According to the World Health Organization (WHO), no region in the world can justify a cesarean rate higher than 10-15%. Cesarean births pose greater risk to the mother's health, slow maternal recovery, and cost over $1 billion dollars annually. A consumer advocacy group, The Public Health Citizen's Research Group, estimates that over half of the cesareans are unnecessary. Why is our cesarean rate so high?

Reasons for the Increase in Cesarean Births:

There are several factors that have contributed to the rising cesarean rate:

1. Increased use of electronic fetal monitoring - fetal monitoring was developed to help the practitioner assess fetal well being during the birth process. As the use of the fetal monitor became widespread and largely replaced the intermittent use of a fetoscope (except among nurse midwives), care providers have identified many more cases of apparent fetal difficulties during labor. In fact, the diagnosis of fetal distress has closely paralleled the increased use of fetal monitoring, with an increase in the diagnosis of fetal distress between 1980 and 1985. When physicians observe disturbing patterns on the monitor they tend to respond conservatively with a "better safe than sorry" attitude which results in a cesarean birth.

Regretfully, it should also be pointed out that there is also an increase in litigation of health care providers based on unexpected and often negative outcomes. Today's childbirth consumer requests and demands a perfectly healthy baby, regardless of situation, environmental factors or chance. Society's willingness to sue physicians have almost forced the physicians hand to reach for the electronic fetal monitor, not only for accurate readings but for proof in liability cases. Physicians are very concerned about the risk of lawsuits and tend to practice "defensive medicine." In the absence of fears of lawsuits, a care provider viewing a mildly disturbing pattern on a monitor or slowed labor might adopt a "wait-and-see" attitude. However, care providers are very aware that people tend to blame them for any problems the baby may have at birth, even if the problems are unrelated to the birth process. As a result, care providers feel uncomfortable using their best judgment; they tend to see the cesarean birth as the safer alternative. Additionally, the threat of malpractice has altered the training of new obstetricians. Many of these new practitioners have had little exposure to managing birth complications without resorting to cesarean section.

2. Routine repeat cesareans - for many years, care providers believed that a woman with a history of a cesarean would require cesareans for all subsequent deliveries. Doctors thought that the pressure of contractions might cause the uterus to rupture at the surgical site. However, a history of a cesarean with a low transverse uterine incision (or "bikini" cut) does not increase the risk of uterine rupture during a subsequent vaginal delivery. Yet, in 1989, 81.5% of all US woman with a previous cesarean had a repeat cesarean despite the fact at least 75% of women can have a successful vaginal delivery after a cesarean. The American College of Obstetricians and Gynecologists recommends that women be encouraged to labor and have a vaginal birth after a cesarean and that routine repeat cesarean be replaced by a specific indication for surgery during the subsequent delivery.

3. Increased use of cesareans for breech deliveries - while some practitioners will attempt a vaginal delivery on babies in specific breech presentations, cesarean section is the preferred method of delivery in many cases. The fear of lawsuits has made practitioners increasingly conservative and some will not try to reposition the baby with an external version. Eighty percent of breech babies are delivered by cesarean.

4. Suspected overuse of cesarean for non-progressive labor (dystocia) - non-progressive labor is a major reason for cesarean. Studies indicate that encouraging alternative treatments like walking, repositioning, and the use of doulas can reduce the cesarean rate. If a woman has a cesarean after a non-progressive labor she can have a subsequently have a successful vaginal delivery. A diagnosis of cephalopelvic disproportion does not mean that a cesarean will be necessary on subsequent deliveries. In fact, up to 77% of women who had a cesarean for non-progressive labor were able to have a vaginal birth after the cesarean (VBAC).

5. Changing demographics of the mother - many women are postponing pregnancy and, as a result, more older women are having babies. Older mothers, especially first time mothers, have a higher incidence of complications.

6. Increased interventions before active labor established - the increased use of amniotomy and epidural anesthesia is suspect to an increase in cesarean section rate. Breaking the bag of waters puts expectant mothers on a time clock to perform. If the needed performance is not accomplished in a certain period of time, augmentation is done. If the augmentation fails, the risk for infection becomes great and a cesarean section is done. Epidurals given before active labor is established often slow or stop labor. Women who attempt to push under the influence of epidurals tend to push very ineffectively. Again, a time clock for performance is created and cesarean section may be the outcome.

7. Maternal medical conditions - more women with chronic health problems like diabetes and heart disease are successfully carrying a baby. In these high risk pregnancies, cesarean birth is often judged safer for mother and/or baby.