Federal health officials released some interesting data Monday aimed at trying to figure out why so many U.S. women are undergoing cesarean sections to deliver their babies.

The rate at which women are having C-sections has soared in recent years. About one-third of all babies are delivered using the surgical procedure. C-sections are necessary sometimes to save the baby or the mother or both. But experts think they're being done far too frequently, putting both the woman and her baby at unnecessary risk, making the mother's recovery a lot harder and adding a lot of extra costs to the nation's health-care bill.

In the new analysis, published in the American Journal of Obstetrics & Gynecology, researchers at the National Institute of Child Health and Human Development analyzed data collected at 19 hospitals about 228,668 births that occurred between 2002 and 2008.

Overall, the researches found that about a third of the deliveries were by C-section. Surprisingly, however, that was even the case for women giving birth for the first time -- not because they had previously had a C-section, which can make trying regular labor riskier. Slightly more than one-third of first-time moms had C-sections. Also surprising was the fact that half of the women attempting regular births had their labor induced. And half of C-sections occurred in women who had been induced but had not even dilated 6 centimeters. That suggests that doctors may be jumping the gun and turning to a C-section too early. It also might support the idea that part of the problem might be that women and their doctors are scheduling their deliveries for convenience.

But none of this proves any of that. It could be that a lot of these C-sections are needed because of problem pregnancies. More women are giving birth at older ages, when complications are more common. More obese women are also giving birth. Obese women are more prone to complications.

About one-third of the C-sections were among women who had had a previous C-section. And among those who tried a C-section again even though they had already had one, they were successful in about 57 percent of the cases.

The researchers stress that the study can't determine exactly how many of the C-sections were really unnecessary and could have been avoided. But the study does provide new evidence that more could be done to avoid women getting C-sections the first time around, and more could at least try a regular birth even if they have had a previous C-section.

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PregnancyWeekly.com

The rise in cesarean-section deliveries in recent years has been characterized by some as a key indication of the over-medicalization of childbirth. While the procedure undoubtedly saves lives and leads to better health outcomes for mothers and infants who face problems during pregnancy and labor, many experts say the procedure is being performed too often, and in many cases for non-medical reasons, putting healthy women and babies at undue risk of complications of major surgery.

The rate of C-sections has reached more than 31% in the U.S., a historical high, according to 2007 data from the American College of Obstetricians and Gynecologists (ACOG). The reasons for the increase are many and have been widely discussed: the rising rate of multiple births, more obesity in pregnant women, the older age of women giving birth. In fact, C-sections have become so common that many women may have an inflated sense of safety about them. "For the most part, moms and babies go through the process healthy and come out healthy, so maybe there's this sense that we're invincible," says Dr. Caroline Signore of the Eunice Kennedy Shriver National Institute for Child Health and Human Development.

But C-section carries all the attendant risks of major surgery; and data show that compared with vaginal birth, cesarean delivery increases the odds that a mother will end up back in the hospital after birth with complications such as bleeding or blood clots.

Now obstetrics experts are actively seeking ways to drive down the number of C-sections. On July 21, the ACOG issued new guidelines recommending that hospitals allow most mothers who desire vaginal birth after cesarean, or VBAC, to attempt a trial of labor, including some mothers who are carrying twins or have had two prior C-sections. Despite studies showing VBAC to be safe for most women — ACOG data suggests that 60% to 80% of women who attempt VBAC will succeed — many hospitals have urged women to undergo a repeat cesarean over the past decade, largely to avoid medical risks and malpractice suits. (Read how postpartum depression can strike fathers.)

Another factor contributing to high C-section rates is the increase in induced labor, especially between 37 weeks and 38 weeks of gestation — a period obstetricians describe as "early term." (While any birth between 37 weeks and 41 weeks is considered full term, some experts distinguish the earlier period.) The use of labor induction in the U.S. has risen from less than 10% of deliveries to more than 22%, between 1990 and 2006, according to data from the Centers for Disease Control and Prevention, and research suggests that induced labor results in C-sections more often than natural labor. A study published in the July issue of the journal Obstetrics & Gynecology found that among more than 7,800 women giving birth for the first time, those whose labor was induced were twice as likely to have a C-section delivery as those who experienced spontaneous labor.

The rate is significant because ACOG guidelines, which have been in place since 1982, recommend against elective inductions in the early term, or anytime before 39 weeks. Research shows that after 41 weeks' gestation, at which point it is standard policy to induce labor, it may lower the risk of medical complications for mother and baby — including the risk of stillbirth — and even decrease the likelihood of C-section delivery, but those same effects are not seen in women who induce labor before the 41-week mark.

Medical reasons for earlier induction may include advanced size or lack of proper growth of the fetus and maternal issues like diabetes. But in an editorial, Signore also suggests that the high rate of early-term induction may reflect lifestyle choices: health care providers' and new parents' desire to control the timing of delivery. "Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date and may request delivery for any number of reasons of comfort or convenience," Signore writes. "However, we must remember that incautious use and timing of interventions — particularly in elective cases — can lead to unnecessarily poorer outcomes for women and newborns."

Several hospitals have already begun reducing medically unnecessary induction as a way to lower the rate of cesareans. In 2006, the Magee-Womens Hospital in western Pennsylvania began limiting the pool of women eligible for elective inductions to those delivering after 39 weeks. The hospital also established stricter protocols for elective induction in women after 39 weeks — insisting on high levels of cervical "ripeness" as measured by the standard Bishop score before induction — and prohibited other labor-hastening efforts, such as the use of cervical ripening agents. Additionally, the hospital instituted a new scheduling system requiring physicians to document specific reasons for induction when used.

Researchers found that under the new policy the overall induction rate dropped 33% and the rate of elective inductions fell by roughly the same amount. What's more, the total number of C-sections among first-time mothers who underwent elective induction dropped 60%. The results of the Magee-Womens study were published in April 2009 in the journal Obstetrics & Gynecology.

If a relatively simple policy shift based on medical evidence can successfully cut the rate of induced labor and C-sections at a single hospital, experts say similar changes applied broadly may help lower the rate of C-sections on a national level.

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PregnancyWeekly.com

In the largest study of its kind, researchers find that the risk of severe breathing problems rises significantly in babies born prematurely, even those born in the so-called late preterm period.

Health experts consider babies born at or after 37 weeks' gestation to be full term, and those born between 34 weeks and 37 weeks to be late preterm. (Preterm is defined as less than 34 weeks' gestation.) Many previous studies have shown that compared with full-term babies, those who are born too early are at higher risk of dying shortly after delivery and are more likely to suffer neonatal complications that require lengthy stays in the hospital.

In the new study, Dr. Judith Hibbard at University of Illinois also found that babies born at 34 weeks were 40 times more likely to have respiratory distress syndrome, a breathing difficulty that often requires a ventilator, than babies born at 38 weeks or later.

Even at 37 weeks' gestation — the point at which mothers may ask for an elective Cesarean section or induced delivery — babies are three times more likely than full-term infants to have respiratory abnormalities at birth. "That's a remarkably increased risk," notes Hibbard, who worked with the Consortium on Safe Labor, a group of 19 hospitals that contributed volunteers and data to the study. "And I have to admit, much higher than I was expecting."

Despite the accepted 37-week full-term cutoff, the American College of Obstetricians and Gynecologists officially recommends that babies not be delivered (unless medically necessary) until after 39 weeks. Yet some 9% of all deliveries in the U.S. still occur just shy of 37 weeks, and a recent study found that as many as 23% of late pre-term births — between 34 weeks and 37 weeks — occur for no documented medical reason.

Hibbard says she was surprised by the high rate of health problems she and her team found in this group, since advances in neonatal care have allowed more high-risk babies to survive and eventually thrive after being born too early. But the fact that respiratory distress syndrome continued to occur in premature infants at 40 times the rate in full-term babies highlighted how risky premature delivery can be. At 34 weeks, infants' lungs and respiratory systems are not fully developed, making it difficult from them to survive outside the womb.

With every week of gestation after 34 weeks, however, Hibbard found that rates of complications dropped — by 40 weeks, only 0.3% of babies showed signs of respiratory distress. While 67% of babies required admission to the neonatal intensive care unit at 34 weeks, only 7% of those born at 38 weeks required the same care. Further, 1.5% of babies delivered at 34 weeks developed pneumonia, compared with practically none of those born at 38 weeks. "To be honest, with studies like this, it's hard to justify deliveries before 39 weeks," says Dr. Richard Waldman, president of the American College of Obstetricians and Gynecologists.

Both Hibbard and Waldman stress that there may be valid medical reasons for delivering a baby early — if the mother has preeclampsia, the dangerously high blood pressure that can occur during late pregnancy, for example, or if the baby is no longer growing properly in the womb — but that doctors should discourage elective delivery before 39 weeks.

The new study adjusted for many of the major contributors to prematurity, such as the mothers' weight and history of other medical conditions, including preeclampsia and diabetes, but the relationship between early delivery and risk of respiratory distress in the babies remained. "I know mothers may request early delivery for a lot of reasons," says Hibbard. "But I hope the obstetrician will pull this study out and say, 'Look, early delivery is not a good idea unless there is really a strong medical indication.'"

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PregnancyWeekly.com

Although acupuncture is promoted as a way to induce labor in women who go past their due date, a new study adds to evidence doubting its usefulness.

Researchers found that among 125 pregnant women who were past their due dates, those who were randomly assigned to undergo two acupuncture sessions were no more likely to go into labor over the next 24 hours.

Of those women, 12 percent went into labor, versus 14 percent of those who were randomly assigned to have a "sham" version of acupuncture.

The findings, reported in the obstetrics journal BJOG, add to evidence that acupuncture may not be an effective way to induce labor in "post- term" pregnancies -- those that go beyond 41 weeks.

About 5 percent to 10 percent of pregnant women have a post-term pregnancy, a delay that raises the risk of complications during labor. Because of this, doctors routinely induce labor when a pregnancy lasts beyond 41 weeks.

During standard labor induction, a doctor uses instruments to rupture the amniotic sac or stretch the cervix, or gives synthetic forms of prostaglandins or oxytocin -- hormones that normally help trigger labor. Acupuncture has been promoted as an alternative; in theory, it may work by stimulating the nervous system, which in turn could cause the uterus to contract.

And there is a need for alternatives in labor induction, said Dr. Niels Uldbjerg, a professor of obstetrics and gynecology at Aarhus University Hospital in Denmark and the senior researcher on the new study.

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PregnancyWeekly.com

In a study of 7,800 first-time mothers who gave birth at one U.S. medical center, researchers found that those who had their labor induced were twice as likely to ultimately need a C-section.

Of all women in the study, 44 percent had their labor induced -- and the researchers estimate that failed induction accounted for 20 percent of the C-sections performed.

The findings, reported in the journal Obstetrics & Gynecology, firm up the link seen in past studies between labor induction and an increased risk of C-section. By definition, labor induction is performed before a woman's body is ready for spontaneous labor, and in some cases there will be problems with labor progression that necessitate a C-section.

The connection is important because while cesarean section is a generally safe procedure, it requires a longer recovery time than vaginal birth, and does present certain risks, such as blood clots, infection at the incision site or in the lining of the uterus, and breathing problems in the baby.

Moreover, the rates of both labor induction and C-section have been on an upward trend in the U.S. since the 1990s. Labor inductions have risen from just under 10 percent of births in 1990 to 22 percent in 2006; and in 2007, C-sections were done in almost one-third of all births.

The current findings suggest that putting more limits on so-called "elective" inductions would help lower the number of C-sections performed nationally, according to lead researcher Dr. Deborah B. Ehrenthal of the Christiana Care Health System in Newark, Delaware.

There are circumstances in which labor induction may be advisable. There is good evidence, for example, that inducing labor benefits mom and baby when pregnancy goes beyond 41 weeks, Ehrenthal told Reuters Health in an interview.

Normally, pregnancy lasts about 40 weeks, and prolonged or "post-term" pregnancy carries an increased risk of certain complications, including stillbirth.

According to the American College of Obstetrics and Gynecology (ACOG), labor induction may also be warranted in certain other circumstances -- such as when a mother has pregnancy-related high blood pressure or diabetes, or when the mother's "water breaks" but labor does not spontaneously begin.

In general, elective labor induction refers to those done with no clear medical reason. It may be done for convenience, for example, or in cases where late pregnancy is causing significant physical discomfort or when a woman wants to ensure that her own doctor delivers the baby.

Of the labor inductions performed in this study, 40 percent were elective. The findings were based on women's medical records, and Ehrenthal said that her team considered any induction without a documented maternal or fetal indication to be elective. The precise reasons for those elective inductions are unknown.

According to Ehrenthal, the bottom line for pregnant women is that they should understand the reasons for and potential risks of all forms of delivery. "It's really important to have a frank discussion with your doctor about all of your options for delivery," she said.

Among these low-risk women, one-quarter of those who had a labor induction ended up needing a C-section, versus 14 percent of those who had a natural labor.

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PregnancyWeekly.com

You should already be drinking copious amounts of water, but here a few things you may not have thought of:

1. Shop for baby: You don't have to spend a thing; just take advantage of all that free air-conditioning in the mall.
2. Skip the spice: There's a temptation to eat spicy food because old wives' tales claim it will get labor moving. But spicy food literally raises the body temperature, making you more uncomfortable. And there's no scientific evidence it will get the baby out anyway.
3. Bring out the baby bath. It's taking up an enormous amount of space just waiting for baby, so get the most out of it -- fill it with cold water and dip your tootsies.
4. Go topless. Nipple stimulation is one natural way to induce labor that might actually hold weight. So set up in the living room with a fan on you and have at it. Bonus points if your partner gets to partake as well -- they do say sex can speed up labor.
5. Pull the pregnancy card. You will be more tired, so work it girl -- ask for HELP around the office, the house, and from that cute bag boy at the grocery store.

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PregnancyWeekly.com

This is a tale of two hospitals.

One has the highest rate of Cesarean sections in the city, the other the fourth lowest. They represent some of the city's obstetric extremes, yet they sit just five miles apart on Staten Island, serving similar populations.

So what accounts for the difference?

In large part, determination, which Dr. Mitchell A. Maiman, the chairman of the obstetrics and gynecology department at one of the two, Staten Island University Hospital, has in ample supply. As New York City’s C-section rate has soared in recent years — by 36 percent, between 2000 and 2007, according to the New York State Department of Health — Dr. Maiman has kept his hospital’s rate around 23 percent of all births.

In 2008, according to numbers released by Choices in Childbirth, an advocacy group for pregnant women, working with state statistics, Staten Island University Hospital’s rate went down, while the rate at the other hospital, Richmond University Medical Center, went up again, to 48.3 percent. That made it, for the fifth consecutive year, the hospital with the highest C-section rate in the city. (The National Center for Health Statistics reported that the Cesarean rate reached 32 percent in 2007.)

Cesarean births are generally considered more prone to complications than natural births, so most hospitals at least pay lip service to their devotion to reducing them. But very few have pulled it off. What seems to have made the difference for Dr. Maiman’s department is building that goal into policy, even when it is unpopular with doctors — even, sometimes, when it may be unpopular with patients.

To start, Dr. Maiman and his colleagues do not allow unnecessary inductions for first-time pregnancies at any point before the 41st week, since they are a main cause of C-sections. They also do not allow C-sections for no reason other than the mother wants one.

C-sections are thought to be relatively lawsuit-proof, and they also let everyone go home on time. But such conveniences do not inform Dr. Maiman’s thinking. “You have to draw the line somewhere,” he said in an interview. “If you went to your doctor and said, ‘I want my gall bladder taken out electively,’ your doctor wouldn’t do that, probably.”

Mother-demanded C-sections are unusual enough that the policy is probably more useful to Dr. Maiman for the message it sends to doctors and patients, a clear sign that he values a non-interventionist policy as long as it is safe. It has become common for hospitals to prohibit what are known as VBACs (for Vaginal Birth After Cesarean, pronounced VEE-back) for reasons having to do with anesthesia availability and, more tacitly, a fear of lawsuits. Dr. Maiman actively encourages VBACs. Residents are trained not only to avoid unnecessary C-sections, but to let higher-ups know if they witness another doctor about to perform one.

Obstetricians with high Cesarean rates, Dr. Maiman said, invite scrutiny; doctors either come to see things his way or end up leaving the hospital.

“If a woman has a third or a fourth Cesarean, the maternal morbidity and mortality is astronomically higher,” Dr. Maiman said. “That’s when you see women dying in childbirth from obstetrical hemorrhage.”

Whether or not you like his policy — maybe you believe a mother’s choice should extend to controlling the hour of her delivery and how much it will hurt — you have to give Dr. Maiman credit for not just creating protocols to protect women’s health, but enforcing them. There is not a lot of incentive for hospitals to let conviction trump convenience, especially when convenience comes with the added bonus of lower legal risk.

Dr. Michael L. Moretti, the chairman of the obstetrics and gynecology department at Richmond University Medical Center, attributed the high rate of C-sections at his hospital to the reputation of its perinatal care center, which he said attracts women with high-risk pregnancies who are more likely to require surgically assisted births.

Dr. Moretti said he and his colleagues were trying to reduce C-sections with peer review of one another’s procedures. Women requesting C-sections are now required to meet with Dr. Moretti to discuss the risks. “What we find is that about half who come in requesting a C-section will change their mind,” he said, “so that’s helped a lot.”

Five miles away, Dr. Adi Davidov, one of Dr. Maiman’s colleagues, described similar conversations — but better results. “I find that most of the time, if you explain to a mother you’ll recover faster, it’s safer,” he said, “then most women will choose a vaginal delivery.”

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PregnancyWeekly.com

Over the past decade, the U.S. maternal mortality rate has nearly doubled, with about 500 women dying of pregnancy-related complications each year. That's a tiny percentage of the 4 million American women who give birth annually. But what's shocking is that among industrialized countries, the U.S. ranks an abysmal 41st on the World Health Organization's list of maternal death rates, behind South Korea and Bosnia-yet we spend more money on maternity care than any other nation.

Amnesty International has designated the U.S. maternal mortality rate a human-rights concern. This month, the organization called on President Barack Obama to address the crisis, noting that two to three women die of pregnancy-related complications in this country every day, as we move further away from the government’s goal of 3.3 deaths per 100,000 live births. The health-care reform bill signed into law by Obama Tuesday could help, as it requires insurance companies, for the first time, to cover prenatal care and some childbirth costs.

Skeptics attribute the rise in the maternal mortality rate to better reporting of maternal deaths—and it’s true that over the past decade, states have revised death certificates to better flag pregnancy-related mortalities. Yet review committees estimate that better reporting only accounts for about 30 to 40 percent of the rise.

More likely, the maternal death rate is going up due to a complex cocktail of factors—causes that reflect a changing population, disparities in poor women’s access to health care, and even Americans’ reliance on cutting-edge medicine. Here are seven explanations for the unsettling rise:

1. A Skyrocketing Caesarean Rate

   Before C-sections became as safe and standard as they are today, pregnant women had few options if they found themselves in an emergency situation; aside from metal forceps, doctors lacked tools to get babies out quickly, which often led to tragedy.

   Yet as lifesaving as C-sections can be, an astounding one in three American women now give birth surgically, up from one in five a decade ago. Healthy women who give birth surgically are 80 percent more likely to be re-hospitalized than healthy women who give birth vaginally; they’re also four times more likely to die. Hemorrhage, infection, and pulmonary embolism are all more common following a surgical birth.

2. More Obese Moms

   As the obesity epidemic swept the country, more overweight women have gotten pregnant and given birth, despite serious risks. One in five women in the U.S. are now obese at the beginning of their pregnancy, according to the Centers for Disease Control. Obese women are more likely to develop hypertension, high blood pressure, and diabetes during pregnancy, which can lead to preeclampsia and other fatal conditions. Preeclampsia is responsible for about 18 percent of maternal deaths in the U.S., and over the past decade, the incidence of the condition rose by 40 percent.

   Labor can also be more difficult for obese women, as soft tissue can impede delivery. Obese women are also at greater risk for delivering bigger babies, needing C-sections, and developing postpartum infections and heart problems.

3. Disparities in Access to Care

   As economic disparities in the U.S. health-care system grew wider over the past several decades, fewer women got the family planning, prenatal, and postpartum care they needed. Currently, one in five women of childbearing age are uninsured, Amnesty International reports. In most states, poor women do qualify for Medicaid once they become pregnant; the problem is, six weeks after giving birth, most of these women are dropped.

   From there, a dangerous cycle can begin: If a woman has risk factors going into her first pregnancy—say, diabetes or hypertension—the conditions often get worse through the process. She can’t afford the medical care to treat her conditions. Nor can she afford contraceptives, so she often ends up getting pregnant again, this time facing even greater risks. By the time she’s back on Medicaid for her next pregnancy, she’s in big trouble.

   The good news is that the new health-care reform legislation will expand access to Medicaid for about 15 million people, and will include prenatal and maternal care in the basic package of services private insurers must cover.

4. Unnecessary Medical Interventions

   Like C-sections, medical innovations such as drugs to induce labor and devices to monitor fetal heart rates can be lifesaving, but they can also lead to complications in healthy women. When an intervention is unnecessary—performed out of convenience or protocol—the harms can outweigh the benefits.

   In many developed countries, induction is used as a last resort, but in the U.S., hospitals induce or accelerate roughly 40 percent of labors. These drugs, in turn, can create more aggressive contractions, which increase the risk of uterine rupture. A woman who is induced is also more likely to end up needing a C-section.

5. Older Moms

   As the rate of childbearing women over 40 has risen, so has the maternal mortality rate. Moms over 35 are more likely to develop gestational diabetes and other complications; they’re also more likely to have twins or other multiples, thanks both to biology and the wonders of fertility treatment—and multiple births are far riskier than single births, for both mother and babies.

   But Elliott Main, a San Francisco-based OB/GYN and principal investigator of the California Maternal Quality Care Collaborative, says that most American women who die in childbirth are in their twenties or thirties.

6. Poor Birth Education

   Maternity-care advocates stress that as birth has become increasingly medicalized, American women have become surprisingly uneducated on the topic.

   In particular, low-income women with limited access to health care may not be aware of the risks of taking certain medications or engaging in certain behaviors during pregnancy. Similarly, advocates point out that with C-sections and interventions on the rise, women feel less empowered to take control of their birth experience—they don’t always know their options or trust their instincts. They must rely completely on hospital staff, who are often overworked, exhausted, and juggling many births at once.

7. Complacency

   Despite the rising maternal mortality rate, pregnancy-related deaths in this country are still rare. Most doctors and nurses will go their entire career without encountering one. Yet as a result, many hospitals have become complacent that mothers just don’t die anymore. Hospitals need to act proactively, paying closer attention to changes in women’s vital signs.

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PregnancyWeekly.com

The Cesarean section rate in the United States reached 32 percent in 2007, the country's highest rate ever, health officials are reporting.

The rate has been climbing steadily since 1996, setting new records year after year, and Cesarean section has become the most common operation in American hospitals. About 1.4 million Cesareans were performed in 2007, the latest year for which data is available.

The increases have caused debate and concern for years. When needed, a Cesarean can save the mother and child from injury or death, but most experts doubt that one in three women needs surgery to give birth. Critics say the operation is being performed too often, needlessly exposing mothers and babies to the risks of major surgery. The ideal rate is not known, but the World Health Organization and health agencies in the United States have suggested 15 percent.

Risks to the mother increase with each subsequent Cesarean, because the surgery raises the odds that the uterus will rupture in the next pregnancy, an event that can be life-threatening for both the mother and the baby. Cesareans also increase the risk of dangerous abnormalities in the placenta during later pregnancies, which can cause hemorrhaging and lead to a hysterectomy. Repeated Cesareans can make it risky or even impossible to have a large family.

The new report notes that Cesareans also pose a risk of surgical complications and are more likely than normal births to cause problems that put the mother back in the hospital and the infant in an intensive care unit. The report states: “In addition to health and safety risks for mothers and newborns, hospital charges for a Cesarean delivery are almost double those for a vaginal delivery, imposing significant costs.”

The highest rates were in New Jersey (38.3 percent) and Florida (37.2 percent), and the lowest were in Utah (22.2 percent) and Alaska (22.6 percent).

The report notes that the rate in the United States is higher than those in most other industrialized countries. But rates have soared to 40 percent in some developing countries in Latin America, and the rates in Puerto Rico and China are approaching 50 percent. A report by the World Health Organization published earlier this year in The Lancet, a medical journal, said hospitals in China may be doing unnecessary operations to make money.

There is no single reason for the continuing increase in the United States. Rising multiple births due to fertility treatments have a role, because they often require Cesareans. But, the report notes, Cesarean rates for singletons increased substantially more than those for multiples. Another factor is that more older women are giving birth nowadays, and they are more likely to have Cesareans — but women under 25 had the greatest increases in Cesareans from 2000 to 2007.

Nonmedical issues are also involved. Obstetricians, fearful of being sued if there is harm to a baby after a normal labor and delivery, are quicker than they used to be to perform a Cesarean.

In an article published last month in the journal Obstetrics and Gynecology, the obstetricians’ college reported that a poll of 5,644 of its members found that 29 percent said they were performing more Cesareans because they feared lawsuits. Eight percent said they had quit delivering babies, and nearly a third of them said it was because of liability issues.

Some of the increase in Cesareans has also come from women requesting the surgery even when it is not medically necessary, Dr. Macones said. Caesareans have become so common that many people do not realize they are major abdominal surgery, with all the attendant risks.

In addition, the increased tendency to induce labor before a woman’s due date, for reasons of convenience, has helped push up the Cesarean rate, because induction is more likely than natural labor to fail and result in a Cesarean.

Repeat Cesareans are another part of the problem. They account for about 40 percent of the total and have become increasingly common in the past 15 years as more and more hospitals have refused to allow women who have had a Cesarean to try to give birth normally. Fewer than 10 percent of women who had Cesareans now have vaginal births, compared with 28.3 percent in 1996. Many hospitals banned vaginal birth after Cesarean because of stringent guidelines set by the obstetricians’ college, which said surgery and anesthesia teams should be “immediately available” whenever a woman with a prior Cesarean was in labor.

An expert panel convened earlier this month by the National Institutes of Health said there were too many barriers to vaginal birth after Cesarean and suggested ways to reduce them. It urged the obstetricians’ group to reassess its guidelines on “immediate availability,” and it urged hospitals to publicize their rates of vaginal birth after Cesarean, so that women could make informed choices about where to give birth. It also acknowledged the problem of malpractice suits but did not make a specific recommendation about how to solve it.

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PregnancyWeekly.com

The rising trend of expectant mothers being involved in every aspect of planning their births has had an unintended consequence - a rise in pre-term deliveries.

"It never would have occurred to me or anyone I knew to think you had any kind of control over when the baby would come out," said Laura Crawford, who gave birth more than a decade ago.

Crawford, producer of the Kentucky Educational Television documentary "Born too Soon," said the increasing incidence of what is called late pre-term births is among the topics explored in the film.

Prematurity rates in the nation have increased quietly over the past two decades, according to public health officials. The premature-birth rate in Kentucky is 15.2 percent, and it's rising faster than the national rate, which is 12.7 percent. Kentucky has one of the highest rates of pre-term births, trailing only Louisiana, Alabama, Mississippi and South Carolina.

Some of Kentucky's rise is related to some not-so surprising subjects, including the rate of maternal smoking (more than twice the national average), poverty and environment.

Other reasons are more surprising. They include the rise in scheduling births.

It's just within the last three or four years that the scope of the problem of late pre-term births - babies born between 34 and 36 weeks' gestation - has become apparent, said Dr. Ruth Shepherd, division director for maternal and child health in Kentucky's Department of Public Health. Roughly 10 percent of all babies born in Kentucky fall into the late pre-term category.

Ideally, she said, babies shouldn't be delivered before 39 weeks.

Often, there are legitimate reasons for early delivery, especially if the health of mother or child is at risk.

Increasingly, choices are made for reasons other than health. Delivery might be scheduled to coincide with grandparents' dates of arrival from out of town, or before Dad must ship out for Iraq.

There are several complicating factors, Crawford said. The documentary states that people tend to underestimate the impact of premature births, especially late pre-term births. They tend to overestimate how accurately a due date can be determined.

Shepherd said there can be real consequences. They can include immediate physical challenges, including underdeveloped lungs and long-term problems involving learning and behavioral disabilities, for example.

And even if a mother gets an ultrasound within the first 16 weeks - the best way to accurately determine the due date - the date can be off by two weeks either way.

Those two weeks can be crucial, she said.

"It's an issue of planning and control," she said. Planning is good. The Centers for Disease Control and Prevention recommends that mothers have a birth plan. But, Shepherd said, "you can take it too far if you don't pay attention to the science."

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PregnancyWeekly.com