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To compare operative delivery rates across regions of the United States from 1987 to 1994 and to evaluate how the rates of severe obstetric lacerations changed during the same period.I used diagnosis and procedure data from the National Hospital Discharge Survey and natality data from the National Center for Health Statistics to describe temporal and regional variations in the rates of cesarean, forceps, and vacuum delivery. I described temporal trends in the rates of cervical and severe perineal lacerations during the same period. I performed exploratory analyses of detailed 1990 data to test for regional differences in demographic risk factors that might explain differences in operative delivery rates.Between 1987 and 1994, cesarean delivery rates fell from approximately 25% to less than 22% in all regions except the South. Operative vaginal delivery rates were stable at 10–12% and were consistently lowest in the Northeast (8.2% in 1994) and highest in the South (12.9% in 1994). Vacuum surpassed forceps deliveries in all regions except the South. The rates of cervical and fourth-degree perineal lacerations declined by 57% and 40%, respectively, whereas the rate of third-degree lacerations did not decline. Demographic risk factors for cesarean delivery were no more prevalent in the South than in other regions. Age under 25 years was the only demographic risk factor for forceps delivery that was more prevalent in the South.In all but the southern United States, cesarean delivery rates declined and vacuum surpassed forceps delivery. These regional differences are not explained by differences in demographic risk factors.