ABSTRACT:Background: Cesarean delivery is now the most frequently performed major operative procedure for childbearing women in the United States. Many of these operations are reported to be unnecessary, and millions of dollars could be saved by reducing their frequency.Methods: Method of delivery was added to the 1989 revision of the standard certificate of live birth. Alabama also added questions on the source of payment for delivery and the provider of prenatal care in 1991, which enabled an investigation of the risk factors for cesarean delivery that occurred in the state during this period.Results: One of every four births in Alabama is by cesarean delivery. The risk of cesarean delivery is not random, and the risk factors include mother's race and age, coverage by private insurance, birthweight, setting where the mother received prenatal care, mother's educational attainment, live birth order, and complications of labor and delivery.Conclusion: With present concerns about health care reform and the costs of health care, a reduction in the cesarean delivery rate could result in significant cost savings.