doi: 10.1097/AOG.0000000000004876.

Online ahead of print.


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Ann M Bruno et al.

Obstet Gynecol.



After the global cesarean delivery rate nearly doubled between 2000 and 2015, cesarean deliveries now account for nearly one third of births in the United States. Although rates have plateaued, the high national cesarean delivery rate has garnered criticism from both lay and Academic communities because it has not been associated with improvements in maternal or neonatal outcomes. Efforts are underway to lower the cesarean delivery rate through implementation of hospital-level and national guidelines. However, the cesarean delivery rate that optimizes maternal and neonatal outcomes is not known. Defining a cesarean delivery rate that optimizes perinatal outcomes and reduces morbidity seems simple. However, there are a host of challenges to such a task, including determining the outcomes that are most meaningful to use, deciding the population that should define the rate, and incorporating person-centered decision making, given that people place different value on different outcomes. Rather than a “call” for cesarean delivery rate reductions of a specific and arbitrary magnitude, we need further attention to defining an evidence-based optimal target. This commentary summarizes current national and international cesarean delivery rate targets, discusses the challenges of identifying an evidence-based national cesarean delivery rate target, and explores future considerations for best defining a cesarean delivery rate target.

Conflict of interest statement

Financial Disclosure Torri D. Metz reports receiving UpToDate royalties for two topics on trial of labor after cesarean. Money was paid to her institution as a site PI for a preeclampsia point-of-care test. Her institution received money to conduct the study, which ended in August 2020. Money was paid to her institution from Pfizer—she was a site PI for a phase III respiratory syncytial virus vaccine trial. She is a member of the Pfizer Medical Advisory Board (January 15, 2021) and site PI for a COVID-19 vaccination trial in pregnancy. She has served on the Society for Maternal-Fetal Medicine Board of Directors. The other authors did not report any potential conflicts of interest.


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