title: Indications contributing to the increasing cesarean delivery rate.
abstract: OBJECTIVE
  To examine physician-documented indications for cesarean delivery in order to investigate the specific factors contributing to the increasing cesarean delivery rate.
  
  
  METHODS
  We analyzed rates of primary and repeat cesarean delivery, including indications for the procedure, among 32,443 live births at a major academic hospital between 2003 and 2009. Time trends for each indication were modeled to estimate the absolute and cumulative annualized relative risk of cesarean by indication over time and the relative contribution of each indication to the overall increase in primary cesarean delivery rate.
  
  
  RESULTS
  The cesarean delivery rate increased from 26% to 36.5% between 2003 and 2009; 50.0% of the increase was attributable to an increase in primary cesarean delivery. Among the documented indications, nonreassuring fetal status, arrest of dilation, multiple gestation, preeclampsia, suspected macrosomia, and maternal request increased over time, whereas arrest of descent, malpresentation, maternal-fetal indications, and other obstetric indications (eg, cord prolapse, placenta previa) did not increase. The relative contributions of each indication to the total increase in primary cesarean rate were: nonreassuring fetal status (32%), labor arrest disorders (18%), multiple gestation (16%), suspected macrosomia (10%), preeclampsia (10%), maternal request (8%), maternal-fetal conditions (5%), and other obstetric conditions (1%).
  
  
  CONCLUSIONS
  Primary cesarean births accounted for 50% of the increasing cesarean rate. Among primary cesarean deliveries, more subjective indications (nonreassuring fetal status and arrest of dilation) contributed larger proportions than more objective indications (malpresentation, maternal-fetal, and obstetric conditions).
authors.affiliation: From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, Connecticut.
authors.forename: Emma L
authors.initials: EL
authors.lastname: Barber
authors.forename: Lisbet S
authors.initials: LS
authors.lastname: Lundsberg
authors.forename: Kathleen
authors.initials: K
authors.lastname: Belanger
authors.forename: Christian M
authors.initials: CM
authors.lastname: Pettker
authors.forename: Edmund F
authors.initials: EF
authors.lastname: Funai
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Illuzzi
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data; D015148:Cardiotocography; D002585:Cesarean Section / Q000706:statistics & numerical data* / Q000639:trends; D003237:Connecticut; D005260:Female; D005318:Fetal Heart / Q000503:physiopathology; D006801:Humans; D007747:Labor Stage, First; D007752:Obstetric Labor, Premature / Q000517:prevention & control; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000503:physiopathology; D018566:Pregnancy, High-Risk; D016064:Vaginal Birth after Cesarean / Q000706:statistics & numerical data