CESAREAN

BIRTH TRENDS:
WHERE YOU LIVE SIGNIFICANTLY
IMPACTS HOW YOU GIVE BIRTH

Cesarean Birth Trends: Where You Live Significantly Impacts How You Give Birth [August 2016]

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BLUE CROSS BLUE SHIELD, THE HEALTH OF AMERICA REPORT

EXECUTIVE SUMMARY
The likelihood that an expectant mother will have a cesarean
delivery1 is determined in large part by where she lives. An analysis
of Blue Cross and Blue Shield (BCBS) companies data taken from
3 million deliveries by BCBS commercially-insured members shows
that the rate of cesarean deliveries is more than twice as high
in some parts of the country than in other parts and that even rates
by U.S. Census Division vary by as much as 35 percent.
While geographic variation in cesarean deliveries is stark, the trend
nationally may be shifting back toward vaginal deliveries. During
a five-year period between July 2010 and June 2015, the cesarean
rate decreased slightly each year within the BCBS population,
to 33.7 percent from 35.2 percent.
The five-year average rate of cesarean delivery is 34.7 percent,
slightly higher than the 32.7 percent rate for the general population
as of 2013, based on National Center for Health Statistics data. The
contrast likely reflects differences in demographic factors, such as
age, associated with the commercially insured and the general population. In this study, mothers insured through BCBS companies are,
on average, 30 years old.2 Among the U.S. population, the average
age of mothers giving birth is approximately 1.6 years younger, or
28.4 years old, based on NCHS data.

STUDY FOUND...
Cesarean rates within
BCBS population

can be twice as high

in some parts of the country

indicates a slight decrease

nationally each year over
a five-year period, 2010-2015

Cesarean rates by
U.S. Census Division
vary by as much as

35%

One potential avenue in lowering cesarean rates entails emphasizing

vaginal deliveries for as many first-time mothers as possible. When
a mothers first child is delivered by cesarean, the chance is 89 percent that subsequent deliveries will be done by cesarean, based on
calculations using NCHS data. About half of the increase in cesarean
rates reflect this. Cesarean delivery remains the safest route for
breech or multiple births for mother and baby.

1. A cesarean delivery is an abdominal surgery in which a doctor creates incisions through skin, the abdominal wall, muscle and the uterus to deliver a baby.
Recovery after a cesarean section is typically longer than that of a vaginal birth. Mothers who have cesarean deliveries may experience as much as six weeks
of post-operation pain and bleeding versus bleeding and vaginal discharge for two to four weeks after a vaginal birth.
2. The average age remained stable during each of the five years of this study.

Cesarean Birth Trends: Where You Live Significantly Impacts How You Give Birth [August 2016]

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U.S. Cesarean Rates Vary Significantly by Census Division3

While an analysis of five years of data from July 2010 to June 20154 shows a slight reversal in the decades-long rise
in the rate of cesarean births in the U.S., many areas still experience extremely high rates of cesarean deliveries.5
In Miami, Florida, and Jackson, Mississippi, for instance, rates are twice as high as in Albuquerque, New Mexico,
and Iowa City, Iowa, even after adjusting for age, multiple births and the rate of breech deliveries. Since populations
in markets of this size record similar rates of complicated births, other factors (e.g., local practice patterns and
malpractice laws) may drive differences in cesarean rates.
One explanation for varying cesarean rates: Each division has a different distribution of ages of delivering mothers
and different rates of clinical conditions associated with cesarean deliveries, such as breech delivery or multiple
births. However, even after adjusting each division to match the national average age distribution and prevalence
of breech and multiple births, nearly all of the variation at the census division level remained from a cesarean
rate of 39.4 percent in the West South Central division to 29.3 percent in the Mountain division.

CESAREAN RATE BY CENSUS DIVISION (2010 2015)

32.0%

29.3%

39.4%

31.1% 39.3% 33.5% 36.8% 35.0%

WEST
NORTH
CENTRAL

PACIFIC

32.2%

NEW
ENGLAND

EAST
NORTH
CENTRAL

MIDDLE
ATLANTIC

MOUNTAIN

WEST
SOUTH
CENTRAL

EAST
SOUTH
CENTRAL

SOUTH
ATLANTIC

3. Census divisions map each state to one of the nine divisions described. Approximately 275,000 records (less than 9 percent of the total) were omitted from this
analysis because they lacked geography information. Each census division was well-represented in the data, with the largest (South Atlantic) recording more than
530,000 deliveries and the smallest (Mountain) registering over 140,000.
4. Data from July 2014 through June 2015 include approximately 70 percent of BCBS medical claims for those 12 months.
5. Claims data cannot fully ascertain the NTSV (nulliparous, term, singleton, vertex) measure commonly used to document low-risk deliveries.

Cesarean Birth Trends: Where You Live Significantly Impacts How You Give Birth [August 2016]

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Cesarean Rates Also Vary Significantly by Market Area

Mirroring divisional data, a small effect on the overall cesarean variation appeared after adjusting for the age
and condition of each city to the national average. For instance, in markets that had at least 5,000 births, Miami,
Florida, recorded the highest adjusted (49.6%) cesarean rates. Albuquerque, New Mexico, registered the lowest
adjusted cesarean rates of 22.7 percent. As with the census divisions, almost all of the variation remained after
adjusting for age, multiple births and breech births. This indicates that such factors as local practice patterns and
malpractice laws are more important in determining the cesarean rate.

RATE
>45%
40% to 44.9%
35% to 39.9%
30% to 34.9%
25% to 25.9%
<25%

CESAREAN RATE DECREASED SLIGHTLY EACH YEAR WITHIN BCBS POPULATION

36%
35.2%

35.0%

34.9%
34.6%

34%
33.7%

Five-year average rate

of cesarean delivery is 34.7%.

*
15
14
20
7/

-6/
13
20
7/

-6/

20

20

14

13
20
-6/
12
20
7/

-6/
11
20
7/

20

10

-6/

20

20

12

11

32%

7/

Cesarean Rate

While geographic variation in cesarean deliveries

is stark, the trend nationally may be shifting back
toward vaginal deliveries. During a five-year period
between July 2010 and June 2015, the cesarean
rate decreased slightly each year within the BCBS
population, to 33.7 percent from 35.2 percent.
While small, this decline is consistent for all five
years and reverses 20 years of increasing cesarean
rates. A 1.5 percentage point decrease represents
approximately 36,000 vaginal deliveries compared
with cesarean sections in the same period.

*Includes a subset, or approximately 70 percent, of BCBS medical claims.

Cesarean Birth Trends: Where You Live Significantly Impacts How You Give Birth [August 2016]

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Cesarean Rate Increases Steadily with Age

Each delivery record contained the mothers
age, which allowed for analysis of results by
age bands for mothers ages 18 through 49.
Not surprisingly, the cesarean rate steadily
increases with age, with mothers ages 18
through 24 recording the lowest cesarean
rate (26.8%) and those 45 through 49 showing
the highest rate (62.6%). Mothers under 20
represent a small fraction of total deliveries,
and mothers ages 25-29 and 30-34 comprise
the two largest age groups by total deliveries.
Again, a prior cesarean delivery strongly
associates with having future cesarean
deliveries.

CESAREAN RATE BY AGE GROUP

(2010 2015)

AGE GROUP

CESAREAN
RATE (%)

18-24

26.8

25-29

31.1

30-34

35.9

35-39

42.9

40-44

50.5

45-49

62.6

Cesarean Delivery Strongly Preferred for Breech and Multiple Births

In addition to age, certain obstetrical conditions associate strongly with cesarean deliveries. In particular,
breech and multiple births (twins, triplets, etc.) have a strong effect on cesarean rates. Often, a cesarean
delivery is the safest route for breech or multiple births for mother and baby, so their strong association
with cesarean delivery is appropriate and expected.

CESAREAN RATE BY PARTICULAR CONDITION (2010 2015)

All Deliveries

34.7 %

Breech

94.8 %

Multiple Births

75.6 %

CONCLUSION AND DISCUSSION

This study reveals that cesarean rates by U.S. local market vary from 25 to 50 percent. This variation is not
driven substantially by differences in the ages or rates of breech and multiple births. Many factors shape
these differences. Additional research should be conducted to assess the effect of variations in local practice
patterns, the legal malpractice environment and other factors.
The Centers for Disease Control and Prevention has developed a measure of severe maternal complications
during and after delivery called Severe Maternal Morbidity, or SMM. These complications include heart
attack, renal failure, eclampsia, internal injuries, hysterectomy or the need for a blood transfusion or
ventilation. In this data, SMMs occurred in 2.9 percent of cesarean deliveries and only 0.8 percent of
vaginal deliveries.6 The interplay, though, is complex between SMMs and cesarean deliveries. Cesareans
might contribute to SMMs, and women at higher risk of SMMs may deliver by cesarean more often.
Besides higher complications, cesareans that are not medically necessary also add cost to the health
care system. For commercial BCBS members, the average cost difference between cesarean and vaginal
deliveries, adjusted for risk, exceeds $4,000 $17,482 vs. $13,325.7

6. The overall prevalence rate of SMMs in this data was 1.5 percentvery close to the national rate of approximately 1.6 percent most recently reported by the CDC.
7. The cost of the episode includes all of the costs associated with the hospital stay during the delivery, including physicians, facility and anesthesia fees.

Cesarean Birth Trends: Where You Live Significantly Impacts How You Give Birth [August 2016]

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APPENDIX
METHODOLOGY NOTES
This report examines the medical claims of more than 3 million deliveries for Blue Cross and Blue Shield
commercially-insured members from July 2010 through June 2015 to assess the trend in overall cesarean
rates nationally and differences in the rate across regions and markets. It also looks at the interaction of
age and key conditions of birth on the rate and makes adjustments to the geographic variation to account
for these factors.
This is the eighth study of the Blue Cross Blue Shield, The Health of America ReportSM series,
a collaboration between the Blue Cross Blue Shield Association and Blue Health Intelligence, which
uses a market-leading claims database to uncover key trends and insights into health care affordability
and access to care.

State and City

Adjusted
Cesarean Rate

State and City

Adjusted
Cesarean Rate

Florida, Miami

49.6%

Georgia, Atlanta

38.6%

Mississippi, Jackson

49.6%

Florida, Tampa-St. Petersburg

38.5%

Texas, McAllen-Edinburg-Mission,
Brownsville-Harlingen

48.8%

Kentucky, Louisville

38.5%

Alabama, Tuscaloosa

38.4%

South Carolina, Myrtle Beach/Florence

46.2%

Georgia, Columbus

38.4%

Florida, Fort Lauderdale

45.0%

Michigan, Saginaw-Bay City-Midland

38.2%

Michigan, Flint

42.5%

Pennsylvania, Erie

38.2%

New Jersey, Bergen-Passaic

42.0%

Oklahoma, Tulsa

38.1%

Alabama, Mobile

41.3%

West Virginia, Huntington-Ashland

37.9%

Arkansas, Little Rock

41.0%

South Carolina, Greenville-Spartanburg

37.9%

New York, Nassau-Suffolk

40.9%

Tennessee, Nashville

37.5%

Florida, West Palm Beach

40.8%

New Jersey, Middlesex-Somerset

37.4%

Florida, Orlando

40.4%

Virginia, Richmond-Petersburg

37.4%

Tennessee, Memphis

40.2%

Florida, Jacksonville

37.3%

Kentucky, Lexington

40.2%

North Carolina, Fayetteville

37.3%

Alabama, Birmingham

40.1%

Connecticut, New Haven-Bridgeport

37.1%

Alabama, Montgomery

40.1%

Oklahoma, Oklahoma City

37.0%

Alabama, Decatur-Florence

39.8%

North Carolina, Hickory-Morganton

37.0%

Texas, Dallas-Sherman-Denison

39.7%

Texas, Fort Worth-Arlington

36.1%

New Jersey, Newark

39.5%

South Carolina, Charleston

36.1%

Alabama, Huntsville

39.2%

Texas, San Antonio

36.1%

Texas, Houston

39.2%

Tennessee, Chattanooga

36.1%

Tennessee, Johnson City-Kingsport

39.1%

New Jersey, Monmouth-Ocean

36.1%

South Carolina, Columbia

39.0%

California, Modesto-Merced

36.0%

Cesarean Birth Trends: Where You Live Significantly Impacts How You Give Birth [August 2016]

State and City

Adjusted
Cesarean Rate

State and City

(7)

Adjusted
Cesarean Rate

District Of Columbia, Washington

36.0%

Delaware, Wilmington-Newark

32.9%

California, Riverside-San Bernardino

36.0%

California, Orange County

32.8%

Missouri, St. Louis

35.8%

Nebraska, Omaha

32.5%

Ohio, Cincinnati

35.8%

Arizona, Phoenix-Mesa

32.4%

Michigan, Detroit-Ann Arbor

35.8%

Iowa, Des Moines

32.2%

Pennsylvania, Scranton-Wilkes-Barre

35.7%

Pennsylvania, Pittsburgh

32.2%

Tennessee,
Nashville/Clarksville-Hopkinsville

35.6%

Illinois, Chicago

32.1%

North Dakota, Bismarck

31.8%

New York, New York

35.6%

Washington, Portland-Vancouver

31.8%

California, Los Angeles-Long Beach

35.6%

Ohio, Columbus

31.6%

Texas, Odessa-Midland

35.4%

Tennessee, Knoxville

35.3%

Washington,
Seattle-Bellevue-Everett-Bellingham

31.5%

Virginia, Roanoke

35.2%

Indiana, Fort Wayne

31.5%

Michigan, Lansing-East Lansing

35.1%

Pennsylvania, Harrisburg-Lebanon

31.4%

Indiana, Indianapolis

34.9%

Iowa, Cedar Rapids

31.4%

Indiana, Gary

34.8%

Pennsylvania, York

31.1%

Ohio, Dayton-Springfield

34.8%

New York, Albany-Schenectady-Troy

31.0%

Texas, Austin-San Marcos

34.8%

Kansas, Kansas City

31.0%

Florida, Gainesville

34.6%

Pennsylvania, Reading

30.9%

Pennsylvania, Philadelphia

34.5%

Ohio, Cleveland-Lorain-Elyria

30.9%

Florida, Pensacola/Fort Walton Beach

34.5%

North Carolina,
Rocky Mount/Greenville

30.9%

34.5%

North Carolina,
Raleigh-Durham-Goldsboro

Connecticut, Hartford

34.4%

California,
Oakland/Vallejo-Fairfield-Napa

30.5%

Pennsylvania, Sharon

34.4%

New York, Buffalo-Niagara Falls

30.5%

Arkansas, Fayetteville-Springdale

34.4%

Massachusetts, Boston-Worcester

30.3%

Iowa, Sioux City

34.2%

Minnesota, Grand Forks

30.2%

Maryland, Baltimore

34.1%

Iowa, Davenport-Moline

29.6%

California, San Diego

34.0%

Washington, Tacoma-Bremerton

29.5%

North Carolina, Charlotte-Gastonia

33.9%

California, San Francisco

28.6%

Virginia, Norfolk-Virginia Beach

33.9%

Colorado, Denver

28.5%

Nebraska, Lincoln

33.7%

Minnesota, Minneapolis-St. Paul

28.4%

Michigan, Grand Rapids-Muskegon

33.6%

Wisconsin, Milwaukee-Waukesha

28.2%

California, San Jose

33.5%

South Dakota, Sioux Falls

28.0%

North Carolina, Asheville

33.4%

Idaho, Boise City

27.6%

Pennsylvania, Lancaster

33.4%

North Dakota, Fargo-Moorhead

27.5%

Pennsylvania, Allentown-Bethlehem

33.3%

Hawaii, Honolulu

27.1%

North Carolina,
Greensboro-Winston-Salem

33.2%

Utah, Salt Lake City-Ogden

27.1%

Iowa, Iowa City

23.7%

Michigan, Kalamazoo-Battle Creek

33.1%

New Mexico, Albuquerque

22.7%

Rhode Island, Providence-Warwick

33.0%

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.
Health Intelligence Company, LLC operates under the trade name Blue Health Intelligence (BHI) and is an Independent Licensee of BCBSA.

16-433-V05