Counting the Cost of Too Many C-sections in Low-Risk Deliveries

After more than a decade of declining, c-section delivery rates in the United States are once again rising. In 2021, there were 1,174,545 c-sections, accounting for 32.1% of all U.S. live births. Remarkably, c-sections are even increasing in young, low-risk, first-time deliveries. C-sections can save lives; however, when elected for non-medical reasons, they pose unnecessary short and long-term risks for both mother and child and cost Medicaid about 50% more than natural deliveries. To quantify unnecessary c-sections in low-risk deliveries, we measured variation in clinician practice, identified excessively high rates, and estimated the national and state fiscal impact of the outliers. Medicaid funded 41% of all U.S. births in 2021. For this reason, we used the 2021 Medicaid fee-for-service data to evaluate clinician c-section rates in all low-risk Medicaid beneficiary deliveries and found that c-section rates by clinicians (N=12,811) vary (mean[SD]0.25[0.15]) (median[IQR] 0.23[0.15-0.31]). Identifying c-section rates over 35% found 2,370 physicians (18.5%) were outliers, and 21 physicians performed c-sections on 100% of their low-risk patients. The estimated excess Medicaid cost of these 41,907 excess surgeries was $186,865,319.55. Geographically, the highest c-section rates in low-risk deliveries were in the U.S. Virgin Islands (60.6%), Puerto Rico (40.9%), Alaska (33.5%), Rhode Island (31.1%), and New Hampshire (29.2%). States with the lowest c-section rates were North Dakota (15.6%), Delaware (17.1%), Colorado (18.5%), and Wyoming (19.4%) and Arkansa/Michigan (tied 19.8%). These results highlighting practitioner, state, and national level details align with the Healthy People 2030 objective of “reducing cesarean births among low-risk women with no prior births.” Quantifying these trends and contextualizing their impact, can help efforts to improve future practices standards, accountability, and stewardship of common resources.