The nation's Caesarean section rate rose to a record level last year, confounding doctors and natural-birth advocates whose efforts to bring the rate down achieved a brief success in the early 1990s.
Last year, 27.6 percent of babies born in the United States were delivered surgically, up from 26.1 percent a year earlier, according to a report yesterday by the National Center for Health Statistics. Put another way, more than 1 million of the 4 million babies born in the United States entered the world via the surgeon's scalpel.
At least part of the increase in C-sections resulted from a steep decline in attempts by women who had previous Caesareans to deliver a second child through the birth canal.
That practice, widely known as VBACS, for "vaginal birth after Caesarean section," might be headed for extinction. In 1996, about 30 percent of women who had had a C-section delivered their second child vaginally. Last year, just 10.6 percent did.
But experts were quick to point out that the rising C-section rate had other causes, too. Chief among them was a growing number of first-time mothers who underwent C-sections without any medical reason.
"We have first-time moms now coming in saying, 'I want to pick my date. I don't want to have incontinence later on if I have labor. I want a Caesarean,'" said a concerned Dr. Mary Jo Johnson, chief of obstetrics at St. Joseph Medical Center in Towson. "I have completely healthy women who come in and ask that."
With VBACS plummeting and first-time Caesareans increasing, doctors said they see no reason why the overall Caesarean rate won't continue to rise.
"It's a fairly spectacular rebound," said Eugene Declercq, professor of maternal and child health at the Boston University School of Public Health. "There is nothing to think this rate is going to come down in the immediate future."
This makes it doubtful that the nation will achieve a 15 percent C-section rate by 2010, a goal that federal health officials promoted in 2000, when the rate was 22 percent.
Doctors' reaction to the report was mixed, with some expressing sadness and others befuddlement.
"It's breaking my heart - it absolutely is," said St. Joseph's Johnson. "I just think it's much more difficult to recover from a C-section."
Dr. Bruce Flamm, a professor of obstetrics and gynecology at the University of California, Irvine, said he would have been horrified a decade ago if someone had told him the C-section rates would rise so high. Now, although the trend goes against his view, he wonders if anyone knows what a desirable rate is.
Over the past 35 years, the C-section rate has gone up, down and up again. "In 1970, the rate was about 5 percent, and it was hard to imagine that within a decade it could quintuple to almost 25 percent," said Flamm.
But that's exactly what happened. Researchers cited many reasons, including doctors' fear of being sued if babies were injured coming out of the birth canal. Another was the convenience - to physicians and mothers - of having labor cut short or eliminated by a trip to the operating room.
At the same time, while C-sections always carried a risk of infection and other complications, modern techniques were making the operation safer.
In the 1990s, the rate leveled off and began to drop as doctors, professional organizations and advocates argued that so many C-sections were unnecessary. The past seven years, however, have seen an about-face, and now the rate is higher than ever.
In Maryland, the rate was 28.5 percent last year, up a point over the previous year. That put the state in the middle of the pack. New Jersey led all states with 33.1 percent, with Utah, at 19.2 percent, having the lowest.
Far from being just a U.S. phenomenon, rising C-section rates are occurring in much of the industrialized world. In Italy, over a third of all deliveries are C-sections, according to Declercq. Australia's rate is about the same as that of the United States.
Still, the increase is not universal: In the Netherlands, the C-section rate is half the U.S. rate.
Declercq, who has published several articles on the subject, said the overall increase here is owed equally to the rise in C-sections among healthy, first-time mothers and to the fall in VBACS.
The decline in VBACS was driven partly by a philosophical reversal by the American College of Obstetrics and Gynecology.
The group, which sets standards for the profession, issued guidelines in 1999 recommending that VBACs be attempted only in hospitals that can provide immediate emergency care if something goes wrong.
That ruled out many small and midsize hospitals, as well as "birthing centers" where deliveries are overseen by midwives. Also, it put a cloud over the practice in general, many experts said.
"It played up the risks of uterine rupture," said Johnson, referring to a complication that sometimes, if rarely, occurs. "In the 1980s, we told patients that the rate of uterine rupture is low, and even if it happened, the risk of catastrophe from that was very low.
"The problem is, medically and legally we've gotten to the point where nobody wants to take a chance."
A recent article in the British Medical Journal reported a 67 percent rise in the United States of C-sections among first-time mothers who didn't need the procedure. The rate went from 3.3 percent of all deliveries in 1991 to 5.5 percent in 2001.
These women were not carrying multiple babies and had full-term children who were positioned normally, head-down toward the birth canal. These factors, along with the absence of other identifiable complications, qualified them as "low-risk" patients, according to Declercq and Fay Menacker of the National Center for Health Statistics, the study's authors.
"There has been a change in the culture around Caesareans," said Declercq.
Johnson said she sees the change among her patients at St. Joseph's, where the C-section rate, 29 percent, was slightly above the state average last year.
She said she won't perform a C-section just because it's more convenient for the mother. If a patient insists, she refers the woman to other doctors who might agree.
Though the operation is much safer today, Johnson noted that women who have repeat C-sections run a greater risk of a complication in which the placenta grows into the uterine wall. In such cases, the baby is delivered - sometimes prematurely - and the woman must have a hysterectomy that ends her ability to bear children.
"When you have your second and third section, the risks go up each time, and the recovery [time] goes up. If you pay your dues with a first vaginal delivery, after that you do well," Johnson said.