(9)1170-4. 1988.

24. National Center for Health Statistics. Advance report of new

data from the 1989 bti certificate. Monthly vital statistics

repofi, VOI40 no 1~ suppl. Hyattsville, Maryland Public Health

Service. 1992.

25. American College of Obstetricians and Gynecologists. Standards for obstetric-gynecologic services. 5th ed. Washington

The American College of Obstetricians and Gynecologists.

1983.

26. American College of Obstetricians and Gynecologists. Committee on obstetrics Maternal and fetal medicine and NAACOG

executive board. Committee statement: Electronic fetal monitoring. Washington DC. 1985. (WMdrawn July 1988).

27. American College of Obstetricians and Gynecologists. Intrapartum fetal heart rate monitoring. Technical bulletin No 132.

Washington American College of Obstetricians and Gynecologists. 1989.

28. Gordon D, Milberg J, Daling J, Hickok D. Advanced maternal

age as a risk factor for cesarean delivery. Obst Gynecol 77(4)

493=7. 1991.

29. Peipert JF, Bracken M. Matemrd ag~ An independent risk factor

for cesarean delivery. Obstet Gynecol 81(2):200-5. 1993.

30. U.S. Department of Health and Human Services. Healthy people

2000. National health promotion and disease prevention objectives. Washington: Public Health Service. 1990.

31. Brockert JE, Stockbauer JW, Semer JW, et al. Recommended

standard medical definitions for the U.S. Standard Certificate of

Live Birth, 1989 revision. Paper presented at the annual meeting

of the Association for Vkal Records and Health Statistics. 1990.

11
List of detailed tables

1. Live births by method of delivery by mother’s region and

State of residence: Total of 49 reporting States and the

District of Columbia, 1990 . . . . . . . . . . . . . . . . . . . . . . .

2. Rates of cesarean delivery and of vaginal birth after

previous cesarean delivery by race of mother: Total reporting area, each region, and 49 reporting States and the

District of Columbia, 1990 . . . . . . . . . . . . . . . . . . . . . . .

3. Rates of cesarean delivery by age and spectied race of

mothec Total of 49 reporting States and the District of

Columbia, 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Rates ofcesarean delivery byagemd Hispanic origin of

mother and by race of mother for mothers of non-Hispanic

origin: Total of 48 reporting States and the District of

Cohrmbia, 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Rates of cesarean delivery by age of mother, live-birth

order, and race of mothe~ Total of 49 reporting States and

the District of Columbia, 1990... . . . . . . . . . . . . . . . . .

6. Rates ofcesarean deIivery bymarital status, age, andra@

of mother: Total of 49 reporting States and the District of

Columbia, 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Rates ofcesarean deIivery byeducational attaiment, age,

and race of mother: Total of 47 reporting States, the

District of Columbia, and New York City, 1990 . . . . . . .

8. Rates ofcesarean delivery forsingleton births by weight

gain during pregnancy, by gestational age and birthweight:

13 Total of 48 reporting States and the District of Columbia,

1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

9. Rates ofcesarean delivery byperiod ofgestation and raw

ofmothec Total of 49 reporting States and the District of

14 Columbia, 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

10. Rates of cesarean delivery by birthweight, period of

gestation, and race of mothe~ Total of 49 reporting States

15 and the District of Columbia, 1990 . . . . . . . . . . . . . . . . . 19

11. Rates ofcesarean delivery byplurality of btihand race of

mothe~ Total of 49 reporting States and the District of

Columbia, 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

15 12. Rates of cesarearr delivery for selected abnormal coalitions of the newborn by race of mothe~ Total of 49

reporting States and the District of Columbia, 1990 . . . . . 20

16 13. Rates of cesarean delivery for selected medical risk:factors, complications of labor and/or delivery, and obstetric

procedures by race of mothec Total of 49 reporting States

17 and the District ofCoIumbia,1990. . . . . . . . . . . . . . . . . 21

17

12
Table 1. Live births by method of delivery by mother’s region and State of residencw Total of 49 reporting States and the District of

Columbia, 1990

Births by method of delivery

Vaginal Ceaarean

Arler

A\\ previous

Region and State birttrs~ Total Caseraan Total Primary Repeat

Allrepmlinga read . . . . . . . . . . . . . . .

Regions

Northeast . . . . . . . . . . . . . . . . . . .

Midwest . . . . . . . . . . . . . . . . . . . .

South . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . .

Northeast

Connecticut . . . . . . . . . . . . . . ...<

Maine . . . . . . . . . . . . . . . . . . . . .

Massachusetts . . . . . . . . . . . . . . . .

NewHampshire . . . . . . . . . . . . . . .

NewJersev . . . . . . . . . . . . . . . . . .

4,110,563 3,111,421 64,298 914,096 575,066

19,665

20,302

23,371

20,761

178,475

203,384

323,530

208,707

111,113

124,201

207,552

132,200

67,362

79,183

115,978

76,607

3,189

1,351

7,730

1,382

11,470

25,678

14,872

1,140

550

16,512

7,043

3,142

3,818

13,379

4,598

6,611

1,645

744

15,298

872

5,321

5,629

3,656

891

1,111

17,626

8,970

4,719

7,346

5,897

792,869

945,843

1,361,731

i ,009,990

597,434

731,906

990,230

791,851

50,123

17,359

92,654

17,569

122,289

297,576

171,861

15,195

8,273

32,055

13,586

70,905

13,666

91,612

223,939

133,343

11,638

6,660

1,056

428

2,215

492

2,380

8,425

4,218

386

245

8,743

3,660

20,542

3,825

30,217

66,632

36,246

2,797

1,593

5,554

2,329

12,812

2,443

18,747

43,154

23,374

1,657

1,043

NewYork~.

Pennsylvania

Rhode Island

Vermont. . .

Midwest:

Illinois . . . .

Indiana. . . .

lowa . . . . .

Kansas . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

43,479

18,362

8,107

8,696

33,478

11,906

18,077

4,659

1,762

36,561

2,159

12,816

26,967

ll,31e

4,865

5,180

20,089

7,308

11,486

2,814

1,088

24,263

1,287

7,495

195,790

66,214

39,409

39,020

153,700

68,013

79,260

24,360

9,250

166,913

10,999

72,895

149,100

65,546

31,237

29,171

118,954

54,408

60,931

19,641

7,427

128,682

8,779

60,027

4,062

1,327

650

791

3,302

1,880

1,755

640

238

3,223

245

1,879

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

Michigan . . . . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . . .

North Dakota . . . . . . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . . . .

Wismnsin . . . . . . . . . . . . . . . . . . .

south

Alabama . . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . . .

DistrictofColumbia . . . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . .

Maryland . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . .

North Carolina . . . . . . . . . . . . . . . .

South Carolina . . . . . . . . . . . . . . . .

Tennea8ee . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . . .

WeetMrginia . . . . . . . . . . . . . . . . .

West

Alaska . . . . . . . . . . . . . . . . . . . . .

Arizona . . . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . . . .

Oolorado . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . .

16,417

10,054

2,767

3,072

50,212

25,850

12,8Q5

19,466

16,915

11,572

23,660

13,112

18,226

70,545

23,214

6,021

10,788

6,398

1,876

1,961

32,586

16,360

8,166

12,122

11,018

6,968

15,206

8,242

12,110

43,806

15,210

3,663

83,467

38,457

11,113

11,850

199,839

112,666

54,362

72,192

80,245

43,5&3

104,525

58,610

74,862

316,423

99,352

22,665

47,000

26,181

8,277

8,680

148,307

86,882

39,026

52,527

50,755

31,901

80,421

45,300

56,520

217,015

74,934

16,494

1,068

582

216

236

3,740

2,036

667

668

1,677

678

2,030

937

1,318

4,754

2,140

257

7,772

4,870

6,116

26,639

8,004

2,128

569

4,434

50,360

2,860

1,481

1,218

889

1,440

1,744

2,965

2,617

5,200

530

11,902

66,895

612,628

53,525

20,469

16,433

11,613

21,599

27,402

42,691

36,277

79,251

6,985

10,072

66,111

475,706

44,316

16,330

13,316

9,168

17,287

22,25a

34,666

29,729

57,266

5,564

389

1,S30

10,025

1,551

464

453

309

471

636

1,518

926

2,226

189

1,795

12,627

136,315

9,078

4,146

3,062

2,383

4,239

5,023

8,148

6,415

14,072

1,336

1,206

8,193

85,935

6,028

2,655

1,664

1,484

2,799

3,279

5,161

3,798

8,872

656

1Incl”deeMUE m methodof deliverynotStsbd.

13
Table 2. Rates of cesarean delivery and of vaginal birth after previous cesarean delivery by race of mother: Total reporting area, each

region, and 49 reporting States and the District of Columbia, 1990

Cesarean delivery rate

Totafl Prima@ Vaginal birth after cesarwans

All All All

Region and Stata races4 White Black races4 White Black races4 White Black

All reporting areas . . . . . . . . . . . . .

Regions

Northeast . . . . . . . . . . . . . . . . . . .

Midwest . . . . . . . . . . . . . . . . . . . .

South . . . . . . . . . . . . . . . . . . . . .

Weat . . . . . . . . . . . . . . . . . . . . . .

Northeast:

Connetilcut . . . . . . . . . . . . . . . . . .

Maine . . . . . . . . . . . . . . . . . . . . .

Massachusetts . . . . . . . . . . . . . . . .

NewHampshire . . . . . . . . . . . . . . .

New Jersey . . . . . . . . . . . . . . . . . .

NewYork . . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . . . . . . .

Rhode Island . . . . . . . . . . . . . . . . .

Vermont. . . . . . . . . . . . . . . . . . . .

Midwest

Illinois . . . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . . . .

Iowa . . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . . .

Michigan . . . . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . . .

North Dakota . . . . . . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . . . .

Wisconsin . . . . . . . . . . . . . . . . . . .

south

Alabama . . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . . .

DietrictofColumbia . . . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . .

Maryland . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . .

North Carolina . . . . . . . . . . . . . . . .

South Carolina . . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . . .

West Virginia . . . . . . . . . . . . . . . .

West

Alaska . . . . . . . . . . . . . . . . . . . . .

Arizona . . . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . . . .

CZdorado . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . .

ZT!.7

23.0

21.7

24.6

20.9

21.4

21.3

22.5

21.8

24.8

23.5

22.3

19.4

19.3

22.6

21.9

20.6

23.6

22.0

18.0

22.9

19.2

19.4

23.8

19.7

17.6

25.9

27.7

25.1

26.1

25.3

22.6

24.9

27.0

25.0

26.6

22.7

22.4

24.4

24.5

23.7

26.7

15.1

16.4

22.3

17.0

20.2

18.8

20.6

19.7

16.4

19.0

17.7

19.7

19.9

23.0

23.5

22.2

25.3

20.8

21.7

21.3

22.9

21.7

25.3

24.3

22.9

19.6

19.3

23.2

22.0

20.6

23.6

22.8

16.4

23.8

19.3

19.0

24.2

19.8

18.2

27.3

26.0

25.3

25.5

26.2

23.5

25.0

29.9

24.5

29.0

23.2

23.1

25.3

24.8

23.6

26.7

16.8

18.9

22.2

17.1

22.5

18.7

20.4

19.6

19.4

19.1

17.7

19.7

19.7

22.1

21.2

19.8

23.0

23.9

19.5

*

21.5

24.6

22.9

21.5

19.4

19.6

*

20.3

21.4

22.9

24.5

18.8

15.6

18.5

17.7

*

21.5

*

14.4

23.3

27.0

24.1

27.4

22.2

21.0

24.0

23.2

26.3

24.2

22.1

21.5

21.4

23.5

23.4

27.5

19.9

19.6

24.6

16.2

24.8

*

●

19.9

22.4

19.0

25.6

24.3

34.3

16.0

16.1

14.9

17.7

14.6

15.2

15.0

15.7

15.6

17.4

16.7

15.3

12.8

14.0

15.7

15.0

14.0

15.4

14.8

12.2

16.2

12.9

12.6

16.4

13.1

11.4

19.0

20.0

18.9

18.8

18.4

16.2

17.7

19.0

18.3

18.2

16.9

15.7

18.0

17.1

17.3

19.3

11.0

13.1

t 5.6

12.5

14.4

12.7

14.3

14.3

13.2

13.5

11.7

13.9

13.7

16.1

16.3

15.1

18.1

14.6

15.3

15.0

15.9

15.6

17.5

17.1

15.6

13.0

14.0

16.1

15.0

14.0

15.4

15.4

12.6

16.8

13.0

12.5

16.6

13.4

11.9

20.3

20.3

19.1

20.1

19.1

16.9

17.7

21.2

17.7

20.0

17.3

16.3

18.8

17.3

17.2

19.3

12.2

13.5

15.5

12.5

17.1

12.6

14.4

14.2

13.9

13.5

11.6

13.6

13.5

15.7

15.3

13.7

16.4

16.7

14.4

*

15.5

*

16.5

15.5

13.9

12.8

*

14.3

14.6

15.6

16.0

12.6

10.4

13.6

11.8

*

15.3

*

8.6

16.7

18.9

18.0

19.3

16.0

15.0

17.2

16.2

19.8

16.5

16.0

14,6

15.5

16.5

17.5

19.7

15.8

13.8

17.2

12.5

16.5

*

*

14.0

16.7

14.0

16.0

18.7

*

19.9

22.8

20.4

16.8

21.3

24.9

24.1

22.3

26.3

17.2

24.7

22.1

25.8

30.8

19.7

15.9

21.3

17.2

19.6

30.2

21.0

25,8

24.2

17.4

21.9

28.1

16.1

12.7

19.5

17.5

17.5

16.5

15.5

10.6

22.1

12.8

20.7

18.1

17.7

15.1

21.1

10.8

36.5

26.9

16.6

34.2

24.5

27.1

25.6

24.6

26.8

33.7

26.2

30.0

26.3

19.7

22.1

20.2

16.1

21.5

24.6

23.9

21.6

26.4

16.6

24.3

20.6

25.7

30.9

20.1

16.1

21.1

16.9

19.6

29.6

19.0

25.9

25.1

16.6

23.1

25.6

15.4

12.9

19.3

16.5

16.6

17.4

15.3

8.3

22.8

10.2

20.5

15.9

16.7

15.0

20.2

10.6

34.4

24.7

16.9

33.6

28.7

27.2

27.2

25.3

24.0

33.6

25.9

29.8

26.1

20.3

26.1

21.4

18.6

1$.6

27.4

*

26.4

*

19.0

26.3

31.6

27.3

*

18.3

13.5

22.6

17.4

20.2

41.2

32.7

26.2

*

21.7

*

25.4

17.6

12.1

20.1

17.1

20.9

20.5

18.1

14.5

21.1

15.9

21.1

16.3

21.3

15.4

23.8

*

*

22.2

12.9

37.4

*

*

*

16.6

*

36.3

*

31.1

*

1Percent of all rhe birlhs that are by cesarean derhe~.

2Number of primary cesaresns per 100 Pwebirths to woman who have not had a previous cessresn,

3N”mber Of vagi~l tjrths after previous cesereen deliiery par 100 he births to women wkh a previous ~SSreSn.

41rrcludesraces other then whte and black.

14
Table 3. Rates of cesarean delivery by age and specified race of mother: Total of 49 reporting States and the District of Columbia, 1990

Asian or Pacific Islander

All American

Age of mother race.sl White B/ask India+ Chinese Japanese Hawaiian IWpino Other

Total cesarean rate3

Alleges . . . . . . . . . . . . . . . . . . . . . 22.7 23.0 22.1 17.5 21.0 20.4 18.2 24.6 19.0

Under 20yeara . . . . . . . . . . . . . . . . . 16.6 16.7 16.6 14.2 10.6 15.0 13.8 12.3 8.5

20-28 years . . . . . . . . . . . . . . . . . . . 21.9 Z?.1 21.9 17.1 16.1 17.0 17.9 19.9 16.3

30-39years . . . . . . . . . . . . . . . . . . . 26.6 26.5 28.5 21.1 24.1 22.3 22.4 30.2 24.5

40-49years . . . . . . . . . . . . . . . . . . . 32.3 31.9 35.8 25.0 38.3 32.3 34.0 44.7 24.9

Agestandardized4 . . . . . . . . . . . . . . . 22.7 22.8 23.3 18.0 18.0 18.5 18.9 22.2 17.8

Ilnoludesbitiof othsrrawnotshown aeparstely.

zl~ludw birthstoAlwte and Eskinws.

%.rcent of aII birthsthatera by cesareandeIiiety.

4w#~ to reflectthe age disbibukmof all raoas.

NOTE ExcludesdareforOklahoma whiih didnotrequirereportingof methodof derwev.

Table 4. Rates of cesarean delivery by age and Hispanic origin of mother and by race of mother for mothers of non-Hispanic origim

Total of 48 reporting States and the District of Columbia, 1990

Hispanis Non-Hispanic

Centraf Other and

All Puerto and South unknown

Age of mother origins~ Total MexI”csn Riosn Cu&rn Arnerisan Hispanis Tota12 Write Black

Totalcessrean ratd

Alleges . . . . . . . . . . . . . . . . . . . . . 22.7 21.2 20.3 22.1 34.7 21.5 22.8 23.0 23.4 22.1

Under 20yeam . . . . . . . . . . . . . . . . . 16.6 15.2 15.3 14.9 19.4 12.3 16.9 16.9 17.3 16.6

20-29 yaars . . . . . . . . . . . . . . . . . . . 21.9 20.3 19.7 22.2 33.5 19.3 22.2 22.2 22.6 21.9

30-39 years . . . . . . . . . . . . . . . . . . . 26.6 27.1 25.7 28.6 40.0 27.9 28.8 26.6 26.4 28.4

40-49 years . . . . . . . . . . . . . . . . . . . 32.3 32.5 30.1 35.6 48.9 35.5 35.4 32.3 31.9 35.9

Ageatandardize@ . . . . . . . . . . . . . . . 22.7 21.8 21.0 23.6 33.7 21.1 23.6 22.9 23.1 23.3

1lm.Wdesrxi@mnotstated.

21neiudeereeea etherthanwhii ar?dblack.

3Perceti of all bitis thatare by ceeamandeliiery.

4SterK@diiedto reflectthe age distributionof all origins

NOTE ExcludesNew HampshireandOk!ahema,whichdid notreponeitherHispaniooriginof motlwror methodof delivery.

15
Table 5. Rates of ceaarean delivery by age of mother, live-birth order, and race of mothe~ Total of 49 reporting States and the District of

Columbia, 1990

Age of mother

tive-birfh order and Under 20 20-24 25-29 30-34 35-39 41H9

race of mother Total yeare years yeara years years vears

Allraces2,3 . . . . . . . . . . . . . . . . . . . . . . . .

Fketchild. . . . . . . . . . . . . . . . . . . . . . . .

Secundchild . . . . . . . . . . . . . . . . . . . . . .

Thirdchild . . . . . . . . . . . . . . . . . . . . . . . .

Fourthchildandover . . . . . . . . . . . . . . . . .

White. . . . . . . . . . . . . . . . . . . . . . . . . .

Fhatchild. . . . . . . . . . . . . . . . . . . . . . . .

Secondchild . . . . . . . . . . . . . . . . . . . . . .

Thirdchild . . . . . . . . . . . . . . . . . . . . . . . .

Fourth childandover . . . . . . . . . . . . . . . . .

Blacl# . . . . . . . . . . . . . . . . . . . . . . . . . .

Firatchild . . . . . . . . . . . . . . . . . . . . . . . .

Secondchild . . . . . . . . . . . . . . . . . . . . . .

Thirdchild . . . . . . . . . . . . . . . . . . . . . . . .

Fourthchild Andover . . . . . . . . . . . . . . . . .

Allraces2,3 . . . . . . . . . . . . . . . . . . . . . . . .

Firatchild . . . . . . . . . . . . . . . . . . . . . . . .

Secondchild . . . . . . . . . . . . . . . . . . . . . .

Thirdchild . . . . . . . . . . . . . . . . . . . . . . . .

Fourthchild Andover . . . . . . . . . . . . . . . . .

Whtie3 . . . . . . . . . . . . . . . . . . . . . . . . . .

Firetchild . . . . . . . . . . . . . . . . . . . . . . . .

Secondchild . . . . . . . . . . . . . . . . . . . . . .

Thirdchild . . . . . . . . . . . . . . . . . . . . . . . .

Fourthchild Andover . . . . . . . . . . . . . . . . .

Black@ . . . . . . . . . . . . . . . . . . . . . . . . . .

Fhatchild.. . . . . . . . . . . . . . . . . . . . . . .

Secondchild . . . . . . . . . . . . . . . . . . . . . .

Thirdchild . . . . . . . . . . . . . . . . . . . . . . . .

Fourthchildandover . . . . . . . . . . . . . . . . .

22.7

24.7

22.7

21.2

17.5

23.0

24.9

22.9

21.4

17.7

22.1

23.9

22.4

21.3

18.1

18.0

24.6

8.9

6.4

8.8

16.1

24a

8.7

8.2

8.7

15.7

23.8

10.4

9.5

9.7

16.6

17.0

15.2

15.8

17.4

16.7

17.0

15.6

16.6

18.0

16.6

17.3

14.7

15.6

17.7

14.7

16.9

6.8

6.3

7.6

15.1

17.0

7.0

6.7

8.4

14.2

17.2

6.6

6.0

7.5

20.3

22.7

18.7

17.6

15.9

20.5

22.6

16.9

17.9

16.6

20.2

24.1

19.2

17.7

15.8

15.0

22.6

7.3

6.5

6.8

15.5

22.5

7.1

6.6

7.0

14.1

23.9

6.1

6.6

7.0

Total cesarean ratel

23.3

27.2

22.9

20.4

15.6

23.4

27.0

22.9

20.4

16.1

24.0

31.5

24.7

21.5

16.3

Prima~ceeerean rate4

16.0

27.1

8.7

7.7

7.4

16.1

26.9

8.4

7.5

7.3

16.1

31.3

11.3

9.3

8.1

25.7

32.3

26.3

23.0

17.7

25.6

31.9

25.9

22.6

17.7

27.5

37.6

30.8

25.5

19.0

16.5

32.2

10.4

9.0

8.8

16.3

31.8

9.9

8.6

8.4

18.3

37.4

15.8

12.7

10.7

28.1

39.3

31.3

26.6

20.1

28.9

3S.8

30.8

26.1

19.8

31.1

43.9

36.5

30.9

23.0

19.0

39.2

13.6

12.0

11.2

18.6

38.7

12.8

11.2

10.5

21.9

43.7

21.7

16.3

15.0

32.3

47.1

37.9

30.5

22.4

31.9

46.4

36.6

29.9

21.9

35.8

52.6

44.9

34.1

28.7

23.5

46.9

20.1

18.1

15.1

23.0

46.1

18.7

17.5

14.6

27.5

52.3

31.1

24.1

20.5

lpercantofalltiie birthsrhatarebycesarean delivery.

21ncludesracesotherthenwhiteandblack.

%cludes births wth birth erder not stated.

4Number of primary cesareans per 1W rwe births to women with no previous cesarean.

NOTEExcludeadats forOklehome,which dldnotrequirsrapoting ofmerhodofdeliiery.

16
Table 6. Rates of cessrean delivery by marital status, age, and race of mother: Total of 49 reporting States and the District of Columbia,

1990

Marital status of mother

Age arrd raoe of motfrer Total Mam”ed Unmenied

Total cesarean ratel

Allracesz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.7 23.8 19.9

Under20years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.6 17.7 16.0

20-29years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.9 22.4 20.4

30-39years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.6 26.7 25.6

40-49years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.3 32.1 33.2

Ware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.0 23.7 20.1

Under20yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I e.7 17.9 15.9

20-29years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1 22.5 20.6

30-39years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.5 26.5 26.1

40-19years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.9 31.7 33.0

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1 26.4 19.9

Under20years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.6 16.6 16.4

20-29yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.9 24.5 20.5

30-39years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.5 30.7 25.7

40-19years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.8 36.8 34.4

lpamantofallbirths tfsstarebyceaaresn deWery

21ncludssrecaso+hsrthenwhiteand b!ack.

NOTEExcludesdate forOk!atmm%whichdidnotwquirerepmfing ofmethodofdelivsry.

Table7. Ratesof cesarean delivery by educational attalnmen$ age, and raceofmothe~ Total of47reporting Ststes,the DMrict of

Columbia, and New York City, 1990

Yearaofachaiicompietad bymother

o-8 9-11 12 13-15 16years

A~eandraceofmother To&# yeara w yeera years or more

TotaIcesareanrate2

Allracess . . . . . . . . . . . . . . . . . . . . . . 22.6 17.5 19.1 23.1 24.6 24.9

Under20years . . . . . . . . . . . . . . . . . . . 16.5 15.2 16.4 17.4 17.2

20-29year3 . . . . . . . . . . . . . . . . . . . . .

. . .

21.9 16.3 20.1 22.5 23.1 22.2

30-39years . . . . . . . . . . . . . . . . . . . . . 26.6 21.5 24.1 27.2 27.8 26.5

40-49yeara . . . . . . . . . . . . . . . . . . . . . 32.2 26.2 2a.7 32.7 33.6 33.7

Whtie . . . . . . . . . . . . . . . . . . . . . . . . . 22.9 17.9 19.7 23.7 24.5 24.4

Under20years . . . . . . . . . . . . . . . . . . . 16.7 15.1 16.7 17.7 16.6

20-29yesre . . . . . . . . . . . . . . . . . . . . .

. . .

22.1 16.8 20.6 23.0 23.0 21.9

30-39years . . . . . . . . . . . . . . . . . . . . . 26.4 22.1 24.9 27.4 27.6 25.8

40-49yeara . . . . . . . . . . . . . . . . . . . . . 31.8 27.9 30.6 32.4 32.4 32.5

Black . . . . . . . . . . . . . . . . . . . . . . . . . 22.0 18.2 17.7 21.8 25.8 31.7

Under20years . . . . . . . . . . . . . . . . . . . 16.5 16.4 16.1 17.3 18.6

20-29years . . . . . . . . . . . . . . . . . . . . .

. . .

21.8 17.9 18.3 21.5 24.5 27.9

30-39years . . . . . . . . . . . . . . . . . . . . . 26.3 23.9 22.4 26.7 29.9 34.6

40-49years, . . . . . . . . . . . . . . . . . . . . 35.6 32.5 28.6 33.7 36.0 43.6

NOTEGrcludesdate forOklshams,Washington,sndNewYorkStste (sxclusiveofNswYarfr CW),whichddno4 requirsrsfwtingof sitharmsthedofdahay orsdwstiansia~”nmant 0fM0ffS8L

17
Table 8. Rates of ceserean delivery for singleton births by weight gain during pregancy, by geetational age and birthweight Total of 48

reporting States and the District of Columbia, 1990

Weight gain during pregnancy

Less than 16-20 21-25 2W0 31-35 36-40 41-45 46 pounds

Gestational age and birthweight Totali 16 pounds pounds pounds pounds pounds pounds pounds or more

Total ceearean I ratez

Allgeetational ages3 . . . . . . . . . . . . . .

Lessthan 2,500 grams . . . . . . . . . . . .

2,500-3,499 grams . . . . . . . . . . . . . .

3,500-4,499 grams . . . . . . . . . . . . . .

4,500 grams or more . . . . . . . . . . . . .

Under 37weeks4 . . . . . . . . . . . . . . . .

Laesthan 21500 grams . . . . . . . . . . . .

2,500-3,499 grains . . . . . . . . . . . . . .

3,500-4,499 grams . . . . . . . . . . . . . .

4,500 grams or more . . . . . . . . . . . . .

37-39 weeks4 . . . . . . . . . . . . . . .

Lessthan 2,500 grams . . . . . . . . . . . .

2,500-3,499 grams . . . . . . . . . . . . . .

3,500-4,499 grams . . . . . . . . . . . . . .

4,500 grams ormore . . . . . . . . . . . . .

40weeks andova# . . . . . . . . . . . . . .

Lessthan 2,500 grams . . . . . . . . . . . .

2,500-3,499 grams . . . . . . . . . . . . . .

3,500-4,499 grams . . . . . . . . . . . . . .

4,500 grams or more . . . . . . . . . . . . .

22.0 22.2 20.4 28.4

28.7

18.1

21.9

36.2

24.9

31.9

18.7

22.3

36.9

21.5

20.0 20.8 21.6 23.6 24.7

29.9

19.6

23.4

37.2

27.5

19.6

24.3

37.9

29.6

18.2

21.0

34.8

31.4

19.1

21.6

34.6

32.5

20.0

22.2

33.1

35.4

21.6

24.3

36.2

36.1

22.3

25.5

37.1

40.6

24.9

29.1

43.2

25.4 24.7 24.2 25.1 25.5 27.8 28.5 31.8

46.0

26.9

30.7

50.7

32.7

20.3

24.2

41.6

29.2

18.5

23.8

41.8

33.0

18.8

21.8

42.5

34.8

20.6

22.8

37.4

38.6

21.4

23.6

32.3

39.7

24.0

25.2

35.7

39.6

24.0

28.7

60.5

23.3 23.8 21.5 22.4 23.3 25.5 26.3 30.0

23.7

19.5

25.6

47.9

18.0

23.3

16.4

19.5

31.8

24.9

19.8

24.7

43.5

27.6

20.5

24.9

40.9

28.5

21.6

25.3

39.4

31.6

23.1

27.7

43.5

32.3

23.8

28.3

43.2

36.0

26.4

32.0

50.2

26.0

21.0

26.6

44.4

24.2

21.4

29.8

46.7

20.2 19.5 17.8 18.8 19.6 21.7 23.2 27.0

25.7

17.8

21.5

34.6

22.9

17.9

21.0

33.6

25.8

16.2

18,8

31.4

27.0

17.1

19.7

32.3

28.0

18.1

20.5

31.1

29.3

19.5

22.4

33.9

33.4

20.3

24.0

34.8

34.4

23.2

27.6

40.8

1Includes births with weight gain not stated.

‘Percent of all births that are by C@sareandeliiety.

slml”des births with geatefional aga or bbthweight not stated.

41ncludesbirths with birthwelght not stated.

NOTE Excludes data for California, which did not report weight gain during pragnamy, and Oklahoma, which did not report weight gain during pregnancy and method of deliveiy.

Table 9. Rates of cesarean delivery by period of gestation and race of mothec Total of 49 reporting States and the District of Columbia,

1990

All Under 28 28-31 32-35 36 37-39 40 41 42 weeks

Race of mother birfhsi weeks weeks weeks weeks weeks weeks weeks and over

Total cesarean rate2

Allraces3 . . . . . . . . . . . . . . . . . . . . 22.7 30.0 37.3 28.8 25.5 23.9 18.8 20.9 23.0

White . . . . . . . . . . . . . . . . . . . . . . . 23.0 33.9 41.7 31.6 27.0 24.7 18.6 20.6 23.1

Black . . . . . . . . . . . . . . . . . . . . . . . 22.1 25.3 30.7 23.3 21.7 21.2 20.6 23.4 23.5

llnaludes births with period of gestation rmt slated.

2percem of all births that are by Ceaereande~~e~.

‘Includes races other than whm and black.

NOTE Excludes date for Oklatmma,which did not require reporting method of deliiery.

18
Table 10. Rates of cesarean delivery by birthweight, period of gestation, and race of mothec Totai of 49 reporting States and the District

of Coiumbia, 1990

Birihweight

Less tfran 2,500 grams

Lass than 1,500 @177S

Less than 1,00& 1,500- 2,0fw- 2,500- 3,@O- 3,500- 4,000- 4,500

Period of gestation I,rxw 1,499 1,999 2,499 2,999 3,499 3,999 4,499 grarrs

and raw of mother Totall Totsl Total grams grams grams grams grams grams grams grams and over

Tofal cesarean rate2

Allraces3,4 . . . . . . . . . . . . . . . 22.7 34.5 43.7 35.3 51.8 42.7 29.4 21.0 19.8 22.1 27.5 37.3

Under 37weeks . . . . . . . . . . . 28.7 37.7 43.6 35.4 52.1 43.0 31.5 23.3 20.7 23.2 28.6 41.7

37-39 weeks . . . . . . . . . . . . . 23.9 30.2 51.0 46.9 51.7 43.1 28.1 21.5 21.7 25.2 31.8 44.1

40 weeks And over . . . . . . . . . . 20.4 28.2 45.0 36.3 46.8 39.8 26.3 19.0 17.8 20.2 25.7 34.8

White4 . . . . . . . . . . . . . . . . . 23.0 37.8 46.4 39.2 56.6 47.0 32.3 22.3 20.0 21.9 27.0 36.6

Under 37weeks . . . . . . . . . . . 31.0 41.5 46.5 39.5 57.0 47.3 35.0 25.8 22.2 23.6 28.8 41.8

37-39 weeks . . . . . . . . . . . . . 24.7 32.9 54.0 42.0 56.0 47.2 30.8 22.9 22.4 25.4 31.7 43.7

40 weeks and over. . . . . . . . . . 20.2 28.8 45.3 32.4 46.3 43.3 27.9 19.4 17.5 19.7 25.1 34.2

Blat@ . . . . . . . . . . . . . . . . . 21.6 28.4 36.2 29.9 43.3 34.3 23.5 18.3 19.4 24.2 32.5 45.5

Under 37weeks . . . . . . . . . . . 24.1 30.4 36.0 29.8 43.3 34.3 24.2 18.0 18.0 22.5 29.3 44.0

37-39 weeks . . . . . . . . . . . . . 21.2 24.6 45.5 62.0 43.5 35.1 22.7 18.4 19.6 24.5 33.4 49.1

40waeks Andover . . . . . . . . . . 22.1 25.2 47.7 50.0 47.3 33.2 23.4 18.4 19.6 24.2 32.2 43.9

1Imludes birth with birthwelghtno+Med.

2Pementof all birh that are by ceaereandeliiery.

Slwludes rases otherthanwldi end blwk.

41noludesMlhs withperiodof gexetionnotatsted.

NOTE Excludesdate for Oklahoma,whichdd notrequirerepating of methodof deliimy.

Tabie 11. Rates of cesarean deiivery by piuraiity of birth and race of mother: Totai of 49 reporting States and the District of Coiumbia,

1990

PIural births

Triplet and otharplural births

Quadruplets

and higher

Race of mother Tokri Singletons Total Twins Total Ttiplats order

Total cesarean ratel

Alirece# . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.7 21.9 55.7 54.7 66.1 66.0 89.0

While . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.0 22.2 66.6 55.5 87.3 87.0 92.2

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1 21.3 52.2 51.8 75.5 75.7 *

1percentof all bitthsthatare by ceesreandeIivery.

21rWudearascs otherthanwfdi end black.

NOTE Excludesdate for Oklahoma,whiih dd notrequirereportingmethodof deliiry.

19
Table 12. Rates of cesarean delivery for aeiected abnormal conditions of the newborn by race of mothe~ Total of 49 reporting States and

the District of Columbia, 1990

Race of mother

Abnormal currdition of the newborn Totali White Black

Total cesarean rate2

Anemia (l-1et.<39/1-lgb.<13) . . . . . . . . . . . . . . . . . . . . . .

Sirthinjur# . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fetal alcohol syndrome4 . . . . . . . . . . . . . . . . . . . . . . .

Hyaline membrane disease/RDS . . . . . . . . . . . . . . . .

Meconium aspiration syndrome5 . . . . . . . . . . . . . . . .

Assisted ventilation Ieae than 30 minutes6 . . . . . . . .

Assisted ventilation 30 minutes or Ionge# . . . . . . . .

Se@res . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26.8

12.6

39.4

47.6

34.5

36.3

48.3

33.5

28.3

11.9

43.5

48.6

35.0

36.3

49.2

34.7

22.7

19.1

36.5

44.1

33.3

36.6

45.5

29.5

llncludaarsceaotherthanwhiie and black.

‘Percent of all birthsthatare bymaaraan deliiry.

3MSSSaCIIUSeW, Nebraska,andTexasdo nOt rapat Wk Oondtiorr.

4N6wYorkStateexclusiveof NewYorkCityendWisconsindo notreportthiscondtion.

5NewYorkStateexclusiveof NewYorkCitydosenotreportthisrendition.

eNewYOW State snd New YoA C~ do notrepxl thiseonditon.

NOTE Excludesdata for Oklahome, which did notrequireraportbrgmethodof deliiery or abnormalcondtic+rsofthe nswbom.

20
Table 13. Rates of cesarean delivery for aeleoted medical risk factors, complications of iabor and/or deiivery, and obstetric procedures

by race of mothen Total of 49 reporting States and the District of Coiumbia, 1990

Race of mother

Medical risk I%L30Gapplication, and obstetric prooedure Tok# White Black

Medical risk facfom Total caaarean ratez

Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cardiac disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Acute orchronic lung disease . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gen”til herpes3,4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hydramnios/oligohydramnios3... . . . . . . . . . . . . . . . . . . . . . . . .

Hemoglobinopath~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hypertension, chronic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hypertension, prsgnancy-associated. . . . . . . . . . . . . . . . . . . . . . .

Eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Incompetentcervi# . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reneldisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rhsensitization5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utennebleedin& . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Complications of labor and/or delivey

Febril e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MWonium,m~erate/heavY . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prematureruptureofmembrane . . . . . . . . . . . . . . . . . . . . . . . . .

Abruptioplacenta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Placentaprevia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otherexcessivebleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Seizuresdunnglabor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Precipitouslabor(lessthan3hours). . . . . . . . . . . . . . . . . . . . . . .

Prolongedlabor(morethan20hours) . . . . . . . . . . . . . . . . . . . . . .

Dysfunctionallabor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Breech/malpresentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cephalopelvicdisproportion3,4. . . . . . . . . . . . . . . . . . . . . . . . . . .

Cordprolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Anestheticcomplications4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fetaldietress3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25.8

26.7

29.8

37.2

46.0

45.6

26.6

41.4

41.6

52.3

29.9

26.3

24.4

33.8

36.4

22.6

28.3

57.7

62.3

26.3

47.0

1.5

40.4

65.2

64.5

97.7

59.5

51.8

62.6

27.1

26.9

31.1

37.1

47.0

46.3

31.6

41.6

41.5

63.1

30.3

2a.7

24.4

33.6

36.6

22.5

29a

56.1

81.6

26.7

46.6

1.4

40.3

64.7

65.4

97.8

59.1

51.4

61.2

24.7

26.2

26.2

40.3

41.4

43.5

24.6

41.3

42.9

51.1

27.9

27.9

24.4

34.7

34.3

22.8

27.6

56.8

82.8

38.4

48.6

1.7

41.7

68.7

78.3

97.7

59.9

52.3

67.0

Obstatricpruedures

Amniocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.0 35.7 40.3

Elaotronicfetal monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.7 21.7 22.1

Inductionoflabor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.9 21.2 28.8

.%mulationoflabor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.9 17.5 19.5

Tocolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.1 31.8 28.7

Uitrasound6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.3 26.5 26.3

Ilmludesrawstier Umnwhteandtmk.

2Psrcentof sI[birthsihst are by cesaresndeliwery.

3NWyo~C~(b~ nottiemmeindw ofNawYorkState) rSpO*~Sri3kfa0W ~~P~~ti~.

%exasdossnetreporl thisriskfectorormmplicstion.

5KenseedeesrW reportthisriekfaotor.

%inoisdcmsnot repofilhisprocadure.

NOTEExcludesdate forOklahoms,whichdidnotrequirerepettingmettmdofdetiery, msdicalriskfastors,compliitioneoflebor Snd/ordeliiaryorobstetricprocedures.

21
Appendix

Contents

Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Sources of data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Computation ofrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . 23

Race of mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...23

Definitions ofmedical terms.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...23

Abnormal conditions ofthe newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Medical risk factors for this pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

ComplicationsofIaborand/ordelivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...24

Obstetric procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . 24

22
Appendix

Technical notes

Source of data

Except as noted elsewhere, data shown in this report are

based on 100 percent of the birth certificates of 49 States (all

States except Oklahoma) and the District of Columbia. The

data are provided to the National Center for Health Statistics

through the Vital Statistics Cooperative Progxam. Information

on selected maternal and infant health characteristics was

derived from items on 1990 certticates of live birth.

Computation of rates

The overall cesarean rate or total cesarean rate is computed as the percent of all births that were delivered by

cesarean. The denominator for this rate excludes births with

method of delivery not stated. The primary cesarean rate is a

measure that relates the number of women having a primary

cesarean delivery to all women giving birth who have never

had a cesarean delivery. The denominator for this rate includes

all births less those with method of delivery classified as

repeat cesarean, vaginal birth after previous cesare~ or

method not stated. The rate for vaginal birth after previous

cesarean (WAC) delivery is computed by relating all VBAC

deliveries to the sum of VBAC and repeat cesarean deliveries,

that is, to women with a previous cesarean section.

Race of mother

Birth data are tabulated by the race of the mother as

reported directly on the birth certificate. If race of mother was

not stated, it was imputed as that of the father, if known. If

neither race was stated, race of mother was imputed as the

race of the mother on the preceding record with known race.

Definitions of medical terms

The definitions that follow are adapted and abbreviated

from a set of definitions compiled by a committee of Federal

and State health statistics officials for the Association for Vital

Records and Health Statistics (31).

Abnormal conditions of the newborn

Anemia—Hemoglobin level of less than 13.0 g/dL, or a

hematocrit of less than 39 percent.

Birth injzq—hnpairment of the infant’s body function or

structure due to adverse influences that occurred at birth.

Fetal alcohol syndrome-A syndrome of altered prenatal

growth and development occurring in infants born of women

who consumed excessive amounts of alcohol during pregnancy.

Hyaline membrane diseaselR.DS-A disorder primarily of

prematurity, manifested clinically by respiratory distress and

pathologically by puhnonary hyaline membranes and incomplete expansion of the lungs at birth.

Meconium aspiration syndrome-Aspiration of meconium by the fetus or newbo~ affecting the lower respiratory

system.

Assisted ventilation (less than 30 minutes)—A mechanical

method of assisting respiration for newborns with respiratory

failure.

Assisted ventilation (30 minutes or more)-Newborn placed

on assisted ventilation for 30 minutes or longer.

Seizures-A seizure of any etiology.

Medical risk factors for this pregnancy

Anemia—Hemoglobin level of less than 10.0 g/dL during

pregnancy, or a hematocrit of less than 30 percent during

pregnancy.

Cardiac disease-Disease of the heart.

Acute or chronic lung disease-Disease of the lungs

during pregnancy.

Diabetes—Metabolic disorder characterized by excessive

discharge of urine and persistent thirst; includes juvenile

onse~ adult onset, and gestational diabetes during pregnancy.

Genital herpes-Infection of the skin of the genital area

by herpes simplex virus.

Hydramnios/Oligohydramnios—Auy noticeable excess

(hydramnios) or lack (oligohyddos) of amniotic fluid.

HemoglobinopathpA blood disorder caused by alteration in the genetically determined molecular structure of

hemoglobin (for example, sickle cell anemia).

Hypertension chronic-Blood pressure persistently greater

than 140/90, diagnosed prior to onset of pregnancy or before

the 20th week of gestation.

Hypertension% pregnanq-associated-An increase in blood

pressure of at least 30 mm hg systolic or 15 mm hg diastolic

on two measurements taken 6 hours apart after the 20th week

of gestation.

Eclampsia—The occurrence of convulsions and/or coma

unrelated to other cerebral conditions in women with signs and

symptoms of pre-eclampsia.

23
Incompetent cervix-Characterized by painless dilation of

the cervix in the second trimester or early in the third trimester

of pregnancy, with premature expulsion of membranes through

the cervix and ballooning of the membranes in the vagina,

followed by rupture of the membranes and subsequent expulsion of the fetus.

Renal disease-Kidney disease.

Rh sensitization-l%e process or state of becoming sensitized to the Rh factor as when an Rh-negative woman is

pregnant with an Rh-positive fetus.

Uterine bleeding—Any clinically significant bleeding during the pregnancy, taking into consideration the state of

pregnancy; any second or third trimester bleeding of the uterus

prior to the onset of labor.

Complications of labor and/or delivery

Febrile—A fever greater than 100 degrees F. or 38 C.

occurring during labor andlor delivery.

Meconium, moderate/heavy-Meconium consists of undigested debris from swallowed amniotic fluid, various products

of secretion, and excretion and shedding by the gastrointestinal trac~ moderate to heavy amounts of meconium in the

amniotic fluid noted during labor and/or delivery.

Premature rupture of membranes (more than 12 hours)—

Rupture of the membranes at any time during pregnancy and

more than 12 hours before the onset of labor.

Abruptio placenta —Premature separation of a normallyimplanted placenta from the uterus.

Placenta previa—hnplantation of the placenta over or

near the internal opening of the cervix.

(.lther excessive bleeding-The loss of a significant amount

of blood from conditions other than abruptio placenta or

placenta previa.

Seizures during labor—Maternal seizures occurring during labor from any cause.

Prolonged labor (more than 20 hours)—Abnormally slow

progress of labor lasting more than 20 hours.

Dysfunctional labor—Failure to progress in a normal

pattern of labor.

Breech/Malpresentation—At birth, the presentation of the

fetal buttocks rather than the head, or other malpresentation.

Cephalopelvic disproportion-The relationship of the size,

presentation, and position of the fetal head to the maternal

pelvis, which prevents dilation of the cervix and/or descent of

the fetal head.

Cord prolapse—Premature expulsion of the umbilical

cord in labor before the fetus is delivered.

Anesthetic complication.r-Any complication during labor

andlor delivery brought on by an anesthetic agent or agents.

Fetal distress-Signs indicating fetal hypoxia (deficiency

in amount of oxygen reaching fetal tissues).

Obstetric procedures

Amniocentesis-Surgical transabdominal perforation of

the uterus to obtain amniotic fluid to be used in the detection

of genetic disorders, fetal abnormalities, and fetal lung maturity.

Electronic fetal monitoring—Monitoring with external

devices applied to the maternal abdomen or with internal

devices with an electrode attached to the fetal scalp and a

catheter through the cervix into the uterus, to detect alndrecord

fetal heart tones and uterine contractions.

Induction of labor—The initiation of uterine contractions

before the spontaneous onset of labor by medical and/or

surgical means for the purpose of delivery.

Stimulation of labor—Augmentation of previously established labor by use of oxytocin.

Tocolysis-Use of medications to inhibit preterm uterine

contractions to extend the length of pregnancy and, therefore,

avoid a preterm birth.

Uh’rasound-Vlsuakation of the fetus and the placenta

by means of sound waves.

24 “U.S. GovernmentPrinting OffIccx 1994— 301-019/00002
Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES 4.

SERIES 5.

SERIES 6.

SERIES 10.

SERIES 11.

SERIES 12.

Programs and Collection Procedures—These reports

describe the data collection programs of the National Center

for Health Statistics. They include descriptions of the

methods used to collect and process the data, definitions,

and other material necessary for understanding the data.

Data Evaluation and Methods Research—These reports

are studies of new statistical methods and include analytical

techniques, objective evaluations of reliability of collected

data, and contributions to statistical theory. These studies

also include experimental tests of new survey methods and

comparisons of U.S. methodology with those of other

countries.

Analytical and Epidemiological Studies—These reports

present analytical or interpretive studies based on vital and

health statistics.These reperk carry the analyses further than

the expository types of reports in the other series.

Documents and Committee Reports-These are final

reperk of major committees concerned with vital and health

Statistics and documents such as recommended model v~al

registration laws and revised birth and death certificates.

International Vital and Health Statistics Reports-These

reports are analytical or descriptive reports that compare U.S.

vitaI and health statistics with those of other countries or

present other international data of relevance to the health

statistics system of the United States.

Cognition and Survey Measurement—These reports are

from the National Laboratory for Collaborative Research in

Cognition and Survey Measurement. They use methods of

cognitive science to design, evaluate, and test survey

instruments.

Data From the National Health interview Survey-These

reports contain statistics on illness; unintentional injuries;

disabiiii use of hospital, medical, and other health services;

and a wide range of special current heaith topics covering

many aspects of health behaviors, health status, and health

care utilization. They are based on data collected in a

continuing national household interview survey.

Data From the National Health Examination Survey, the

National Heaith and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination Survey—

Data from direct examination, testing, and measurement on

representative samples of the civilian noninstitutionalized

population provide the basis for (1) medically defined total

prevalence of specific diseases or conditions in the United

States and the distributionsof the populationwith respect to

physical, physiological, and psychological characteristics,

and (2) analyses of trends and relationships among various

measurements and between survey periods.

Data From the Institutionalized Population Survevs—

Discontinued in 1975. Reports from-these surveys ‘are

included in Series 13.

SERIES 13. Data From the National Health Care Survey—These

reports containstatisticson health resources and the public’s

use of health care resources including ambulato~, hospital,

and long-term care se!vices based on data collected directly

from health care providers and provider records.

SERIES 14.

SERIES 15.

SERIES 16.

SERIES 20.

SERIES 21.

SERIES Z.

SERIES 23.

SERIES 24.

Data on Health Resources: Manpower and FaciIities—

Discontinued in 1990. Reports on the numbers, geographic

distribution, and characteristics of heetth resources are now

included in Series 13.

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statistics on health and health-related topics collected in

special surveys that are not part of the continuing data

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Compilations of Advance Data From Vital and Health

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information from the National Center for Health Statistics’

health and demographic surveys, They are compiled in the

order in which they are published. Some of these releases

may be followed by detai!ed reports in Series 10-13.

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mortalii that are not included in regular, annual, or monthly

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are included.

Data on Natslity, Marriage, and Divorce-These reports

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not included in regular, annual, or monthly reports. Special

anaiyses by health and demographic variables and

geographic and trend analyses are included.

Data From the National Mortality and Natality Surveys—

Discontinued in 1975. Reports from these sample surveys,

based on vital records, are now pubfishedin Series 20 or 21.

Data From the National Survey of Family Growth-These

reports contain statistics on factors that affect birth rates,

including contraception, infertility, cohabitation, marriage,

divorce, and remarriag~ adoption; use of medicai care for

family planning and infertilii and related maternal and infant

health topics, These statistics are based on national surveys

of childbearing age.

Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy—

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and divorces based on final data from the National Vital

Statistics System that were published as supplements to the

Monthly V&d Stati.si7csRepOtt (MVSR). These reports provide

highlights and summaries of detailed data subsequently

published in Vital Statistics of the Urr~ted States. Other

supplements to the MVSR published here provide selected

findings based on final data horn the National Vital Statistics

System and may be followed by detailed reports in Series 20

or 21.

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