Healthy Beginnings / Reducing Cesarean Births

Reducing First-Birth Cesarean Birth Rate – NTSV2022-02-01T15:16:52-08:00

Safe Births. Healthy Mothers and Babies.

Cesarean (C-section) deliveries can be life-saving procedures when medically necessary, but they carry a higher risk of negative outcomes for mothers and babies. Complication rates for women also increase with each C-section delivery. Current trends in maternity care show that many pregnant women undergo procedures such as C-sections, repeat C-sections, and labor inductions that may not be medically necessary.1

The C-section rate among low-risk, first-time mothers (also called Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate), is the proportion of live babies born at or beyond 37.0 weeks gestation to women in their first pregnancy, that are singleton (no twins or beyond) and in the vertex presentation (no breech or transverse positions), via C-section birth. Narrowing variation and lowering the average C-section rate will lead to better quality care, improved health outcomes, and reduced costs.2

Indicator Progress

In 2012 (baseline year), the NTSV Cesarean Birth Rate was 27.0%. The most recent rate available is 23.4% (2018). We hope to reach a target of 23.9% or lower by 2022.

More Data about Cesarean Births



Current Rate




Indicator Highlights

Data Snapshot: Trends & Disparities

First-birth Cesarean Birth Rate, Over Time

First-birth Cesarean Birth Rate, by Demographic Category

First-birth Cesarean Birth Rate, by County


Indicator: First-birth Cesarean Birth Rate – Nulliparous Term Singleton Vertex (NTSV)

Description: The C-section rate among low-risk first-time mothers; i.e. the cesarean delivery rate among births that are nulliparous (first births), term (> 37 weeks gestational age), singleton (not twins or triplets) and vertex (not breech).   Over the last 15 years, the C-section rate has risen from 21% to 33% with no observed improvements in maternal or newborn health outcomes.  C-sections in the NTSV population account for 60% of increase in the overall primary C-section rate in the last decade and represent 90% of the variation in hospital performance. The indicator is calculated from hospital patient discharge data linked to birth certificate data–both of which are submitted by hospitals to state agencies.

The Payer categories in the bar chart are defined as follows from the source data:

a) Medi-Cal

b) Private

c) Other public: Includes “Medicare”, “County Indigent”, “Other government”, “Other indigent”

d) Uninsured: “Self-Pay” in data source

“Worker’s Comp” and “Other” have not been included from the source data. The data source also has two Hispanic categories (US and foreign born), which have been combined into one Hispanic category in the chart.

Data Limitations: The NTSV C-section rate is the C-section measure utilized by the Joint Commission in its Perinatal Care measure set (required for accreditation among hospitals that perform > 1100 deliveries annually) and has been endorsed by the National Quality Forum. The NTSV C-section rate does differ from the C-section rates promulgated by the Agency for HealthCare Research and Quality (AHRQ); the definitions of the Joint Commission and AHRQ versions differ in ways that lead to C-section rate differences of up to  ten percentage points.

Indicator Source: Original source of data is from hospitals, who send data to OSHPD(establish) and Vital Records. CMQCC(establish) originally developed the measure specifications and calculates the measure on all California hospitals for the full eligible measure population (100% sample) based on statewide data from OSHPD and Vital Records.  The current measure steward is the Joint Commission, and some hospitals directly submit their rates to the Joint Commission, but is usually based on a 20% sample and does not represent all California hospitals.

Data Sharing Agreement: CMQCC has data use agreements with OSHPD and the California Department of Public Health-Vital Records to utilize patient discharge data(PDD) and birth certificate data to link the data and calculate the measure.

Indicator Calculation Methodology:

Data Collection Methodology: California hospitals are required to submit PDD to OSHPD, and to submit birth certificate data to the California Department of Public Health-Vital Records. After undergoing Institution Review Board and other approval processes, CMQCC received permission to receive and utilize these statewide data sets to calculate perinatal measures. The NTSV rate is calculated based on the full population of births in California.

Program URL Link:

1. Lally, S., & Lewis, V. (2014). Maternity Care Patient Engagement Strategies. Integrated Healthcare Association, 1-12.
Weblink: Pacific Business Group on Health. (September 2014). Variation in NTSV C-Section Rates. Pacific Business Group on Health.

3. California Health and Human Services Agency. (2014, March 31). California State Health Care Innovation Plan. Retrieved November 15, 2015, from

4. CMQCC indicator metadata

5. The California Health and Human Services Agency. (2014, April 10). California State Innovation Model Initiative – Maternity Care Initiative for Health Plans and Hospitals – Working Draft. Retrieved November 15, 2015, from

6. CMQCC – Opportunities for Change,

7. Main, E., & Castles, A. (n.d.). Rational Approach to Reducing First-birth (NTSV) Cesarean Birth Rates. Retrieved November 15, 2015, from

8. California Maternal Quality Care Collaborative (2016). NTSV Cesarian Section 2015 Indicator Data Update. /goals/healthy-beginnings/reducing-first-birth-cesarean-birth-rate-ntsv/

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