In 2014, 1.3 million women in the United States delivered via cesarean, placing the rate at 32.2%, down just .7% from the peakin 2009.Thatyear, cesarean rates hit 32.9%, capping steady increases that started in 1996, when the rate was 20.7%. The rapid rise (a 50% increase over 13 years) came on the heels of a decline in the cesarean rate from 23.7% in 1987 to 20.8% in 1997— the only time in the past 3 decades that it fell in a developed country. The drop in the late 1980s and early 1990s was accomplished primarily because trials of labor after cesarean (TOLACs) had been rare and the rate of attempts rose to more than 40% in women with prior cesareans. Interestingly, the rise in TOLAC was accompanied by a slight decline in primary cesarean deliveries. In the 1990s, the increasing rates ran contrary to guidance from Healthy People 2010 (and then Healthy People 2020), which set a 15% goal for primary cesareans. The wide variation in cesarean rates among institutions is striking. The rate varies significantly even when controlling for characteristics that would account for indicated cesareans. The statistics are dramatic and concerning, leading to these key questions: Why is the cesarean rate rising, and is the rise influencing maternal or neonatal outcomes?
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