Reducing Primary Cesareans


In spring 2015, the American College of Nurse-Midwives (ACNM) launched the Healthy Birth Initiative: Reducing Primary Cesareans Project.

This initiative offers the opportunity for maternity care professionals and health systems to make system changes aimed at reducing the incidence of Primary Cesarean Births in the United States, which have reached alarming rates without associated improvements in health outcomes for mothers and babies.

Facts about Primary Cesarean Sections in Low Risk Women:

  • Low risk is defined as pregnancies that are: nulliparous, term, singleton, vertex presentation or NTSV

  • Cesareans, which can be lifesaving, pose greater risks of morbidity and mortality than vaginal delivery for low risk women.1

  • There is a 15 fold variation in NTSV cesareans (2.4% to 36.5%) in the USA.2

  • Unwarranted variation (that which cannot be attributed to a medical indication) indicates an opportunity for quality improvement.

  • Labor abnormalities and “non-reassuring” fetal heart rate tracings account for 60% of NTSV cesareans.3

Reducing Primary Cesareans Learning Collaborative: ACNM has an ongoing multi-hospital learning collaborative aimed at reducing primary cesarean births in low risk women through the support of physiologic labor and birth. The first learning collaborative began in 2016 with support from the Transforming Birth Fund. Between 2016 and the present, 26 multi-disciplinary hospital teams from across the country have engaged in implementing one of three models aimed at reducing NTSV cesareans. The models are aimed at supporting progress in labor, increasing comfort in labor, or encouraging the use of Intermittent Ausculation (IA). Hospitals are supported by a customized data center, a web-based registry where participants in this collaborative upload data each month on the key metrics for their bundles, and are able to see how their results trend over time in terms of reducing cesareans. More information about the teams that have participated is available at the link below.

Interested in joining?


  1. Clark SL, Belfort MA, Hankins GDV, Meyers JA, Houser FM. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol. 2007; 196(6):526.e1–526.e5. [PubMed: 17547880]

  2. Kozhimannil KB, Law MR, Virnig BA. Cesarean Delivery Rates Vary 10-Fold Among US Hospitals; Reducing Variation May Address Quality, Cost Issues. Health affairs (Project Hope). 2013;32(3):527-535. doi:10.1377/hlthaff.2012.1030.

  3. Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 118(1):29–38. 2011.