In February 2014, The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) released an Obstetric Care Consensus statement titled Safe Prevention of the Primary Cesarean Delivery (ACOG & SMFM, 2014). Currently, one in three women who give birth in the United States does so by cesarean. Importantly, the rapid increase in the rate of cesarean delivery since 1996 has not been associated with improved rates of maternal or neonatal morbidity or mortality, nor can the increased rate be accounted for by characteristics of pregnant women, such as age, weight, and ethnicity. These concerning facts and the wide variation in cesarean rates in the United States, particularly for nulliparous women at term gestation with a single, vertex presenting fetus, underscore the need for a concerted national effort to reduce unnecessary cesarean deliveries. The total cesarean rate varies by state from less than 23% in New Mexico and Alaska to nearly 40% in Kentucky (Martin, Hamilton, Ventura, Osterman, & Matthews, 2013). The rate also varies by hospital from 2.4% to 36.5% among low-risk women (Kozhimannil, Law, & Virnig, 2013).

Variations in practice, including diagnostic labeling, absence of evidence-based care prior to and during labor, and failure to wait likely account for the disparity in cesarean rates. In descending order of frequency, the clinical diagnoses leading to primary cesarean include the following: labor dystocia (slow progression of labor), abnormal or indeterminate (nonreassuring) fetal heart rate, fetal malpresentation (particularly breech presentation and occiput posterior), multiple gestation, and suspected fetal macrosomia. None of these is an absolute indication for cesarean delivery. Specific strategies to reduce cesarean delivery for each of these diagnoses are offered in the consensus statement with emphasis on more precise, contemporary definitions and systematic application of evidence-based approaches to maximize the potential for safe vaginal birth. Nurses, midwives, and physicians share responsibility for the implementation of these strategies.

The consensus statement by ACOG and SMFM should be required reading for every nurse, midwife, and physician who cares for pregnant women and their fetuses during labor and birth in our nation's hospitals. Awareness is the initial step required to change attitudes and transform the culture around vaginal birth and cesarean delivery. Nurses are key to this culture change through clinical leadership, expert interdisciplinary collaboration, and direct intervention with women. Nurses can facilitate progression of labor through low-technology approaches, evidence-based application of high-technology approaches, and protection of the time women need to progress during labor. Although national agendas to safely reduce the primary cesarean delivery rate are critical, real change will only occur with the implementation of multiple strategies at the local unit and institutional levels. Strong interdisciplinary formal and informal leadership is essential.

I frequently hear it said that many women want cesareans and are not willing to be patient for labor to proceed. Providers feel pressured to perform cesareans by women and their families. I believe this is partially the result of nurses (and physicians) abrogating our fundamental responsibility to educate women about the processes of childbirth from a psycho-physiologic perspective that benefits the maternal/fetal transition from woman with child to woman and child and the short- and long-term risks of cesarean delivery for the woman, the infant, and future pregnancies. Thus far, we have been very successful in convincing a significant proportion of young women that cesarean delivery is not only as safe as but perhaps preferable to vaginal birth. The data are in, and the experts agree that this is simply not true. It is appropriate to celebrate normalcy in childbirth, understand its substantial variation, and make the protection of normalcy a national agenda.

Perhaps it is time for a public health campaign to help women and their families understand that though cesarean delivery can be lifesaving in specific situations, it is associated with more harm than benefit when used inappropriately. Efforts to stem the tide of inappropriate use of primary cesarean delivery are in the best interest of the public health (particularly women and infants and quality, cost-effective health care) and are also the right and ethical thing to do. I commend our medical colleagues for writing this important consensus statement. Now it is time for all of us to get to work and create the change in the care of pregnant women that is required to safely and swiftly reduce the rate of primary cesarean delivery in the United States.


  1. Top of page