In Utah, it might be related to the concentration of Mormons. They may be adamant about not having c-sections because they tend to have large families. Doctors don't recommend a woman have more than 3 c-sections, I believe. Alaska may have less concentration of ob-gyns to perform them. The World Health Organization estimates that only around 10% of births should be c-sections. Do you have any data on episiotomies? Those are no longer recommended except in emergencies, but they are still being done in non-emergency situations.

In addition to fear of lawsuits, I think there is a strong tendency on the part of doctors to believe they are "in control" when they perform c-sections and schedule inductions. They know they can "handle" surgical complications and induced labor has a set schedule: cervical induction at time X, pitocin at time Y, and c-section by time Z if baby hasn't been born. Everything about modern obstetrical care is geared toward the statistical average, including the "length" of gestation being set at 40 weeks. There is no deviation allowed from the average, which totally ignores the fact that averaging millions of women means you will have many, many women who SHOULD gestate beyond 40 weeks, who SHOULD labor for more than 24 hours after their water breaks, etc. Ironically it's the doctors' own interventions that cause the biggest problems: repeated cervical checks for progress after water has broken introduces bacteria & causes infection, necessitating c-section; inducing labor before baby is ready causes stalled/failed labor necessitating c-section; failure to wait for labor to progress beyond 24 hours necessitating c-section...the list is practically endless. Perhaps physicians ought to consider that the best approach really OUGHT to be "hands off" unless it's a real emergency!

The more we start following a low intervention EVIDENCE BASED model of care, the fewer c-sections there will be. Pregnancy is a NORMAL and Natural state of being, and not a medical condition. Women's body,s have a stomach to digest food, a liver to filter waste. and a uterus to grow a baby. In most cases, all of those things work just fine when left alone. We need to treat pregnancy as normal, and respect and trust the womans body, just as we trust her body to digest food. When there are clear indications that there may be something wrong, then care should be transferred to a medical specalist (OB/GYN) Untill then, a trained midwife and the midwifery model of care should be the norm. That is how we lower the c-section rate.

To Emily about episiotomies -

http://www.acog.org/from_home/publications/press_releases/nr03-31-06-2.cfm (although some of the wording is a bit vague)

http://www.medscape.com/viewarticle/702541
(this article talks about the decline and why)

http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10926&nbr=5706
(findings show recommendations of restricted use of episiotomies and why so)

I had someone actually tell me she would "opt" for a c-section rather than "go through all that pain". Somehow there's a fiction that a c-section is less painful and easier than a vaginal birth. I've had one horrible c-section and tried hard to dispell her illusions about a "painless birth" via c-section.

Also not mentioned is the fact that C-sections spike nationwide at around 5 pm or during doctor's shift changes.
Doctors want to be able to go home to the family and when they have to choose between waiting around for a woman to naturally birth her child or to simply make an incision and cut the child out, the simpler answer seems clear.
There is a great documentary on this called The Business of Being Born and I highly recommend it.

I know that (between the states) the ones that seem to have higher rates have higher minority populations, I don't remember where I saw the study but minority women, unfortunately, in this country are more likely to die during Childbirth, some of the causes listed were poor prenatal care and maternal health. I would go out on a limb and say also it has to do with the population numbers in those states as well and the convenience for Dr.'s to deliver larger numbers of babies. Additionally I would say that maybe it has something to do with the insurance companies (and their mandated regulations like constant EFM and containment in bed after ones water has broken here's an interesting article on constant electronic fetal monitoring and the increase in C-Sections http://www.philly.com/inquirer/health_science/weekly/20100426_Test_leads_to_needless_C-sections.html) and the state run health programs in those states and how much they reimburse for a normal spontaneous vaginal birth vs. C-Section, which I have noticed shapes the model of care, which again can facilitate having a high number of C-sections... Who knows although it needs to change!

My grandfather and great grandfather were town doctors....delivered thousands of babies. My dad is in Anesthesiologist, primarily for obstetrics.

My personal opinion is that there is such a wide variety of factors here...tradition, society, vanity, medicine, insurance, personalities, etc. You're going to have to get a heckuvalot of data to do any real significant analysis.

The notion that doctors do C-sections for convenience is difficult to substantiate. Do you really want a labor of increasing risk going after hours when resources might take a bit longer to muster? Or is it just because a doctor has a dance recital to get to? I think both situations occur frequently, but what kind of data is going to show that?

Is it a control issue? I've met plenty of "rock star" surgeons at dinner parties...but I don't want a passive doctor either. What data is going to point to an overly aggressive or overly passive doctor?

I will say that the historical mortality rates pretty much debunk any "childbirth is not a medical condition" nonsense. Anecdotally , my grandfather stopped doing home deliveries because of the tragedies.

We have two kids...both by C-Section due to breech presentation. Anyone who thinks they are less painful or more convenient is nuts. But some people think that...how are you going to parse that out of the data?

It's a big ball of thousands of causes and effects, and everyone seems to have an agenda. Good luck with that one!

UNfortunately, we as a country are not willing to accept any damage to any child which occurs during birth. Therefore, docs do sections....and in the long run, you have a healthy baby. Isn't that what matters?

Birth isn't low-risk until that kid is out and screaming....Textbook case: 19 year old mom, first baby, ample room, no difficulties....until we got to failure to descend, late decelerations, a 3x nuchal cord and FHT of 25!....time to get me to a hospital and I would've had a dead or brain-damaged baby.

It's all about the bottom line and litigation. Doctors pay more on their insurance premiums a year than most of us make in 2 years. Just saying your practice supports VBAC actually RAISES their premiums (I'm reaching here but maybe a planned c-section costs less than an emergent one?? especially on that may need a hysterectomy?) They don't truly care about the woman and the baby anymore. They don't care about the woman's feelings, nor do they care even about the woman's and baby's physical well being. As long as the doctor and the hospital has covered their butts (i.e. sectioned the woman because s/he can then say that they did the most they could possibly do to save mom and baby) they just don't care. That's why I URGE every women to research their caregivers just as much as they'd research a car (if not more). Give them a test drive, ask them lots of questions, and if in the end you just plain don't like them, or have a bad feeling about them, move on to the next until you do. YOU are in control of your own body and what happens to YOUR baby. YOU are responsible to find the best care for both. Don't just lay your life in the hands of someone because they happen to be the first caregiver on the list of caregivers covered by your insurance. You have options, research them, and THEN decide. :)

Another interesting question I wonder about is how many of those Caesarians are emergency vs. elective Caesarians and what the indications are? There's actually a really interesting study that came out last year looking at indications for C section by race (see http://www.ncbi.nlm.nih.gov/pubmed/19788975). Anyway, they found that the largest increase was in elective C sections with "no indication" -- which is consistent with a rise in C-sections due to the US being a litigation nation as well as an increased rate of "Caesarean delivery on maternal request" (but, the rate of that seems questionable).
Another issue is that apparently a lot of Obs-Gyn trainees are no longer exposed to a lot of vaginal births (especially operative ones with forceps and such) and so C-sections are what they know and are more comfortable with.

On the state variance issue, a lot of health care regulation is determined at the state level, including the scope of practice and licensing of health care professionals and the requirements for health care facilities. In NJ, where I live, there are no birthing centers--they are not allowed for some reason. So it's either hospital or home birth, and I don't believe that insurers will pay for home births. I've also heard that NJ has the highest per capita number of lawyers, though I don't remember if that was reliable info. It seems like one big gray area is the interpretation of electronic fetal monitoring--this is why I wound up having a c-section--"nonreassuring" patterns. I later found out that there is a huge lack of agreement on what constitutes nonreassuring, so risk averse docs may be too quick to suggest that baby is at risk and pressure women into c-sections. I doubt that there is ever a disincentive for doing a c-section--no one questions that, whereas if a c-section is not done and a child suffers a birth injury, there is a risk of a lawsuit. As a previous poster suggested, there may be more pressure to avoid c-sections in states like Utah and Idaho that have large Mormon populations where more than two children may be the ideal.

I must quibble with this statement:
"[M]others request that their labor be induced. She may have a grandmother in town or a military husband about to be deployed and she wants to have the child while her family can be present."

Stating that women's requests are the main reason for inductions is just blatantly wrong. Most women will report that their doctor asked if they wanted to schedule an induction for fallacious medical reasons or because the doctor is going out of town or doesn't want to work the weekend or pull an all-nighter. It would be more accurate to say that the "convenience inductions" are not done for the mother's convenience but for the convenience of her doctor.

I wanted to have a natural birth and planned for it, but unfortunately had a very difficult pregnancy. I had doctors who were more mid-wifey in their thinking and they did everything they could to encourage a natural birth. In the end, they were aware that my problems were too risky for anything except an emergency c-section at 33 weeks. It sucked, but I recovered quickly and baby is now a healthy thriving 4 year old. I had unusual doctors though, who did everything in their power to work toward a natural birth. I think they are the exception and NOT the norm.
Interesting that when they closed the c-section, they made sure to do it in such a way that I could choose a V-bac the second time around. (Haven't gotten that far yet.) Apparently, doctors usually use a quicker and less secure method of closing the c-sec - and assume that later pregnancies will be delivered the same way. I don't know the ins and outs of this - but it does provoke questions!

Just quickly because my kids are hassling me - check out the differences in the statistics in a country where the default is that you go to a midwife unless there are complications (when you go to an OBGYN) rather than the default being to see an OB - who is after all a specialist in birth with complications. The Netherlands is one off the top of my head - their c-section rates and death rates are MUCH lower than countries (like the US and Australia) where an OB is the default.

"I don't have any illusions that the hospitals have the best interests of the
women/babies at heart. Convenience, teaching opportunities, money, all come
before the woman and baby.

A (nurse) friend heard several residents joking about "pit to distress" i.e. everyone gets pitocin until either the baby goes into distress or the mother "fails to progress" (does not perform on their timetable) and then they do a section. Thus the 40% cesarean rate." -

-"Over heard" From an anonymous OB Nurse in the USA. It should shed some light----

That was a comment from an ob nurse from her specific hospital. The rate WAS 40% at the time of the quote.

Going a little beyond the U.S. discussion...

Here in China, there are so many reasons that women opt for a C-section; wanting to have the baby on an auspicious date is one that particularly baffles me. (And it certainly seems that, as commenters have been saying, the doctors push for them, too.) There's a skimpy China Daily article here: http://www.chinadaily.com.cn/china/2010-01/14/content_9317593.htm and an article from the Canadian press here with more statistics: http://www.cbc.ca/health/story/2010/01/13/c-sections-world.html

The WHO survey seems off to me, though, since it seems like they focused on capital cities--which, at least in China, are typically more affluent than the villages and cities where the majority of Chinese live, and probably see a higher number of C-sections, voluntary and otherwise.

One thing neither of these articles cite is the possibility that some of the voluntary C-sections are the result of the perceived prestige of a C-section and/or a medically induced labor. The nouveau riche (or nouveau middle class) are showing off automobiles, drinking imported wine and coffee, and buying multiple units in the high-rises shooting up in even provincial capitals--and it seems to me that C-sections fall into the same category. I get the impression that giving birth "naturally" here is seen as somewhat backward, less sophisticated and less safe. (Perhaps, too, only being allowed one chance to give birth leads a woman to want to "do it right"--and you know it's right if it's more expensive!)

What a fascinating discussion.
Based on the experience of myself and my friends and family, I hope to never need an induction, epidural, or caesarean, and I'm hoping next time I'll get by without an episiotomy seeing as I know what I'm doing now after having giving birth once before!

I do agree that minimal intervention is best, but I also recognise that intervention can be incredibly valuable and it has lowered the infant and maternal mortality rates.

Though, a baulk at some things I've heard about pregnancy management. Like a lady I was talking to one day who agreed strongly with her obstetrician that it wouldn't be long before all babies would be delivered caesarean (just weeks before she was to go in for her second elective caesar). And another lady who was the receptionist at an obstetricians office who was horrified when I that my sister was past 41 weeks and considering induction, because in the practise she worked at all women were offered inductions on their due date.

I went through the public system (in Australia) with my son because I had no choice at the time, but in all my pregnancies since I've not even considered going through a private OB because I've just heard too many negative (in my mind) things about interventions, when I know that at our local public hospital it is very midwife driven and they strongly encourage natural labours. I feel incredibly confident in my ability to give birth next time because of the practices I've seen at the hospital, and from what I've heard from friends who have given birth there. They have all been encouraged to birth naturally, but never forced and interventions are always available.

New Jersey is supposed to be a booming centre for the fertility industry. There are more multiple births per capita which often require c-sections. This is a 2005 article from the New York Times called Triplet Nation (sorry I can't find more recent stats). http://www.nytimes.com/2005/10/23/nyregion/nyregionspecial2/23njTRIPLET.html

So it's a double whammy, technically speaking. Fertility treatments are more likely to result in multiple births requiring multiple c-sections.

In Canada, I've seen quotes from OB's that blame women for the increase in c-sections. They claim that, because women are delaying childbirth, we're getting fat & out of shape. Naturally, this means we can't manage childbirth naturally. I've heard midwives report these comments and seen them in newspaper articles. Midwives also report that the likelihood of a c-section rises dramatically after 6 p.m. and on weekends. The clock starts running when the docs want to go home or get their time off. Good weather also seems to play a role.

Hm. This whole discussion just cements my inclination to adopt if my husband and I ever decide on kids.

Interesting how many commenters choose to represent the two "sides" to this as "doctors" and "women." As if there were no such things as women who are doctors, or even women who are doctors who have had pregnancies...

I'd have to agree with previous posters regarding each state's laws regarding midwifery. I'd also like to see a map, if one exists, of the average age of first-time mothers for each state. The younger the mother, the more easily she can be convinced to lie flat on a delivery bed and let the doctors 'do their jobs' instead of letting gravity and nature take their course.... leading to more C-sections, which lead to more C-sections. I know it's possible, but I don't know anyone who has had a successful VBAC.

Hmm, Connections:

So, Utah and Idaho are heavily Mormon states. This is probably a prime factor. Alaska and New Mexico are the states with the 2 highest First Nation populations. Not sure if this factors, but it is interesting. Hawaii similarly, it also has a huge Japanese-American population, which might factor. Vt has low as well, and frankly it's a very au natural state, very hippy. Grew up there, Know from experience. Not sure what's up with Wisconsin.

NJ, well, an explanation has been fostered. It's also just a hugely urban environment. No idea why WV is so much higher then VA. FL, LA and MS...Shrug. All high minority states, but not the highest. Know that laws in LA are pretty backward in all kinds of ways(Napoleonic common law).

I also wonder if maternity leave varies by state? As a student, I wasn't eligible for leave. But a friend "wasted" two weeks of maternity leave because she had to take it starting on her due date, then had a baby nearly two weeks later. If women have to choose between waiting out the baby and having a full maternity leave, perhaps some are choosing the full 6 weeks to bond with their infants? Six weeks is a ridiculously short time for maternity leave. Plus, I think the family medical leave act has some sort of stipulation for men whose partners have had a c-section - they get longer leave or concurrent leave? Just throwing this idea out there - I don't know the specifics of maternity leave, since I wasn't eligible for it (as a grad student).

There’s a lot of comments on here that, as a practising obstetrician, make me angry.

Given the choice of taking someone to theatre in the middle of the night, when that women could have a perfectly good vaginal delivery on her own, is not something that we’re keen to do. Caesarean sections at full dilation are difficult. We’d much rather they pushed the baby out. Anyone who says that an obstetrician performing a highly technical and complicated procedure in the middle of night is doing so because they can’t be bothered to watch a vaginal delivery doesn’t know what they are talking about. End of.

Most women will have perfectly normal vaginal deliveries, and in a country which has midwife led care, we don’t get involved in all of births. We get involved when things are not normal. And for some women, birth is not a normal process. Pre-eclampsia, post partum haemorrhage and shoulder dystocia are not occurrences in normal births, and they need medical-led care. You need to know the difference between uncomplicated and complicated pregnancies, and you definitely need to acknowledge that not everyone is normal.

The rising section rate is the price we pay for having no women dying in obstructed labour. If you look at maternal death rates from 50 years ago, women did die of obstructed labour (we’ve been measuring maternal deaths in the UK for over a hundred years) and that’s unacceptable. Now that we don’t see it happening anymore, we forget that it once caused mortality.

Most women, if left on their own will eventually go into labour, but evidence-based medicine suggests that we have a cut off of term plus 14. It’s not based on a whim. And yes, some of these inductions will fail ending up in sections, because we don’t fully understand exactly how to induce labour in such a way that we’re exactly mimicking the natural labouring process.

@Gwenyth - This article specifies how cultural attitudes towards birth among First Nations people are helping to improve VBAC rates at an aging, but progressive, hospital in NM. Other positive factors include the important role that midwives play in deliveries and the salary and insurance structures within the hospital. It's an inspiring story, attesting to a realm of possibilities for change. http://www.nytimes.com/2010/03/07/health/07birth.html

Does anyone have any statistics on these "magic bonding" hormones? because my mom worked for CNMs and she said that the bonding hormones were found in anyone who was in the room when the baby was born, not just the mother.
Being raised in PA where my mom worked at the birth center, I don't know what i'll do here in IL when i want to have a baby. I agree that the hospital isn't a place to have a baby unless the mother or baby is in trouble and needs medical attention... but i also want to have a trained medical professional like a CNM there!
Because they are so misunderstood, the midwives mom worked for had to be extra careful to make the best decisions for mom and baby- they were super proud of their C-section rate of 9%. Unfortunately, the birth center had to close because it was impossible for the midwives to afford insurance anymore.

Oh! That is why I feel HIGH around birth!! LOL!!!

"The cognitive dissonance one sees when people who say they’re fighting for women’s autonomy pull this biology-is-destiny shit…" AND
"Yeah, as a woman in the biological sciences I really roll my eyes at this crap. So all this is preordained? Fighting biology is useless? Guess this scientist’ll get back in the kitchen then. :p"

Don't pigeon-hole, please.

I graduated from West Point and served 7 years as an army officer. No matter how hard I trained, my lungs will always be smaller, my legs shorter, and my muscles smaller than the men. That's figthing biology.

My three children were all born drug and intervention-free, my last baby being born at home (planned homebirth.) The unintended consequence of using biology to my favor - power. Natural birth is a very powerful thing, and, gee, it's something men cannot do. That's not WHY I chose to birth naturally, but it was a nice side-effect. Ever wonder why in many native cultures, birth is a rite of passage for women? It's difficult thing, but in the end, makes you feel great, and powerful. Like running a marathon, or climbing a mountain.

The experience that a woman gets when she births a baby naturally can not be told. It is like touching something and experiencing the feeling, "hot", or falling in love, a person can't just tell someone what it is, and have them know it.

Women who choose to give themselves over to be "saved" from birth are missing something immeasurable, inexplicable and hugely important.

Bagelsan, now we’re getting somewhere :) I’m sorry you are not cheery about childbirth. But honestly, I can’t blame you. The mainstream media usually portrays birth as an emergency, the woman screaming out of control, everyone else screaming and freaking out. That’s Hollywood, and that’s not a true reflection of how natural birth is. May I recommend a documentary called Orgasmic Birth? Don’t be freaked out by the name. Not all the births in the film are actually orgasmic, but they are gentle and peaceful. These are real births, not Hollywood. Or if you prefer, pick up a book such as Ina May’s Guide to Childbirth – you will walk away with a very different view on birth. Now I’ll address your questions:

"And because women are generally undervalued the rest of their lives (and while performing their other many, many functions) so having an event where the focus was on her seemed special by comparison?"
Seemed special? You don’t think birth is special? Growing a baby for nine months and then doing difficult exercise (labor) longer than many athletic events to deliver the baby? Methinks you are also undervaluing women.

"Because something so unpleasant and dangerous needed all the hype built up around it or else women would be more likely to abort instead?"

Again, there are very, very, very few situations where birth is truly dangerous. The interventions doctors do quite often lead to the emergencies which they must then “save” women from.

"Because patriarchies love population-increasing pressure to be exerted on women and girls? Because it was one of the areas where women were allowed to control the situation and exclude men? Because it proved that a woman was fertile and not a waste of food and space?"

You know, it’s ironic, because the obstetrician-patient (pregnant mother) relationship is pathetically patriarchal. In native cultures, and all cultures up until about the 19th century, birth was attended by midwives and other women. Then male doctors decided they wanted to exert their power over birth too. The worst change was forcing women to give birth in the “lithomy” position, with the woman lying flat on her back, legs spread eagle. For whom is this position easiest? The doctor. First of all, the woman in this position is not able to use gravity to her advantage. Upright and squatting positions open up the pelvis 30% more. It’s no wonder the male OB’s needed to invent things to get the baby out – foreceps, vacuum extractor, episiotomy. All the while telling the woman to relax – ever tried to relax with a stranger staring at / messing with your genitals? Heaven-forbid the doctor should have to move to the floor to catch the baby. There is a great wisdom in midwifery practices and the generational knowledge of birth we have all but lost in our society. OK, well what about female OB’s? They behave the same way as the male OB’s – they ‘fell-in’ on the obstetrics that was already in place. Check out this article written by a feminist women’s health care writer who argues for a midwife-model-of-care. http://www.scienceandsensibility.org/?tag=freedom-of-movement
Furthermore, today’s OB’s often use scare-tactics and sexist comments to persuade the mother to comply with their wishes. Here is just one example of scare-tactics: http://myobsaidwhat.com/2010/04/17/you-can-get-up-and-go-home/ and sexism:
http://myobsaidwhat.com/2010/04/24/dont-you-think-your-husband-would-rather-you-had-a-cesarean/

Some women choose to have a c-section all on their own, for their own reasons. To say that they are "missing" out on something is not only insulting, it smacks of telling women that their choices can't be valid because they aren't *your* choices. That's hateful and misogynistic thinking.

To say they are missing out on the "best" part of the experience is to say that she is not "really" a mother, that all her sleepless nights, diaper changing, worries and triumphs amount to nothing. To say she has missed out on something "hugely important" is to say that every other thing she will do as a mother is diminished because she chose to have a c-section. To take 12-36 hours of her life and make that the most important thing EVAR is to reduce her to a caricature of womanhood that is pushed upon us day in and day out by a patriarchal culture that views women as objects.

That's awful and insulting and wrong, wrong, wrong.

The only time a woman's birthing plan ought to be an issue is when *her* desires are ignored. Period.

Could it be that some women simply CHOOSE to have C-sections and that it's not always just doctors imposing it upon patients? I never want to have a kid, but if I did, I'd certainly prefer a C-section to a vaginal delivery, hands down. I'd choose an epidural, if needed, as well, as would many women.  Of course, I'd prefer not giving birth at all to either.

It's good to aknowledge the failings of medical practice, and some doctors can be overly controlling in the birthing department. But lots not ignore the eperiences of women, and how our CHOICES also impact those statistics.