Among many health care professionals, it is fashionable to attribute our skyrocketing cesarean rate to increasing numbers of “older” and obese women having babies. As women age, the rate of health complications such as hypertension and diabetes do increase. And obesity is associated with increased risks for both mothers and babies. But is this the reason for our escalating cesarean rate?

Last year, in an article published in the American Journal of Obstetrics and Gynecology, researchers for the Consortium on Safe Labor found that cesareans done for women with advancing maternal age were mainly due to repeat, prelabor cesareans. Obesity was associated with substantially higher cesarean rates in all categories (primary vs repeat, and prelabor vs intrapartum). But the most important concern raised in this study was the increase in the primary cesarean rate. Researchers found that high numbers of cesareans were done in the first stage for dystocia before 6 centimeters and high numbers of cesareans were done in second stage before 3 hours was reached in nulliparous women and before 2 hours was reached in multiparous women. As in many other studies, they found that the cesarean rate among induced labors was twice as high as among spontaneous labors. The authors called upon clinicians to reduce the rate of cesarean delivery associated with a high rate of induction of labor AND to avoid cesarean surgery for dystocia before active labor is established. They also called for increased access to and education about VBAC.

Now, in the July 2011 edition of Obstetrics and Gynecology, another study looks at indications contributing to the increasing cesarean delivery rate. The authors flat-out state that:

“Studies examining differences in medical risk factors for expectant mothers, including obesity, have not concluded that changes in maternal risk profile explain the increasing cesarean delivery rate.”

They also say that, “Maternal request for elective cesarean also does not appear to account for the magnitude of the increased cesarean rate.”

In this study, researchers analyzed the rates and indications for primary and repeat cesarean delivery among 32,443 live births at Yale-New Haven Hospital between 2003 and 2009. The cesarean rate increased during this time period from 26% to 36.5%. They noted that the prevalence of advanced maternal age and weight of 4,500 grams or more were stable over time. They found that the greatest increases in cesarean delivery were due to subjective indications such as nonreassuring fetal heart tracings, labor arrest disorders, and suspected macrosomia. The authors acknowledged that the rising cesarean rate may be linked to medico-legal issues, scheduling issues, economic pressures, provider-driven and patient-driven medicalization of birth, increased labor induction rates, and a broader perception of cesareans as safe. In order to reverse the rapidly escalating cesarean delivery rate, these authors call on clinicians to develop clearer evidence-based guidelines regarding fetal status, labor arrest, and assessment of macrosomia. They also recommend increased provider accountability for the decision to perform cesarean delivery at the practice, departmental, hospital, or state level. Finally, they also call for increased patient education and involvement in decisions during pregnancy as well as changes in methods of reimbursement, and medico-legal reform.

Childbirth educators can help meet this challenge by continuing to present information on factors that increase the risk for cesarean surgery such as induction and admission to the hospital before labor is well established. Educators can do a better job of encouraging greater participation in decision-making during labor by having students role-play situations such as one in which the physician recommends a cesarean for slow labor progress before 6 centimeters has been reached. Women need to know that too many cesareans are being done for the wrong reasons. And childbirth educators need not to be afraid to say so.