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Why is the cesarean rate increasing?

Posted by on Feb. 20, 2011 at 5:46 PM
  • 14 Replies

Why do you think the cesarean rate is increasing?

  (The U.S. cesarean rate is at a record high of 32.9%;  in 1965 it was 4.5%.)

Why the National U.S. C-Section Rate is Rising | Cesarean Section

"If you don't know your options you don't have any"          ~Korte & Scaer

"If you choose not to decide you still have made a choice."    

by on Feb. 20, 2011 at 5:46 PM
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by on Feb. 20, 2011 at 6:39 PM


From widespread use of electronic fetal monitors to liability issues, many experts believe that there are multiple causes of the cesarean rate increase.

Why are Cesareans Increasing?

Exploring the likely reasons that the increasing cesarean rate is at an all-time high.

Oct 4, 2006 Brenda Lane

Cesarean Birth - Lisa Setrini-Espinosa
Cesarean Birth - Lisa Setrini-Espinosa

As the cesarean rate approaches 30%, many people are starting to question the reason for the cesarean rate to have doubled in the last several decades. There are many possibilities that have likely contributed to the increasing rate. Let's take a look at what many experts in the birthing community are saying about the causes of the increasing cesarean rate in the United States.

Electronic Fetal Monitoring

Some believe that the increase in the use of electronic fetal monitoring is a likely reason for the increase in the cesarean birth rate. One of the biggest problems with fetal monitoring is exactly how to interpret the results. A claim made for the use of electronic fetal monitoring is that it identifies a baby who is having difficulty in labor (known as fetal distress or non-reassuring fetal heart rate.) However, several studies have shown that external electronic fetal monitoring is not any more accurate in diagnosing fetal distress than periodic manual checks of the baby's heart rate (also called auscultation.)

One interesting perspective on the misuse of external monitoring comes from the inventor, Dr. Edward Hon. Dr. Hon, along with another physician, Dr. Orvan Hess, invented the electronic fetal monitor in 1957 to treat women with high-risk pregnancies. In the 1960's, electronic fetal monitoring began in widespread use.

Thirty years later, Hon said at a conference on "Crisis in Obstetrics: The Management of Labor," "If you mess around with a process that works well 98% of the time, there is much potential for harm....[most women in labor may be] much better off at home [than in the hospital with the electronic fetal monitor.]" Is our misuse of electronic fetal monitoring in hospitals causing unintended problems?

Since the research on electronic fetal monitoring indicates that it has not improved outcomes, it is not surprising that there are critics of external fetal monitoring even among medical professionals. An editorial in the British Medical Journal (Goddard, 2001) stated that intermittent auscultation of the baby's heart rate by a nurse or midwife during labor is ideal. Goddard states that, "There is good evidence that one to one care alone has a powerful effect on the labouring woman, reducing intervention.8 The cardiotocograph (fetal monitor) can become a surrogate for this best quality care and has a major impact on the caesarean section rate."

If, in fact, electronic fetal monitoring has been a contributor to the cesarean rate, the numbers of women being "monitored" during labor paints a very large picture. In the 2002 LIstening to Mothers survey, 90% of women had electronic fetal monitoring during their labors.

Labor Inductions

Some experts blame the rising induction rate on the increase in cesarean births. There is a strong possibility that as the induction rate continues to climb, we will also see the cesarean rate follow suit. The 2002 Listening to Mothers Survey indicated the rate of labor inductions may be approaching nearly 44%. Inductions bring with them a combination of multiple interventions such as continuous electronic fetal monitoring and IV's as well as restriction of movement and foods/fluid, and the increased likelihood of epidural anesthesia. We can only guess then, that the rising induction rate, if not the sole culprit for increasing cesareans, is a significant contributor.

Epidural Anesthesia

Epidural rates in some hospitals in the US today hover between 60-90%. Given that epidural anesthesia also requires continuous electronic fetal monitoring, it may be hard to isolate which medical intervention may be increasing the cesarean rate the most; the monitoring or the medication.

There is some speculation that epidurals may either cause the baby to rotate into a posterior position or make it harder for a baby already in a posterior position to rotate to a more favorable anterior position. Babies in a posterior position (also called OP or occiput posterior) are notorious for causing labor to be slower, more painful and potentially harder to be born vaginally. This alone could be a possible cause for the increasing cesarean rate.

One study in 2005 showed that if the mother received an epidural when her baby's head was still "high" in her pelvis, that it did, in fact, make it more likely for the baby to be in a posterior position. Another study (Green Journal, 2005) showed that epidural analgesia was associated with OP. Of the women with epidurals 12.9% had OP babies at delivery compared to only 3.3% without epidural analgesia. For a complete review of the study, see the Spinning Babies web article on epidurals and OP babies. This above-referenced site also has some great information on turning posterior/OP babies.


There is speculation that care providers have increasing worries today about malpractice. Are doctors, primarily those involved with obstetrics, more likely today to be involved in malpractice issues? Is this reaction fear-based or is it real?

The AMA reports that Americans are filing 3 times more lawsuits than they did 10 years ago. The startling reality is that 50% of obstetricians have been sued for malpractice in the last 4 years. As a result, insurance premiums are also soaring to the point where many obstetricians are paying up to 30% of their annual income or more for malpractice insurance. So the threat of lawsuits is indeed real. The big question is how to find balance between being patient if mothers need to more time to labor, (especially in cases where there are no indicated risks,) and a physician's legal concerns.

Breech Babies

Another factor is that the number of breech babies now delivered by cesarean have greatly increased. Years ago, the mode of delivery for breech babies was nearly always a vaginal birth and physicians were trained to handle this more complicated delivery. However, about 97% of breech babies are now delivered by elective cesarean, often before 40 weeks, with only a small handful of physicians and midwives skilled to perform breech births. Even though they only make up for about 4% of all births, this number is nearly all but become another brick added to the cesarean pile.

Mother's Request

Some have suggested that mothers are asking for more cesareans with a first baby (called cesarean demand on maternal request or CDMR) and that this is one of the reasons for the cesarean rate to increase. The 2006 Listening to Mothers I and II surveys dispute this theory, however. The most recent interview of over 1315 women showed only .08% (or 1 woman) chose a cesarean with a first baby for no medical reason. Cesarean demand on maternal request is not likely to be a major factor in the current increase in the cesarean rate.

Final Thoughts

It is very likely that all of these factors have played a role in the increasing cesarean rate in this country. Will the cesarean rate peak and begin to decline? Will it continue to rise? Some have speculated that we could see a 50% cesarean rate. Only time will tell.

As consumers, expectant mothers who do not want a cesarean should ask good questions of their provider and educate themselves about how to reduce their chances of a cesarean.

by on Feb. 20, 2011 at 6:53 PM
They can't constantly monitor my baby now, I seriously doubt they will be able to during labor. When I go in for monitoring I'm sure the nurses hate it, because they can't just strap me in and leave me, she punches at it, moves, and the machine loses her heartrate. The nurses have to hold the monitor on by hand and move when she moves. It's a pain, and sometimes they just do a sonogram rather than sit next to me chasing the baby for twenty minutes. I really feel like it's out of convenience for the doctors. The results of the fetal monitor are just a tool they use to show you that your baby isn't doing well and you need a c section.
by on Feb. 20, 2011 at 6:55 PM

I am going to say the number 1 reason is money money money maternity care makes up to 80% of hospital revenue now more than half of that revenue is from c-sections because they are 2 to 3 times the cost of a vaginal delivery but use less than half the resources that a vaginal delivery does. 

by on Feb. 20, 2011 at 7:03 PM
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by on Feb. 20, 2011 at 7:05 PM
Doctors also charge LESS for a c section than a vaginal delivery, but the hospital costs for a c section vs a vaginal delivery are outrageous. Doctors like c sections because they are in and out and done. Hospitals make serious cash for them. The monitoring, the possibility that the pain medication they give you stalling your labor, along with inductions failing if your body is not ready and medical staff not being able to give you more than twelve hours because of constant cervical checks and risk of infection, all contribute to scaring women into having a c section. Some c sections are needed, but they are definately abused in our medical system because childbirth is big business in this country.
by on Feb. 20, 2011 at 7:08 PM

I think its a little bit of a lot of different things.  I agree that the over monitoring plays a role. They wanted me to have a c-section when I was already 10 cm dilated because of heart decels. I was able to push him out quickly though.   Also, money and convenience. Doctors don't have to be called out in the middle of the night for planned c-sections and inductions. Mainly its the prinicipal of CYA  (cover your ass) medicine.  Doctors are being sued so much lately that they over order tests, and do unneccessary procedures in "just in case" situations instead of taking the chance that its very probably things are just fine. 


by on Feb. 20, 2011 at 7:11 PM

btw.. I made my post before I read your info.. the thing about liability is so true. You should the ultrasound orders that come through my dept. for no real good reason other than CYA medicine. Thats why Tort reform is so important.  While I agree that no all doctors are the best, they would be a lot better in general if they could do their jobs without fear of litigation. 

by on Feb. 20, 2011 at 7:12 PM

 *Shrugs* .. My Dr said he didn't want to do a C-Section because there is a ton of paper work (we were talking about my birth plan, when I said I didn't want a C-Section) .. I was in labor for 23hrs & absolutely tired and in pain.  They asked if I wanted a C-Section and at that point I told them I didn't care what they did.  After he was born, the dr said I stopped dilating because the baby was facing the wrong way (not breech, just face up instead of face down)

by on Feb. 20, 2011 at 7:48 PM

I guess it depends on who delivers your baby and which hospital you birth at. The hospital I gave birth at would rather you deliver vaginally then do a c section. One of the residents was in the room talking to me when a nurse came in to pull her to the side. I heard the nurse tell her a woman came in completely dilated but wants a c section because she was to scared to give birth vaginally. The resident told me she would be right back because she had to go to the next room. That made me realize it's not just doctor's or hospital's but also some patient's choice. My mom tells me that I'm lucky I got to have my daughter vaginally with the complications I had because she didn't have a choice when she had me.

by on Feb. 20, 2011 at 7:50 PM
It's the final step in the cascade of interventions...

Too many inductions, not enough vbac support, women rushing to the hospital at the first sign iof labor (putting them on 'the clock' and the they take too long and are sectioned), oh and the BIG one $$$$$$$$$$$$$!!!
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