Maternal Morbidity Associated With Vaginal Versus
Cesarean Delivery
Lara J. Burrows, MD, Leslie A. Meyn, MS, and Anne M. Weber, MD, MS
OBJECTIVE: To describe postpartum maternal morbidity
associated with mode of delivery in term, singleton
pregnancies.
METHODS: The Magee Obstetric Medical and Infant data-
base was examined for the years 1995 to 2000. Patients were
grouped into 6 types of delivery mode: spontaneous vagi-
nal delivery, operative vaginal delivery, primary cesarean
delivery without trial of labor, primary cesarean delivery
with trial of labor, repeat cesarean delivery without trial of
labor, and repeat cesarean delivery with trial of labor.
Multivariable logistic regression provided odds ratios and
95% confidence intervals (CI) for morbidity by delivery
mode adjusted for demographic characteristics and comor-
bidities. Spontaneous vaginal delivery was used as the
referent group (odds ratio ⴝ 1).
RESULTS: Of 32,834 subjects, 27,178 had vaginal delivery
(operative ⴝ 4,908; spontaneous ⴝ 22,270) and 5,656 had
cesarean delivery. Third- or fourth-degree lacerations oc-
curred in 1,733 (7.8%) women who had spontaneous vagi-
nal delivery compared with 1,098 (22.3%) who had opera-
tive vaginal delivery. Overall, 523 women (1.6%) had
endometritis. Compared with spontaneous vaginal deliv-
ery, primary cesarean delivery with trial of labor conferred
a 21.2-fold increased risk of endometritis (95% CI 15.4,
29.1). Even without trial of labor, women after primary
cesarean delivery were 10.3 times more likely to develop
endometritis (95% CI 5.9, 17.9) than after spontaneous
vaginal delivery. The risk of transfusion was highest in
women delivered by primary cesarean after labor, 4.2
times higher (95% CI 1.8, 10.1) than spontaneous vaginal
delivery. The risk of pneumonia was 9.3 times higher (95%
CI 3.4, 25.6) after repeat cesarean delivery with labor. Deep
venous thromboses occurred in 15 (0.1%) after spontaneous
vaginal delivery, 2 (0.04%) after operative vaginal delivery,
and 12 (0.2%) after cesarean delivery.
CONCLUSION: Compared with spontaneous vaginal deliv-
ery, cesarean delivery is associated with increased risks of
endometritis, the need for transfusion, and pneumonia;
however, these rates are lower than reported previously.
From the Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-
Womens Hospital, Pittsburgh, Pennsylvania.
This research was presented in abstract form in September 2003 at the Annual
Meeting of the American Urogynecologic Society, Hollywood, Florida.
VOL. 103, NO. 5, PART 1, MAY 2004
© 2004 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.
(Obstet Gynecol 2004;103:907–12. © 2004 by The Amer-
ican College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: II-2
Recently interest has grown with idea that injury sus-
tained during childbirth might contribute to the subse-
quent development of pelvic floor disorders. This has
prompted some clinicians to question the potential ben-
efits of a “prophylactic” cesarean delivery. Concur-
rently, the debate over whether “elective” cesarean de-
liveries should be performed on maternal request is
escalating.
Whether cesarean delivery is performed for medical
indications or at the patient’s request, data regarding the
respective morbidities for vaginal and cesarean deliver-
ies are poorly defined. There are few reports on morbid-
ities associated with vaginal birth. Until recently, events
such as anal sphincter lacerations were not even consid-
ered significant sources of morbidity.
The earliest reports on cesarean deliveries focused
mainly on mortality associated with the procedure.
However, maternal mortality has become increasingly
rare in developed countries. Many studies evaluating
maternal morbidity associated with cesarean delivery
were performed in the 1970s and 1980s; since then,
obstetric practice has changed considerably. Therefore,
the goal of this study was to provide a current descrip-
tion of maternal morbidity for cesarean and vaginal
deliveries.
MATERIALS AND METHODS
This study was a review, which used the Magee Obstet-
ric Medical and Infant database, of 32,834 women who
delivered at Magee-Womens Hospital from 1995 to
2000. This number included patients who were term (37
weeks of gestation or greater) with a singleton pregnancy
and who had only 1 delivery or their first delivery at this
institution. The data were captured as they passed
through medical records and electronically interfaced
with the database. This interface contained all Interna-
tional Classification of Diseases, 9th Revision, diagnosis
0029-7844/04/$30.00 907
doi:10.1097/01.AOG.0000124568.71597.ce
Table 1. Demographic Characteristics of 32,834 Women With Term Singleton Deliveries in the Magee Obstetric Medical
Infant Database From 1995 to 2000
Spontaneous Operative Repeat cesarean Repeat cesarean with
vaginal vaginal without trial of labor trial of labor
(n ⫽ 22,270) (n ⫽ 4,908) (n ⫽ 865) (n ⫽ 768)
Race†
White 18,005 (81.2) 3,827 (78.2) 740 (85.7) 623 (81.4)
Black 3,444 (15.5) 865 (17.7) 104 (12.1) 123 (16.1)
Other 737 (3.3) 199 (4.1) 19 (2.2) 19 (2.5)
Mean age (y) 28.7 ⫾ 6.0 28.4 ⫾ 6.1 32.7 ⫾ 4.8 32.3 ⫾ 4.8
Median gestational age (wk) 39 (37–44) 39 (37–43) 39 (37–42) 39 (37–43)
Median gravidity 2 (1–18) 2 (1–18) 3 (2–10) 3 (2–15)
Primiparous 10,442 (46.9) 3,180 (64.8) 0 0
Median education (y)㛳 14 (8–22) 14 (8–21) 14 (9–24) 14 (9–23)
Smoked during pregnancy¶ 2,904 (13.1) 720 (14.7) 128 (14.8) 127 (16.6)
Marital status
Married 13,643 (61.3) 2,838 (57.8) 662 (76.5) 551 (71.7)
Single 6,617 (29.7) 1,649 (33.6) 109 (12.6) 155 (20.2)
Other 2,010 (9.0) 421 (8.6) 94 (10.9) 62 (8.1)
Maternal weight on admission 3,184 (16.6) 605 (13.9) 223 (29.2) 186 (26.8)
⬎ 91 kg#
Data are presented as n (%), mean ⫾ standard deviation, or median (overall range)
* P value from Pearson’s ␹2 test.
†
117 missing.
‡
P-value from one-way analysis of variance.
§
P-value from Kruskal-Wallis test.
㛳
3,245 missing.
¶
112 missing.
#
4,366 missing.

and procedure codes. In addition, trained chart abstrac-
tors reviewed each medical record after every delivery
and coded the information into an electronic format for
demographic variables, such as maternal history of
smoking. Variables were validated later by manual re-
view of 100 arbitrarily selected medical records. This
study was approved by the Magee-Womens Hospital
Institutional Review Board.
Patients were categorized as follows: spontaneous vag-
inal delivery, operative vaginal delivery, primary cesar-
ean delivery without trial of labor, primary cesarean
delivery with trial of labor, repeat cesarean delivery
without trial of labor, and repeat cesarean delivery with
trial of labor. A trial of labor was defined as an attempt to
achieve a vaginal delivery in patients who had no mater-
nal or fetal contraindications to such an attempt. This

Table 2. The Frequency of Comorbidities for 32,834 Women Stratified by Mode of Delivery
Spontaneous Operative Repeat cesarean Repeat cesarean with
vaginal vaginal without trial of labor trial of labor
Comorbidity (n ⫽ 22,270) (n ⫽ 4,908) (n ⫽ 865) (n ⫽ 768)
Preeclampsia 432 (1.9) 132 (2.7) 10 (1.2) 10 (1.3)
Pregestational diabetes 84 (0.4) 13 (0.3) 11 (1.3) 5 (0.7)
Systemic lupus erythematosus 24 (0.1) 10 (0.2) 0 0
Sickle cell disease 196 (0.9) 47 (1.0) 0 0
Chronic hypertension 230 (1.0) 66 (1.3) 0 0
Pregnancy-induced hypertension 1268 (5.7) 273 (5.6) 0 0
Chorioamnionitis 822 (3.7) 350 (7.1) 8 (0.9) 69 (9.0)
Episiotomy 11,603 (52.1) 3,316 (67.6) 0 1 (0.1)
3rd- or 4th-degree perineal laceration 1733 (7.8) 1098 (22.4) 0 1 (0.1)
Premature rupture of membranes 947 (4.3) 271 (5.5) 2 (0.2) 32 (4.2)
Prolonged rupture of membranes 501 (2.2) 154 (3.1) 2 (0.2) 22 (2.9)
Preterm spontaneous uterine contractions 140 (0.6) 24 (0.5) 3 (0.3) 5 (0.7)
Prolonged 2nd stage of labor 168 (0.8) 255 (5.2) 0 11 (1.4)
Data are presented as n (%).
* P value from Pearson’s ␹2 test.

908 Burrows et al Maternal Morbidity for Different Modes of Delivery OBSTETRICS & GYNECOLOGY
 deep venous thrombosis (DVT), pulmonary embolism,
urinary tract infection, intraoperative complications, and
Primary cesarean Primary cesarean pneumonia.
without trial of labor with trial of labor Morbidities were tabulated for each mode of delivery.
(n ⫽ 657) (n ⫽ 3,366) P* Patients were analyzed based on gravidity, parity, age,
race, level of education, marital status, history of smok-
572 (87.5) 2,743 (81.7) ⬍ .001 ing, maternal weight on admission, and the following
61 (9.3) 500 (14.9) maternal conditions: preeclampsia, pregestational diabe-
21 (3.2) 115 (3.4)
30.4 ⫾ 6.0 29.2 ⫾ 6.0 ⬍ .001‡ tes, systemic lupus erythematosus, sickle cell disease,
39 (37–42) 40 (37–44) ⬍ .001§ hypertensive disease, premature rupture of membranes,
1 (1–9) 1 (1–11) ⬍ .001§ prolonged rupture of membranes, preterm spontaneous
491 (74.7) 2,902 (86.2) ⬍ .001 uterine contractions, prolonged second stage of labor,
14 (8–20) 14 (8–23) ⬍ .001§ and chorioamnionitis in labor. Because maternal height
72 (11.0) 410 (12.2) ⬍ .001
⬍ .001 and prepregnancy weight were not recorded in the data-
435 (66.2) 2,001 (59.4) base, maternal weight on admission was dichotomized as
147 (22.4) 1,017 (30.2) less than or equal to 91 kg (200 lb) and greater than 91 kg
75 (11.4) 348 (10.3) (200 lb) as a proxy for obesity.
148 (25.6) 752 (25.7) ⬍ .001 By using a ␹2 test at the .05 significance level, this
study had greater than 99% power to detect a significant
difference in the rate of morbidities across all 6 delivery
groups based on the occurrence of these morbidities in
included both spontaneous and induced labor. In the the database. Except for DVT in the operative vaginal
database, the existing “labor” variable categorized pa- delivery group, which had a rate of 0.04%, all morbidi-
tients as those who had “spontaneous labor,” “induced ties occurred at a rate of 0.1% or more. All statistical
labor,” or “no labor.” Patients who were categorized as analyses were performed by using SPSS statistical soft-
“no labor” had undergone a scheduled cesarean deliv- ware 10.1.4 (SPSS Inc, Chicago, IL). Normality was
ery, either primary or repeat for a given indication. For defined by visually assessing the shape of the frequency
the purposes of our analysis, we combined the spontane- distributions. Normally distributed variables were pre-
ous and induced categories to represent patients who sented as mean ⫾ standard deviation. Data that were not
labored in any capacity. This is how we were able to normally distributed were presented as median values
group our cesarean delivery patients into those who did with overall ranges. The associations of delivery mode,
and did not have a trial of labor. International Classifi- demographic characteristics, and maternal conditions with
cation of Diseases, 9th Revision, codes were used to maternal morbidity were evaluated by using Pearson’s ␹2
identify patients with the following complications: post- or Fisher exact tests where appropriate. The associations of
partum hemorrhage, blood transfusion, endometritis, demographic characteristics and maternal conditions with
delivery mode were evaluated by using Pearson’s ␹2, one-
way analysis of variance, or Kruskal–Wallis tests where
Primary cesarean Primary cesarean appropriate. All statistical tests were evaluated at the .05
without trial of labor with trial of labor significance level. Separate multivariable logistic regression
(n ⫽ 657) (n ⫽ 3,366) P* models were developed to identify factors independently
23 (3.5) 200 (5.9) ⬍ .001 associated with each morbidity. Variables with P values less
6 (0.9) 27 (0.8) ⬍ .001 than .1 were considered for inclusion in the models. Models
0 0 .06 were developed by using forward stepwise regression
0 0 ⬍ .001 based on the likelihood ratio test statistic. Variables were
0 0 ⬍ .001
1 (0.2) 1 (0.03) ⬍ .001 retained in the model if the Wald ␹2 test statistic had a P
16 (2.4) 632 (18.8) ⬍ .001 value of .05 or less.1
0 8 (0.2) ⬍ .001
0 1 (0.03) ⬍ .001
13 (2.0) 231 (6.9) ⬍ .001 RESULTS
2 (0.3) 232 (6.9) ⬍ .001
3 (0.5) 19 (0.6) .8 Of 32,834 subjects, 27,178 had vaginal delivery (opera-
0 115 (3.4) ⬍ .001 tive ⫽ 4,908; spontaneous ⫽ 22,270) and 5,656 had
cesarean delivery. Third- or fourth-degree lacerations
occurred in 1,733 (7.8%) women who had spontaneous

VOL. 103, NO. 5, PART 1, MAY 2004 Burrows et al Maternal Morbidity for Different Modes of Delivery 909
Table 3. Postpartum Morbidities in 32,834 Women From 1995 to 2000 Stratified by Mode of Delivery

Endometritis, Pneumonia,
Delivery group n Endometritis adjusted* Pneumonia adjusted†
Spontaneous vaginal 22,270 97 (0.4) 1.0 (Referent) 17 (0.1) 1.0 (Referent)
Operative vaginal 4,908 33 (0.7) 0.9 (0.6, 1.5) 9 (0.2) 2.3 (1.0, 5.4)
Repeat cesarean without trial of labor 865 23 (2.7) 9.9 (5.8, 16.9) 4 (0.5) 5.2 (1.5, 18.1)
Repeat cesarean with trial of labor 768 35 (4.6) 14.6 (9.2, 23.1) 5 (0.7) 9.3 (3.4, 25.6)
Primary cesarean without trial of labor 657 20 (3.0) 10.3 (5.9, 17.9) 2 (0.3) 4.7 (1.1, 20.4)
Primary cesarean with trial of labor 3,366 315 (9.4) 21.2 (15.4, 29.1) 4 (0.1) 1.7 (0.6, 5.2)
Total 32,834 523 (1.6) 41 (0.1)
Data are presented as n (%) or odds ratio (95% confidence interval).
* Adjusted for age, race, smoking, admission weight ⬎ 91 kg (200 lb), chorioamnionitis, prolonged rupture of membranes, and vaginal
lacerations.
†
Adjusted for education and smoking.
‡
Adjusted for episiotomy, pregnancy-induced hypertension, age, preeclampsia, chorioamnionitis, and prolonged second stage of labor.
§
Adjusted for preeclampsia, chorioamnionitis, and sickle cell disease.
㛳
Adjusted for prolonged second stage of labor.

vaginal delivery compared with 1,098 (22.3%) who had
operative vaginal delivery. There was a total of 12,602
episiotomies performed.
The demographics for patients in the database strati-
fied by delivery mode are provided in Table 1. The
method of delivery differed significantly by age and
racial group (P ⱕ .001). White women were more likely
than black women to undergo cesarean delivery without
a trial of labor. Women who underwent repeat cesarean
delivery were older. The frequencies of comorbidities
stratified by delivery mode are shown in Table 2. Table
3 shows the adjusted odds ratios (OR) stratified by
delivery type for endometritis, pneumonia, postpartum
hemorrhage, transfusion, and DVT.
Endometritis, the most frequent morbidity, was most
strongly associated with cesarean delivery. Compared
with spontaneous vaginal delivery, cesarean delivery
after trial of labor was associated with a 14.6-fold in-
creased risk of endometritis for repeat procedures and a
21.2-fold increased risk after primary procedures.
Women with chorioamnionitis were 3.2 times more
likely to have endometritis when adjusted for delivery
mode, age, race, smoking, admission weight, prolonged
rupture of membranes, and vaginal laceration. Those
who sustained an anal sphincter laceration were 2.9 to
4.5 times more likely to develop endometritis compared
with those who did not have a laceration when adjusted
for delivery mode, age, race, smoking, admission weight,
prolonged rupture of membranes, and chorioamnionitis.
Prolonged rupture of membranes conferred a 2-fold
increased risk of endometritis. Patients whose weight on
admission was greater than 200 pounds were 30% more
likely to develop endometritis.
Of the 41 patients (0.1%) who developed pneumonia,
those who underwent cesarean delivery incurred the
greatest risk. Women who had repeat cesarean delivery
after trial of labor were 9.3 times more likely to have
pneumonia than women after spontaneous vaginal deliv-
ery. Smokers had an adjusted 2-fold increased risk of
developing pneumonia.
Regarding postpartum hemorrhage, the spontaneous
vaginal delivery and operative vaginal delivery groups
had the highest rates, which were 5.0% and 4.7%, respec-
tively. Independent risk factors for postpartum hemor-
rhage were episiotomy (OR 1.3; 95% confidence interval
关CI兴 1.1, 1.4), pregnancy-induced hypertension (OR 1.7;
95% CI 1.4, 2.1), preeclampsia (OR 2.3; 95% CI 1.8,
2.9), chorioamnionitis (OR 1.9; 95% CI 1.6, 2.3), and
prolonged second stage of labor (OR 2.1; 95% CI 1.5,
2.8).
Of the 5,656 patients who underwent cesarean deliv-
ery, 49 (0.86%) received blood transfusions compared
with 61 of 27,178 patients after vaginal delivery (0.22%).
Patients who had cesarean delivery with trial of labor
sustained the highest risk, more than a 4-fold increase.
Compared with spontaneous vaginal delivery, patients
had an adjusted 5-fold increased risk of being transfused
if they had preeclampsia or sickle cell disease. The
presence of chorioamnionitis increased the risk (ad-
justed) of transfusion 3-fold.
Of the 29 patients who had DVT, 15 (0.1%) had
spontaneous vaginal delivery, 2 (0.04%) had operative
vaginal delivery, and 12 had cesarean delivery (0.2%). A
prolonged second stage of labor conferred a 6.1-fold
increased risk of DVT. When stratified by delivery
mode, primary cesarean delivery with trial of labor
imposed the highest risk of DVT, which was 3.9 times
higher than spontaneous vaginal delivery. Four patients
had pulmonary emboli, 2 after spontaneous vaginal de-
livery (0.007%) and 2 after primary cesarean delivery
(0.04%), 1 with trial of labor and 1 without.

910 Burrows et al Maternal Morbidity for Different Modes of Delivery OBSTETRICS & GYNECOLOGY
 Postpartum
Postpartum hemorrhage,
hemorrhage adjusted‡ Transfusion
1,105 (5.0) 1.0 (Referent) 40 (0.2)
231 (4.7) 0.8 (0.7, 0.97) 21 (0.4)
28 (3.2) 0.8 (0.6, 1.2) 4 (0.5)
20 (2.6) 0.6 (0.4, 0.96) 6 (0.8)
18 (2.7) 0.7 (0.4, 1.1) 3 (0.3)
131 (3.9) 0.8 (0.6, 0.9) 36 (1.1)
1,533 (4.7) 110 (0.3)
Nine patients underwent hysterectomy at the time of
delivery: 2 after spontaneous vaginal delivery, 2 after
primary cesarean without trial of labor, 3 after primary
cesarean with trial of labor, and 2 after repeat cesarean
with trial of labor. These patients were too few in num-
ber to undergo statistical modeling. The median age of
these 9 patients was 28 years, 3 were primiparous, 5 had
chorioamnionitis, and 1 had preeclampsia.
Of the 5,656 cesarean deliveries, 22 intraoperative
injuries were reported (0.38%) in the database, 11 of
which were cystotomies. Six occurred during primary
and 5 during repeat cesarean delivery. Other injuries
included broad ligament and bladder flap hematomas,
lacerations of the uterine artery or urethra, and injury to
the mesosalpinx.
DISCUSSION
The most important finding of this study is that, al-
though overall rates of morbidity for cesarean deliveries
are higher than for vaginal births, they are not as high as
reported previously. The most common postoperative
morbidity attributable to cesarean delivery across stud-
ies are infectious; endometritis has been reported to
occur in 6 –18% of procedures.2–5 The overall rate of
6.9% after cesarean delivery in our study is on the low
end of that range. Primary cesarean deliveries after labor
carry a higher risk of infection than repeat procedures
without labor and our findings are consistent with this.6
Postpartum hemorrhage occurred most commonly in
the vaginal delivery groups. This was an unexpected
finding and may reflect underestimation of the blood loss
at cesarean delivery. Alternatively, this may reflect in-
creased blood loss related to episiotomy use or other
perineal or vaginal trauma. Although patients after spon-
taneous vaginal delivery had the highest rate of postpar-
tum hemorrhage in this study, patients who had cesar-
ean delivery had a higher transfusion rate. Perhaps this
discrepancy is the result of inaccuracies in estimating
blood loss, different definitions of postpartum hemor-
rhage for vaginal and cesarean deliveries, or the possibil-
VOL. 103, NO. 5, PART 1, MAY 2004
Deep venous
Transfusion, Deep venous thrombosis,
adjusted§ thrombosis adjusted㛳
1.0 (Referent) 15 (0.1) 1.0 (Referent)
2.2 (1.3, 3.7) 2 (0.04) 0.5 (0.1, 2.2)
3.0 (1.1, 8.3) 0 Not applicable
4.2 (1.8, 10.1) 1 (0.1) 1.9 (0.2, 14.2)
2.6 (0.8, 8.5) 1 (0.2) 2.3 (0.3, 17.8)
4.4 (2.7, 7.1) 10 (0.3) 3.9 (1.7, 8.9)
29 (0.1)
ity that clinicians are more likely to transfuse if a patient
has had surgery. As with the other morbidities, parity
was a not a significant predictor of postpartum hemor-
rhage.
Regarding postpartum hemorrhage, the OR for pri-
mary cesarean deliveries without trial of labor was de-
creased. The ORs for other cesarean delivery types were
also decreased but not to a statistically significant level.
Interestingly, a recent study examining maternal mor-
bidity associated with cesarean delivery without labor
found that women who underwent primary cesarean
delivery without labor were less likely to have postpar-
tum hemorrhage compared with those who had sponta-
neous onset of labor.7
Previous reports of blood transfusions with cesarean
delivery range from 1.2% to 6.3%,5,8 which is higher
than the rates found in this study (0.3–1.1%). This may
reflect improvements in surgical technique or the in-
creasing reluctance of practitioners to transfuse patients.
Patients who had cesarean delivery after trial of labor
had a 4-fold higher transfusion rate compared with spon-
taneous vaginal delivery. This may be the result of the
fact that performing cesarean delivery after substantial
descent of the fetus increases the chance of uterine,
cervical, and vaginal lacerations. Furthermore, this
group inclues patients who had urgent and emergent
deliveries. The need for blood transfusions is more com-
mon with emergency surgery.5
The occurrence of DVTs in the cesarean groups
(0.21%) was lower than the 0.6 –1.8% reported to date
and highlights the rarity of this condition.6,9 Pulmonary
emboli have been reported in 0.1– 0.2% of cesarean
deliveries.5,10 In our series, the rate was even lower at
0.04%. Given that this was such a rare occurrence re-
gardless of delivery type, one cannot draw any meaning-
ful conclusions regarding risk by mode of delivery.
It is interesting that white women were more likely to
undergo cesarean delivery without trial of labor. This
may reflect different practice patterns among private
practitioners and resident staff, especially regarding vag-
Burrows et al Maternal Morbidity for Different Modes of Delivery 911
inal birth after cesarean delivery. Irwin et al11 found that
black women were more likely to undergo a cesarean
delivery than their white counterparts. Alternatively,
Gould et al12 found that white women had the highest
primary cesarean delivery rate, and this association ap-
peared to be related to socioeconomic status.
This study has the inherent limitations of a retrospec-
tive review. As with any database, there is the potential
for errors in data entry. Unfortunately, variables such as
the urgency with which cesarean deliveries were per-
formed, intraoperative injury, paralytic ileus, and wound
cellulitis were not reliably recorded in this database or in
the medical records system. This was a limitation, espe-
cially regarding intraoperative injuries. Although there
are specific codes for the different procedures performed
for various intraoperative injuries, there is enough vari-
ation in the procedures that we did not feel the data were
robust enough to allow comparisons between the differ-
ent delivery types. A small number of complications
were documented, prohibiting us from drawing valid
conclusions from these data. Additionally, because of
limitations in the information contained in the database,
some patients were artificially categorized. For example,
we were unable to consider situations such as those who
did not progress past the first stage of labor but who
ultimately had a cesarean delivery. Ideally we would
have been able to consider such details as they may have
an impact on maternal morbidity. Additionally, our data
are limited to the index hospitalization (the delivery); if
rehospitalization occurred, this information would not
have been captured. Finally, these data were obtained
from a tertiary medical center; therefore, these results
may not be generalized to many community settings.
Although several studies have examined morbidity
associated with cesarean delivery, few studies have com-
pared these with morbidity of vaginal delivery, such as
anal sphincter lacerations and perineal wound break-
down or postoperative complaints common to both
types of delivery, such as persistent pain, urinary incon-
tinence, and fecal incontinence. Hannah et al13 found
that patients who had planned cesarean delivery for
breech presentation were 38% less likely to report post-
partum urinary incontinence, and they did not have an
increased risk of various other problems at three months
postpartum. We were unable to assess the aforemen-
tioned morbidities because they were not recorded in the
database or they primarily occurred in the outpatient
setting. Prospective studies taking these measures into
account are needed to fully characterize maternal mor-
bidity by delivery type.
912 Burrows et al Maternal Morbidity for Different Modes of Delivery
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Address reprint requests to: Dr. Lara J. Burrows, Department
of Obstetrics, Gynecology and Reproductive Sciences, Magee-
Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213;
e-mail: lburrows@mail.magee.edu.
Received October 24, 2003. Received in revised form January 7, 2004.
Accepted January 23, 2004.
OBSTETRICS & GYNECOLOGY