What’s Behind the Cesarean Section Surge?

by Suzanne Koup-Larsen

When her doctor said it was time for a C-section, Jaime Rowlyk of Woolwich, NJ, mom of now-two-year old Alden, tried to negotiate. “Can you give me five minutes to think about it?” she asked.

The doctor gave her just one minute. After 12 hours of labor with virtually no dilation and soaring blood pressure, Jaime’s body was beginning to break down and there was no time for back and forth. In retrospect, Jaime believes the medical staff at the hospital saved her life with a C-section on the day her son was born.

While cesareans are obviously very useful in preventing potentially serious complications for both mother and baby, the World Health Organization recommends that they should be performed in no more than 15 percent of all births.

But in 2006, the U.S. cesarean birth rate was 31.1 percent, according to the National Institute for Health Statistics. Delaware and Pennsylvania had similar numbers with 30.7 and 29.7 percent respectively, but New Jersey led all U.S. states with a cesarean rate of 37.4 percent.

This disparity between the recommended and actual frequency of surgical births has many people asking why so many C-sections are performed in the U.S. and why the number continues to rise. The U.S. percentage of C-sections was only 20.7 in 1996.

Risks and Reasons

Induced Labor Also on the Rise

Like C-sections, labor inductions can allow mothers to schedule their deliveries but they do not require major surgery. According to the National Center for Health Statistics, induced labor rates have more than doubled since 1990, increasing to 20 percent of births in 2003.

Mom Tina Yerkes had induced labors with two of her three pregnancies and calls both of her inductions great experiences. Ultimately, she
elected to have labor induced because the clock was ticking on her maternity leave. “Being a working mom, I wanted as much time as possible with the baby before going back to work,” she says.

While there are several methods, the most common way to induce labor involves administering a drug called Pitocin through an intravenous drip. Medical reasons for induction include:

Post-date pregnancy. Most doctors agree that women should not carry a pregnancy more than two weeks past their due date.

Maternal medical issues. These can include diabetes or high blood pressure.

Abnormal fetal growth. A very small baby, measuring in the tenth percentile or less for its gestational age, will likely be induced.

Water has broken but contractions don’t start. If labor doesn’t set in within a day, birth will probably be induced.

According to Gordon Ostrum, Jr., MD, there are few if any additional risks to inducing labor compared to waiting for birth to occur spontaneously. However, there is a higher risk that a C-section will be necessary if the cervix doesn’t ripen, or become soft and favorable for delivery, after induction has been attempted.

Despite its life-saving capabilities, a C-section is major abdominal surgery and does carry risks. The two biggest potential problems are bleeding and infection resulting from the surgery. There is also a small risk of injury to surrounding organs, such as the bowel or bladder.

These risks increase with each successive C-section. In addition, because it is major surgery, a C-section requires a much longer recovery time than vaginal deliveries.

But these risks are relatively small, especially in comparison to complications that can arise during pregnancy and delivery. Some medical reasons that a primary, or first, C-section may be performed include:

Malpresentation of the fetus. If the baby is positioned any way but facing downward, a C-section will likely be performed.

Fetal distress. Signs from monitors indicate the baby is not tolerating labor.

Failure to progress in labor. If dilation discontinues or the pushing stage is unproductive, a C-section may be necessary.

C-sections are usually performed if the mother has conditions such as diabetes or high blood pressure.

Another reason a C-section can be recommended before labor begins is the size of the baby. If the baby is estimated to be too large (generally greater than 11 pounds) to fit through the mother’s pelvis, a C-section is usually recommended.

Inaccurate Estimates
The size of the baby is estimated in several ways, including ultrasound and physician palpations, or examination of the mother’s abdomen. Unfortunately, the accuracy of these procedures can only get within 15 percent, and that can mean a pound or two in baby weight.

Brooklawn, NJ, mom Tina Yerkes’ son was estimated to weigh 10 pounds or more, but in reality he was born at 8 pounds, 2 ounces. According to Melanie Schatz, MD, of Main Line OB/GYN in Paoli, PA, one recent study showed that ultrasound measurements, doctor palpations and the mother’s feelings all had the same accuracy in predicting the baby’s weight!

Pam Udy, president of the International Cesarean Awareness Network (ICAN), an organization with a mission to prevent unnecessary cesareans through education, says, “C-sections have become the end-all cure-all to every pregnancy complaint and labor complication.” In her own experience, a C-section was performed on her after terrible indigestion developed 38 weeks into her pregnancy. No other remedy was suggested.

Due to high rate of lawsuits, doctors seem to order C-sections more quickly than in the past. Doctors tend to err on the side of caution if fetal monitor tracings or anything else is abnormal during labor. Dr. Schatz says the thinking is “better to have a healthy baby than a vaginal delivery at all costs.”

Sindu Srinivas, MD, a clinical fellow at the Hospital of the University of Pennsylvania and a member of the Committee for Professional Liability at the American College of Obste-tricians and Gynecologists agrees that “the liability issue definitely plays some role” in climbing C-section rates.

For More Info

International Cesarean Awareness Network,


MedlinePlus, (search: cesarean or search: induced labor)

WebMD, (search: cesarean or search: induced labor)

Repeat Cesareans
According to Gordon Ostrum, Jr., MD, acting chair of the OB-GYN Department at the Christiana Care Health System in Delaware, “Repeat cesareans are the other large driving force,” in rising U.S. C-section rates.

Because research has shown a small but increased risk of uterine rupture during vaginal births after cesareans (VBACs), some moms and doctors alike avoid them for fear of potentially dangerous complications. Also, some mothers are less receptive to enduring labor in subsequent pregnancies if they’ve had a C-section in the past. Today, most pregnant women who have had a C-section will likely have another for subsequent births.

While most physicians discourage purely elective C-sections, they are becoming a more common request. “Our society is very convenience oriented,” Dr. Ostrum says. “People wish to be delivered on a schedule.”

Labor is unpredictable, and making an appointment for surgery takes away some of the guesswork. Both physicians and mothers have plans they’d like to make and schedules they’d like to keep; scheduling delivery offers the option of knowing exactly when a baby will be born. Still, an elective C-section remains a controversial subject. “There are as many people for it as there are against it,” says Dr. Schatz.

Before your child is born, it is important to weigh the benefits and risks of C-sections. “Everything’s a discussion with the patient,” says Dr. Schatz. Do your best to inform yourself and prepare yourself mentally before your due date.

Pam Udy of ICAN suggests mothers be ready to ask their doctors, “What is the medical justification for this? What is the reason for this procedure?” before agreeing to it.

If a C-section is recommended, Udy suggests asking for a second doctor’s opinion if there is time. Ultimately though, she says trust your instincts and listen to what your body’s telling you.

Suzanne Koup-Larsen is a local freelance writer.