2004 C-section rate is all-time U.S. high at 29%: medical, legal, and choice issues combine.(News)

Cesarean sections constituted 29% of all births in the United States in 2004--a record high for the country, government officials have said.

The increase reflects an 8% hike in primary cesareans and a 13% decrease in vaginal birth after cesarean (VBAC) since 2002, according to preliminary birth data for 2004, which were released by the National Center for Health Statistics.

The primary cesarean rate for 2004 was about 20%, compared with about 18% in 2002. The 2004 VBAC rate was less than 10%, down from 13% in 2002 (www.cdc.gov/nchs).

The increase in primary C-sections and decrease in VBACs continue a trend established in the mid-1990s, the report noted. In 1996, C-sections accounted for just more than 20% of all U.S. births, with primary C-sections constituting about 13% of the surgeries. At the same time, VBACs rose to about 28% of births to women with a prior C-section. But since 1996, VBACs have declined sharply while C-sections have steadily increased.

The numbers are the result of a "perfect storm" of medical, legal, and personal choice issues, according to Bruce L. Flamm, M.D., area research chairman and a practicing ob.gyn. at the Kaiser Permanente Medical Center in Riverside, Calif. "All the forces are pointing toward higher C-section rates," Dr. Flamm said in an interview.

Increased intrapartum information available through electronic fetal monitoring can combine with malpractice worries to sway some ob.gyns. toward suggesting a C-section. "During labor, most ob.gyns. have in the back of their minds that any of the little blips on the monitoring strip could be used in a legal claim," he said. "While scientifically, there's not much basis for that, it can sound good in a court of law."

Similar legal worries are helping to drive down the numbers of women attempting a VBAC. "The doctor is always faced with the possibility of a uterine rupture and a lawyer who says, 'Why didn't you just do a repeat cesarean?' as if there was no risk to that procedure, either."