By Rebecca Dekker, PhD, RN, APRN

This guest post comes from Rebecca Dekker, PhD, RN, APRN, of Evidence Based Birth. Rebecca is a researcher and a nursing professor who formerly served as a member of the executive board of ImprovingBirth. You can follow Rebecca on her Facebook page and on Twitter.

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Note: This article and the accompanying graphic were updated in February 2018.

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On Labor Day 2012, I created this table to mark the “state of maternity care” in the United States. As we draw close to the end of 2012, I have updated this table and re-posted it here on The new table can be shared as an image or as a PDF here—and please feel free to share, pin, tweet, email, and print! The references are available both here at and Evidence Based Birth (click here).

I was actually sick this past Labor Day. I was lying in bed as I worked on the article that included the original version of this table. As I compiled the evidence about the state of our maternity care system, I kept thinking to myself: “These numbers are insane. Something has got to change.”

Interestingly enough, at the very moment I was composing this table on Labor Day, nearly 10,000 women were rallying across the nation for evidence-based maternity care. Women all across the U.S. stood up together with each other and with their families and said—to our healthcare system, to our providers, and to each other—“You know what? We can do better. We deserve respectful, evidence-based maternity care.”

In my opinion, women hold more power than they think. As women rally together on the streets—in greater numbers each year—and say, “We can do better,” then I believe it will happen. We will see an improvement in birth.

In fact, the main reason I have become involved in is so that someday, my daughter won’t have to fight for evidence-based care— for her, it will be a given.

This work is my gift to her.

Evidence Based Birth - State of Maternity Care in the U.S. Updated 2018

* Please note: Continuous updates to table and references are made as necessary. This article and the accompanying graphic were updated in February 2018.



  1. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Kirmeyer S, Mathews TJ, Wilson EC. Births: Final data for 2009. National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. November 2011;60:1-70. Read the free full text here.
  2. *In 2007, 27% of low-risk females with no prior cesarean birth had a C-section. (The majority of this percentage consists of first-time mothers; however, because this includes a small number of women with prior children, this number may differ slightly from other data reported on the internet). Data accessed from September 2012 from Click here to see the healthy people data set. Scroll down to MICH 7.1 and click on the link that says “Reduce cesarean births” to see the data.
  3. National Quality Forum. NPP Maternity action team. 2012. This is a multi-disciplinary team (including representatives from ACOG, midwifery, nursing, and many other organizations) that joined together in 2012 to work on reducing the C-section rate in the U.S. Accessed November 25, 2012. Read more about the Maternity Action Team at this website.
  4. American Academy of Family Physicians. Trial of labor after cesarean, formerly trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. 2005. Accessed November 23, 2012. Read the free full text here.
  5. Bangdiwala SI, Brown SS, Cunningham FG, et al. NIH consensus development conference draft statement on vaginal birth after cesarean: New insights. NIH consensus and state-of-the-science statements. 2010;27. Read the free full text here.
  6. Laughon SK, Zhang J, Grewal J, et al. Induction of labor in a contemporary obstetric cohort. American journal of obstetrics and gynecology. 2012;206:e481-489. Read the summary here.
  7. Zhang J, Troendle J, Reddy UM, et al. Contemporary cesarean delivery practice in the United States. American journal of obstetrics and gynecology. 2010;203:e321-326. Read the free full text here.
  8. *In this table, “artificial induction” refers to labor induction with medications. a. Artificial induction with Pitocin (Oxytocin): U.S. Food and Drug Administration. Oxytocin drug label. 2008. The BLACK BOX is the FDA’s strongest warning for drugs available on the U.S. market. Read the black box warning against elective induction with Oxytocin on this label here. b. Artificial induction with Cytotec (Misoprostol): U.S. Food and Drug Administration. 2009. FDA Alert: Risks of Use in Labor and Delivery. Read the alert here.
  9. Mozurkewich E, Chilimigras J, Koepke E, et al. Indications for induction of labour: a best-evidence review. British Journal of Obstetrics and Gynecology. 2009:116(5):626-636. Read the summary here.
  10. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to mothers II: Report of the second national U.S. Survey of women’s childbearing experiences:. The Journal of perinatal education. 2007;16:9-14. Read the free full text here.
  11. a. (Pitocin augmentation in spontaneous labor) Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour. Cochrane Database Syst Rev. 2011:CD007123. Read the summary here. b. (Pitocin augmentation in women with epidurals) CostleyPL, East CE. Oxytocin augmentation of labour in women with epidural analgesia for reducing operative deliveries. Cochrane Database Syst Rev. 2012:CD009241. Read the summary here.
  12. Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev. 2007:CD006167. Read the summary here.
  13. Bricker L, Luckas M. Amniotomy alone for induction of labour. Cochrane Database Syst Rev. 2000:CD002862. Read the summary here.
  14. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (ctg) as a form of electronic fetal monitoring (efm) for fetal assessment during labour. Cochrane database of systematic reviews. 2006:CD006066. Read the summary here. There is no reference for “intermittent” electronic monitoring because no studies have ever been conducted on this method of monitoring.
  15. Coco A, Derksen-Schrock A, Coco K, et al. A randomized trial of increased intravenous hydration in labor when oral fluid is unrestricted. Family medicine. 2010;42:52-56. Read the free full text article here.
  16. Kavitha A, Chacko KP, Thomas E, et al. A randomized controlled trial to study the effect of iv hydration on the duration of labor in nulliparous women. Archives of gynecology and obstetrics. 2012;285:343-346. Read the free full text article here.
  17. Chantry CJ, Nommsen-Rivers LA, Peerson JM, et al. Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance. Pediatrics. 2011;127:e171-179. Read the free full text article here.
  18. Noel-Weiss J, Woodend AK, Peterson WE, et al. An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss. International breastfeeding journal. 2011;6:9. Read the free full text article here.
  19. Singata M, Tranmer J, Gyte GM. Restricting oral fluid and food intake during labour. Cochrane database of systematic reviews. 2010:CD003930. Read the summary here.
  20. Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews. 2009:CD003934. Read the summary here.
  21. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2012;5:CD002006. Read the summary here.
  22. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009:CD000111. Read the summary here.
  23. The information in the table refers to water during the first stage of labor only (not during pushing/birth). Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during childbirth. Cochrane database of systematic reviews. 2011:CD003766. Read the summary here.


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  1. Bishop Bradley says:
    Your comment is awaiting moderation.

    What a timely piece now! Thank you so much for such a fantastic post.
    I saw your books earlier, but this one I believe on of the
    the best, same as this one How can you
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    I can recommend this guide to everyone who is interested in that subject.

  2. Steven D'Amore says:

    While i have only one child, I was present at several hospital births. I have never seen disregard for the mothers wishes in what care and birth they wish to have. Never have i heard abusive language. As i admire your presence and purpose to make things better, your going about it all wrong. Doctors and OBGYN’s choose effective safe methods that they are comfortable with to ensure both mother and infant survive the birthing process. If Birthing was so simple we would just stay at home and lay on our living room floor with a bucket of warm water. Its deadly and a highly dangerous surgical procedure. While i have met and been with women who have had surgical procedures during the birthing process that changed altered or made sex life after painful, i sympathize but understand there is a good possibility they might not have survived the process with out it.

    1. Wyndraga says:

      Some of us do stay home with a bucket of warm water (and maybe even a highly trained midwife) and give birth with great results. You have been misled to think it is a “deadly and a highly dangerous surgical procedure”. No. Some births are dangerous while the vast majority are not. Many “routine” and unnecessary interventions that are in place in most hospital settings cause complication that end up to be very dangerous.

    2. Bree says:

      I will always have more faith in women’s intuition than physicians’ opinions when real evidence is lacking. I think the movement for improving birth addresses this perspective. Birth is not a surgical event. I birthed my three children in my home with no bells, whistles, or machines that go “bing.” Women’s bodies are capable of bringing forth children. They have been doing so for thousands of years without meddling hands, drugs, or machines. What women really need from those around them is support – to empower them as they work through and conquer the challenge that is birth. The rewards for doing so are many and amazing! Please, no fear mongering; it is not helpful. Thank you.

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