The number of cesarean sections performed in the United States has been on a steady rise since the mid-1990s. The reasons for this trend are varied and not likely to change in the foreseeable future. An increasing tendency to perform repeat cesarean section, older patients having babies, obesity and medical malpractice litigation are just a few reasons the rate continues to rise.

Repeat cesarean section has come back into vogue after a strong push to reduce the cesarean section rate by encouraging vaginal delivery after cesarean section (see the other articles on this web site about cesarean sections including my article titled, Considering the Safety of a Vaginal Birth After Cesarean Section). Unfortunately, up to 1% of all women attempting a vaginal birth after cesarean (VBAC) experience some significant complications (the most common and dangerous of these is the scar from a prior delivery tearing open). Fearing the possibility of such complications, many of my patients are opting to have a repeat cesarean section; this is the number one reason for the increase.

Older patients seem to have a higher incidence of surgical deliveries, as well. Now, I’m using the word older loosely here because by medical reproductive standards, we refer to patients 35 years and up as older. More of these women tend to have medical conditions (e.g., high blood pressure, diabetes, kidney disease) that make it difficult for the baby to withstand the “stress” of labor. I also believe an older woman’s uterus may not contract as effectively as a younger woman’s, and her tissue is a little less willing to stretch, making passage of a baby more difficult and slow. Ultimately, this combination of factors increases an older woman’s chances of needing a c-section.

Obesity is also contributing to the increasing c-section statistics. Overall, the number of obese Americans has jumped markedly in the past 20 years. In one southern state, 7% of pregnant women were obese in 1980; today, that number is 24%. And obstetricians know that obesity increases the chances of a cesarean delivery because the baby is generally bigger and the mom is more likely to have other medical conditions such as high blood pressure.

The number of multiple births is increasing in the U.S. due to the increasing use of assisted reproductive technology such as in vitro fertilization. These pregnancies tend to end in c-section more frequently because many of the babies are in unusual positions at the time of labor. Another relatively new development impacting the c-section rate is the universal recommendation by the American College of Obstetrics and Gynecology to perform c-sections on all breech babies (for a singleton pregnancy).

Another consideration…don’t underestimate the impact of medical malpractice worries on doctors’ behavior. Sadly, we are constantly being second-guessed by “armchair experts,” making it harder for us to stand by as nature performs its miracles. Instead, we look over our shoulders, trying to ensure that every baby is delivered without a hint of stress. I have attended thousands of labors and reviewed the handiwork of many of my colleagues; I can tell you there isn’t always a black or white answer in how to manage a labor. Obstetricians wish we could guarantee perfect results every time, but it just isn’t possible. So, we err on the side of performing c-sections when there is any doubt about the potential for complications. Surprisingly, the increased number of c-sections has not reduced the incidence of cerebral palsy. This calls into question the wisdom of our reacting to concerns about the baby’s health during labor by performing a c-section. After exhaustive study of this question many experts now believe that only a very small percentage of cases of cerebral palsy are caused by stress during labor (perhaps as little as 5% of cases).

Lastly, there is a new trend sweeping the country: patient-requested c-section. Some women don’t want to go through a vaginal birth. This involves a small number of women now, but these requests are certainly becoming more commonplace. This year, I had several patients request an elective surgical delivery. I am uncomfortable with this concept but willing to discuss it with the patient to gain a better understanding of her concerns and wishes. Speaking with my fellow obstetricians, I know this discussion is being repeated in offices around the country. And I’m sure this will inevitably increase the number of c-sections performed.

In the end, we all want healthy babies. Does it matter if the baby is delivered vaginally or by c-section? I think the answer is still yes. We should not forget that a c-section is an operation with the possibility of surgical complications. And we can’t underestimate the risk of future complications and difficulties associated with subsequent pregnancies and repeat c-sections. I hope we find a suitable balance, one that helps our patients and promotes good health.