What's Behind the High Rates?
Maternal-request cesareans aside, there are many reasons why c-section rates are skyrocketing. The increase in fertility treatments has produced more high-risk multiple births. Also, first-time mothers are older and heavier. Studies show that women over 35 are far more likely to have c-sections than younger women, and overweight moms-to-be are nearly four times as likely to have one.
Ironically, medical advancements that were meant to help with the birthing process have contributed to the spike in cesareans. The likelihood that a woman will need surgical intervention during delivery goes up if: she's taken labor-inducing drugs (these can result in prolonged or difficult labors); she's had an epidural (walking helps labor progress, but an epidural restricts a woman's mobility); or she's hooked up to a fetal-heart-rate monitor (this also restricts mom's movements, plus many doctors consider any heart-rate change to be a sign of fetal distress and immediate cause for surgery).
"There's no clear-cut answer to how long a woman should labor or when exactly a baby is in distress," says Kimberly Gregory, MD, an obstetrician and gynecologist at Cedars-Sinai Medical Center in Los Angeles. "Many doctors err on the side of caution and throw in the towel early." A baby who's in trouble must be delivered as quickly as possible to avoid injury. And doctors are also worried about lawsuits: Failure to perform a cesarean early enough is one of the top reasons obstetricians are sued.
The role of VBACs
Perhaps the most significant change in labor-room practices over the last decade is a reluctance among hospitals and doctors to allow vaginal births after cesareans (VBACs). Repeat cesareans account for 35 percent of all surgical deliveries today. VBAC deliveries were uncommon until the 1980s, because doctors warned that the stress of contractions and pushing would cause the uterine muscle to rupture, a potentially fatal condition for mother or baby. But after studies placed the rupture risk at only about 1 percent, doctors began recommending VBACs if the reason for the prior cesarean was unlikely to happen again -- for example, if your first baby was breech, but your second is head down. In 1996, the country's VBAC rate hit a high of 28 percent. As of 2004, it's dropped to a mere 9 percent.
So what happened? Although the rupture rate didn't change, there were simply more VBAC births occurring, which meant more total deaths -- deaths that made national headlines. In 1999, spurred by these well-publicized reports, ACOG modified its VBAC guidelines, stating that a medical team must be "immediately available," which means that an ob-gyn and anesthesiologist should be standing by and an operating room ready each time a VBAC is attempted. (Previously, the guidelines had suggested that a surgical team be "readily available.") "That one little word -- 'immediately' -- was enough to panic the medical community. Suddenly, surgery, even if it wasn't medically warranted, seemed less risky than the chance of getting sued," says Tonya Jamois, president of the International Cesarean Awareness Network (ICAN). ICAN estimates that more than 300 hospitals nationwide no longer permit VBACs because they're concerned about liability.
"Although it wasn't ACOG's intention, these guidelines have made obstetricians afraid of VBACs," says Sebastian Faro, MD, a Houston obstetrician and gynecologist. As a result, more mothers today choose a second c-section birth, in part because their doctors strongly recommend it.