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Abstract

Background: The rising rate of cesarean delivery (C-sections) in the United States has raised concerns about overuse, particularly for unnecessary primary C-sections performed without clear medical indications. Georgia consistently ranks among states with higher C-section rates, yet limited research has examined the burden and contributing factors of unnecessary C-sections at the state level.Methods: A retrospective population-based analysis was conducted using Georgia vital records data from 2013 to 2023. In aim 1, we conducted analysis on primary singleton C-sections and estimated the prevalence and trends of unnecessary C-sections. In aim 2, we examined the nonclinical risk factors associated with unnecessary C-sections. Results: Among the study population, 21.53% of primary C-sections among singleton births lacked any documented clinical indication and were classified as unnecessary. The rate of unnecessary C-sections declined from 25.25% in 2013 to 17.87% in 2021, which is a modest increase observed in more recent years. Over the study period, Hispanics had 17% higher odds (aOR: 1.17, 95% CI: 1.10–1.16), and Asians had 6% higher odds (aOR 1.06, 95% CI 1.01–1.11) of undergoing unnecessary C-section relative to White women. Deliveries among married women (aOR: 1.12, 95% CI: 1.10–1.15), women with lower BMI, morning deliveries and those whose deliveries that were attended by midwives (aOR: 1.35, 95% CI: 1.47–1.60) and other non-physician providers (aOR: 1.15, 95% CI: 1.03–1.28) were also at higher odds of undergoing an unnecessary C-section. Receiving WIC (aOR: 0.83, 95% CI: 0.81–0.85) or tobacco use (aOR:0.81, 95% CI: 0.77–0.86) was associated with lower odds. Substantial regional variation was observed across Georgia. Conclusion: Unnecessary primary C-sections among singleton births remain a significant public health issue in Georgia despite modest declines over the study period. Both findings highlight the multifactorial nature of cesarean decision-making and the importance of addressing both clinical, patient- and system-level contributors to reduce unnecessary C-sections and improve maternal care quality.

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