Chapter 3: Vaginal and Cesarean Birth

Mode of Birth

“Overall my birth and delivery went very well. I am glad I was able to have a vaginal delivery that I was hoping for. If I could do it all over again I would not change anything.” We devoted considerable focus in our survey to topics relating to mode of birth, given growing national and California recognition of the overuse of cesarean birth, the associated risk and cost with safely avoidable cesarean births, and the many policy initiatives in California to reverse the trends. Integrated Healthcare Association. (n.d.). Smart Care California, Focus Area: C-Sections. Retrieved 25 April 2018, from here To provide more appropriate care to childbearing women, it is important to understand current patterns of mode of birth, the focus of this opening section.

Sorting All Births by Mode of Birth

“My OB was supportive, knowledgeable, and worked extremely hard to make sure I had a vaginal birth. Also, our nurse was fantastic.” Table 4 places the birth of every woman in our survey in one of eight groups, depending on whether it was vaginal or cesarean and by further breakdowns. By far, the largest group is 65% of women with no previous cesarean who had a vaginal birth that was “unassisted” (i.e., with no vacuum extraction or forceps). While 17% had one or more cesareans in the past, only 2% of the total had a vaginal birth after cesarean (VBAC). Combining these groups, the proportion of unassisted vaginal births in California was 67%. Just 2% of women in our survey had an assisted vaginal birth with vacuum or forceps (data we obtained from survey participants’ birth certificates), resulting in 69% of participants with any vaginal birth. Clinical practice guidelines support fewer cesareans by increasing both of the small groups with just 2% of childbearing women each: women with VBAC and women with safe, judicious assisted vaginal birth, and by increasing vaginal birth in women who have not had a previous cesarean. American College of Obstetricians and Gynecologists’Committee on Practice Bulletins – Obstetrics. (2017). Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology, 130(5), e217-e233. Retrieved 10 August 2018, from here;

American College of Obstetricians and Gynecologists. (2015, reaffirmed 2018). Practice Bulletin 154: Operative vaginal delivery. Obstetrics & Gynecology, 126(5), e56-65. Retrieved 14 April 2018, from here;

American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine. (2014, reaffirmed 2016). Safe prevention of the primary cesarean delivery. Obstetric Care Consensus, March (1). Retrieved 19 October 2017, from here

Cesarean planning status varied widely by past cesarean status. In the case of primary, or first-time, cesareans, more than 2 in 3 women reported the cesareans were unplanned and occurred during labor (11% among 16%). In the case of repeat cesareans, almost all (13% among 15%) were planned or scheduled and generally occurred before the onset of labor. The sum of first-time cesareans (in 16% of all women) and repeat cesareans (in 15% of all women) yields the total cesarean rate among our participants: 31% (Table 4).

Table 4

Mind the Denominator: Variety of Cesarean Rates

Many cesarean rates are used when considering mode of birth. Table 5 further clarifies the four different population groups and denominators used in four different cesarean rates, and presents survey results for each. The total cesarean rate is the proportion of cesareans among all births. In our survey, nearly 1 woman in 3 had a cesarean, for a total cesarean rate of 31%. Thef primary, or first, cesarean rate is the proportion of cesareans among all women who have never had a cesarean — both those giving birth for the first time and those who have only given birth vaginally in the past. In our survey, 19% of women who had never had a cesarean had one in 2016. The repeat cesarean rate is the proportion of cesareans among all women who have had one cesarean or more in the past. In our survey, 85% of women who had had one cesarean or more again gave birth by cesarean.

Finally, the “NTSV” cesarean rate is the proportion of cesareans among low-risk first-birth women. Limiting the rate to low-risk women makes for fairer comparison, for example, across hospitals. The great majority of women whose first birth is vaginal have vaginal births in future pregnancies; thus, the focus on women giving birth for the first time. NTSV stands for a woman having her first birth (Nulliparous) and giving birth after 37 or more weeks’ gestation (Term) to a single baby (Singleton) that is born in a head-first (Vertex) position. The NTSV cesarean rate is a performance measure that is used throughout the country and extensively by Covered California and other entities in California. California leaders aim for an NTSV rate less than 23.9%, and women in our survey reported an NTSV rate of 26% in 2016. We calculated this with survey results and – for vertex presentation – participants’ birth certificates. We did not have access to participants’ discharge records to incorporate certain exclusions in the official nationally endorsed low-risk, first-birth cesarean measure. The official measure using discharge records was slightly lower, 25%, in California in 2016.

Table 5

Figure 29 shows the proportion of all birthing women who are impacted by the four different cesarean rates. The total cesarean rate is straightforward and impacted 31% of our sample. The primary cesarean rate impacted 16%, and the repeat cesarean impacted 15%, together adding up to that total rate. While critical for policy and stakeholder direction, the NTSV cesarean rate impacted a smaller proportion of women in our study, just 9%.

Total Cesarean Rate and Primary Cesarean Rate

“[The worst thing about my care was] my doctor threatening me to do a C-section if I couldn’t ‘figure out how to push correctly.’ Also pressured me to have an episiotomy.”

“[The best thing about my care in the hospital was] the patience that the labor and delivery doctor had with me. He also didn’t jump the gun for me to get a C-section when he could have.”
The total cesarean rate of 31% varied by different subgroups. As shown in Figure 30, the total cesarean rate among Black women was distinctly higher than the rate within other racial/ethnic groups (p =.05). Women covered by Medi-Cal were more likely to have a cesarean birth (34%) than women with private insurance (28%) (p < .01).

Women who had an obstetrician as their prenatal care provider (32%) had a distinctly higher total cesarean rate than women who had a midwife as their prenatal provider (18%) (Figure 30) (p < .01). While higher-risk women using an obstetrician for prenatal care likely explain some of this 14-point difference, we also examined NTSV cesarean rates limited to low-risk, first-birth women, and there was once again a sharp distinction between those using an obstetrician (28%) and a midwife (17%) (p < .01) for prenatal care. Self-selection may also play a role, as women may seek out a midwife with the hope of decreasing their chances of a cesarean.

As discussed in Appendix C, any comparison between our subgroup cesarean rates and those derived from other sources must consider our survey methodology, including the basis for our numerators and our denominators. Please see Appendix C for further discussion.

“Doctors DO encourage C-sections. … I don’t think my C-section was entirely necessary.” Among respondents who speak English at home, 22% with labor doula support had a cesarean birth versus 31% with no labor doula support (p = .04) (see Chapter 1 for the rationale for limiting doula analyses to women who speak English at home).

When we combine race/ethnicity and payer (Figure 31), differences become even more pronounced. Privately insured women experienced a spread in total cesarean rates of more than 20 percentage points across four racial/ethnic groups (p < .01), and women covered by Medi-Cal experienced a spread of 10 percentage points (p < .01). Almost half (46%) of Black women with private insurance had cesarean births, a rate more than 50% higher than any other racial/ethnic group with private insurance (p < .01). Another striking difference by payer is among Asian and Pacific Islander women: those with Medi-Cal coverage had a total cesarean rate of 45%, more than 60% higher than those with private insurance (27%) (p < .01).

Women who reported feeling pressure from a health professional to have a cesarean had a cesarean rate triple (75%) that of women who reported they had not experienced such pressure (25%). (Further discussion of pressure to have cesarean and other interventions appears in Chapter 4.)

Main Reason for Having a Primary Cesarean

The most commonly cited reason (69%) for an initial or primary cesarean was a health problem of the woman or her baby that required a cesarean, followed by an unsuccessful labor induction (17%) and concern the baby was too big (11%). Only 3% of women indicated there was no medical reason (Figure 32).

Maternal Request Cesarean Remains Rare

“I felt rushed to deliver or else have a C-section.” We combined responses to two questions: (1) if the woman asked about a planned primary cesarean and (2) if she understood that her primary cesarean was not for a medical reason. We have used the cross-tabulation of such questions in the past to identify maternal request primary cesareans. In this case, only 1.3% of women with a primary cesarean (5 out of 385 actual respondents) met these criteria for a maternal request primary cesarean, a figure that is consistent with our prior studies.

Mode of Birth in Women With One or More Past Cesareans

Repeat Cesareans and Interest in Vaginal Birth

“The hospital I would be delivering at would not let me have a vaginal birth because I had a previous C-section.”

“I didn’t like how I was forced to have another C-section when I was attempting a VBAC.”
Among women who had a repeat cesarean, 46% indicated they had had an interest in having a VBAC. This level of interest is notable in the environment of persistent repeat cesarean rates of nearly 9 in 10. We asked women who had an interest whether they had had the option of planning a VBAC, and almost half (48%) reported that they had not had the option. When asked about reasons for not having the option of planning a VBAC (and to “choose all that apply”), more than 6 in 10 (62%) reported that their provider and nearly 1 in 6 stated that their hospital (17%) did not allow VBAC, while 39% identified a need for a cesarean for their recent birth (Figure 33).

Among women who indicated an interest in a VBAC but ended up with a repeat cesarean, 32% reported that they experienced at least some time in labor.

Characteristics of Women with VBAC

“No one really believed I could achieve a VBAC and kept giving me all the reasons why it wouldn’t work even though they ‘supported my choice.’”

“[The best thing about my care was] that we were heard and that they respected my wishes and they pretty much did everything I said – because ultimately, I wanted a VBAC and I was able to fight for it.”

About 1 in 6 pregnant women in California (17%) approached their most recent birth having had at least one prior cesarean. Among those, just 1 in 7 (15%) had a VBAC, while 85% had a repeat cesarean. VBAC rates varied by subgroups. Across racial/ethnic groups, VBAC rates ranged from just 8% among Black women to 16% among White women (16%) (p < .01). Women with Medi-Cal coverage had a lower rate of VBAC (13%) than women with private insurance (17% rate) (p < .01). We found large differences in VBAC rates between women who primarily had an obstetrician (14%) and those who primarily had a midwife (33%) for prenatal care (p < .02). This may reflect a commitment of many midwives to support planned VBAC and of women with an interest in VBAC who choose midwifery care, as well as greater need for cesarean in women with obstetrical care (Figure 34).

We asked survey participants whether they had experienced any pressure from a health care professional to have a cesarean. Women who reported that they had experienced pressure to have a cesarean were less likely to have a VBAC (12%) than women who did not experience pressure (15%) (p < .01). Women who primarily spoke Spanish in their homes (19%) were more likely than those who spoke English (12%) to have a VBAC (p < .01).

Main Reason for Having a Repeat Cesarean

“I didn’t like how I was forced to have another C-section when I was attempting a VBAC.”

We asked women who had had a repeat cesarean to identify the reason for having a cesarean that best applied to their situation. For more than 6 in 10 (62%), the reason was the fact of a past cesarean without a medical indication. Approximately 15% said that she or her baby had had a health problem calling for a cesarean in the present birth, and about 1 in 5 (18%) said it was a combination of both past cesarean and present health issue. For 2%, there had been no health benefit, and the cesarean was for a nonmedical reason (Figure 35.)

“I had a lot of support during delivery which I believe helped me deliver vaginally after a C-section.” Looking by subgroups at women who identified previous cesarean as the main indication for their recent, repeat cesarean reveals a greater likelihood that White women and women with private insurance would have a reason for their recent cesarean that was not simply the fact of a prior cesarean. In the greatest spread across rWhiteacial/ethnic groups, 73% of Black women reported that the fact of a previous cesarean was the main reason for their recent cesarean, in comparison with 46% of women (p < .01). Previous cesarean was the main indication for 64% of women with Medi-Cal coverage versus 54% of women with private insurance (Figure 36).

Understanding Decision-Making About Birth Options After One or Two Cesareans

“I was very supported in my decision to have a drug-free VBAC, both from the midwife I was seeing and when I saw any OB-GYNs during my pregnancy. All of the labor and delivery staff … were very helpful and friendly, and I pretty much had the birth that I had wanted to have.”

We repeated a sequence of questions from our last national Listening to Mothers survey designed to understand clinical decision-making processes. These were adapted with permission for maternity care following extensive research investigating 10 other clinical scenarios. Zikmund-Fisher, B.J., Couper, M.P., Singer, E., Ubel, P.A., Ziniel, S., Fowler, F.J., Levin, C.A., & Fagerlin, A. (2010). Deficits and variations in patients’ experience with making 9 common medical decisions: the DECISIONS Survey. Medical Decision Making, 30(5 suppl), 85S-95S. We asked women with one or two past cesareans a screener question to identify those asked this sequence: had she spoken in pregnancy with a maternity care provider about scheduling another cesarean because of her past cesarean(s)? The screener thus identified those who considered options of waiting for labor or planning another cesarean. We limited this to one or two past cesareans as guidance and evidence support offering VBAC and information about it to most women with one or two past cesareans.

Table 6 summarizes results of decision-making processes for this group. These questions were asked of about 3 in 4 women among those with one or two past cesareans who said they had discussed the possibility of having an intervention — a repeat cesarean — with their maternity care provider (74%).

Table 6

We asked the women how much they had discussed both reasons why they might want to have a repeat cesarean and reasons why they might not want to have a repeat cesarean. Their responses, shown in Figure 37, suggest that the information was overall skewed in favor of the procedure. For example, more than 1 in 3 (36%) had no discussion at all about why they might not want to schedule another cesarean, versus 6% who had no discussion about why they might want to schedule another cesarean. At the other end of the spectrum, 42% had a lot of discussion about why to have the procedure versus 18% who had a lot of discussion about why not to have the procedure. Virtually all providers (94%) spoke at least “a little” about reasons for a cesarean, compared with 64% who spoke at least “a little” about reasons not to have a cesarean (p < .01 for amount of discussion for and against another cesarean).

Moreover, almost one-third of respondents (32%) indicated that the discussion was not framed as a matter of choice. We further asked whether their care provider had made a recommendation about whether or not to have a repeat cesarean, and about 3 in 4 women (74%) reported that their provider had made a recommendation. We then asked women who had been given a recommendation, what it was, and providers favored a repeat cesarean by more than 7 to 1 (65% to 9%) (Figure 38).

“To have a VBAC was my OB’s suggestion, and even though i wanted this, she made me feel like it was a real possibility. ... I love my OB and her support.” We looked at actual mode of birth, and found that the VBAC rate among women who had had these discussions was 11%, whereas the VBAC rate among women who said they had not had such a discussion was 30% (p < .01). Finally, we asked women who had made the decision, and found that a plurality (45%) felt it was a joint decision, followed by 34% who felt it had been their own decision. Just 22% identified their provider as the main decision-maker. Given both skewed information and skewed recommendations, women with previous cesareans may erroneously feel that that they are making informed decisions about how to give birth.

This look at decision-making discussions helps to understand why just 2% of all births in our study were VBACs. Further analysis of results from this question sequence in our national Listening to Mothers III survey is available. Declercq, E.R., Cheng, E.R., & Sakala, C. (2018). Does maternity care decision-making conform to shared decision-making standards for repeat cesarean and induction after suspected macrosomia? Birth, 45(3), in press.