Degree Name

DrPH (Doctor of Public Health)


Public Health

Date of Award


Committee Chair or Co-Chairs

Nathan Hale

Committee Members

Michael Smith, Deborah Slawson


The overutilization of cesarean deliveries is a major public health issue in the United States (U.S.). The rates of cesarean deliveries have increased substantially from the mid 1990s. Low-risk, defined as nulliparous, term, singleton, vertex (NTSV) pregnancies with no medical indication of need, and elective cesarean deliveries have been implicated as drivers of these increases. Elective cesarean deliveries are NTSV cesarean deliveries in which no trial of labor was attempted. There is a lack of clear rationale as to the noted increases in cesarean delivery rates as the evidence shows that these procedures provide no additional health benefits to mothers or infants. In fact, excessive use of cesarean sections has been associated with poorer health outcomes and quality of care, and higher health care expenditures. The purpose of this dissertation is to examine the current variation in NTSV and elective cesarean deliveries in the U.S., and further to examine the extent to which national trends are mirrored in Appalachia, a region disproportionately burdened by lack of health care resources and poor health outcomes.

A repeated cross-sectional analysis of the prevalence of NTSV and elective cesarean deliveries in the U.S. between 2016 and 2020 was conducted using individual-level vital records data. Differences were examined by rurality and Appalachian designation. Logistic regression and marginal analyses were used to examine changes in the prevalence of these outcomes over time while adjusting for additional pertinent covariates.

Approximately 25% of NTSV births are delivered via cesarean section, and 37% of those NTSV cesarean deliveries are elective. No practically significant differences in the prevalence of NTSV cesarean deliveries were noted based on rurality or Appalachian designation. However, there were significant variations in the prevalence of elective cesarean deliveries by geography. Rates of elective cesarean deliveries were significantly lower in rural communities compared to metropolitan, or urban, communities. Non-Appalachia had predominantly higher prevalence of elective cesarean deliveries compared to the Appalachian sub-regions. The findings of this dissertation suggest that while variations in health outcomes may be driven by geographic designations, variations in health services utilization are likely driven by other factors, such as institutional and provider characteristics.

Document Type

Dissertation - embargo


Copyright by the authors.

Available for download on Friday, September 15, 2023