"MORE THAN HALF"??? Really? That is scary, and thankfully, not true where I practice.
At my hospital, the rate is more like 23%. I do believe there is a real increase in csection rates, and part of it can be directly correlated with rising INDUCTION OF LABOR rates. (among other things I will address in a few minutes).
Many women, I believe, are induced for labor before their bodies are "ripe". Why? Well for convenience, very often. Most often women will badger our physicians "to get it over with" They are tired of being pregnant, very tired of the discomforts and sleepless nights. But physician convenience strongly comes into play here, too. You will VERY often see a physician induce labor when he/she is on-call for a given period of 24 hours or scheduled to go out of town, or some other such thing. But it comes down to this fact: If the body is NOT ready to give birth, very little we can do in the medical community will truly change that. "failed inductions" and "failure to progress" are seen all the time in my practice.
Another factor: The use of continuous fetal heart monitoring is VERY controversial. Its value in improving outcomes in labor/deliver has been called into question over the years, and it has been postulated by some it does not improve the outcomes. Definately, some health care providers are eager to "jump the gun" when a baby has some questionable or non-reassuring patterns, and "call the section". Anecdotally, I have observed over time, the most experienced OB's tend to "wait it out" a bit longer, as long as there are reassuring aspects to the fetal heart patterns. The newer ones tend to get very excited and eager to go to section.
I also think consumer demand and litigious natures of obstetrics guide the rising rates. People want what they want and they want it NOW in our society! There are women who have actually told me they would prefer a csection to "save my bladder" or not have to endure hours and hours of labor. On our parts as HCP's, we are eager to always have good outcomes, so again, when a baby starts to show distress, the csection is always considered to prevent decreased oxygenation/acidosis later on, of the baby. In some cases, this is warranted. But how many, truly? I have seen 9/9 Apgar scores on countless babies who had truly "crummy strips" while mom was in labor. So, what did we accomplish? Well, some would say the csection was the reason the baby came out ok, saving further stress. Others would say we are "jumping the gun". Again, the practice will always to "err on the side of caution", particularly in obstetrics.
To sum it all up from where I sit (and this is just me, now), I think there are a lot of reasons csections are on the rise:
1. the use of continuous fetal heart monitoring (raises anxieties of both birth family and health care providers)
2. the ever-increasing litigious nature of the society in which we practice and live
3. the increasing rates of induction for purposes that are outside the realm of truly MEDICAL necessity
4. the increased desire to "meet a schedule" of both birthing family and doctor
5. the increasing expectation by the public that everything be "by the book" perfect. less than perfect outcomes (as seen on Baby Story) are not tolerated by anyone, even if they are not truly "bad" (I am putting this poorly, but I lack better words). doctors/midwives are under great pressure to produce the ideal out come on a schedule, I am trying to say.
6. Later bladder and pelvic integrity are being looked at more and more. Labor/birth are being increasingly linked (not necessarily rightfully, IMO), with later incontinence and the rise in hysterectomies and "bladder tucks" is being seen, as well. In my opinion, we are a nation in search of a quick, easy and permanent "fix"---- ("why do all those damn kegals, keep my weight in check, etc., when I can just have my bladder tucked later or avoid all this altogether by having a csection"?)----- our surgery rates reflect it, including csection and later, hystectomy and bladder procedures.
7. One truly legitimate concern: the rise of LGA babies (large for gestational age). I think we are seeing ever-increasing rates of gestational and Type 2 diabetes in the population, and as a result, larger babies are being born. We are becoming fatter and fatter and our eating habits worse and worse, leading to earlier occurences of diabetes, that used to set in more in people in their 50s and beyond. To expand:
Many physicians will do serial size u/s to see how big the baby is, and will induce at anywhere from 36-38 weeks' gestation to avoid the very real and present danger of of dystocia (the baby getting "stuck", particularly at the shoulders). If a baby is measured as truly macrosomic (greater than 4200 grams generally), , particularly in a woman with a pelvis that is measured to be small, a csection is very strongly considered and encouraged to avoid the dangers of dystocia. Diabetes is *EPIDEMIC*, and so we in the obstetric community have to respond in kind---yes by education and prevention, but also by avoiding dystocia of macrosomic fetuses. But make no mistake, diabetes has HUGE and increasing consequences in the birthing community as well as the general population.
Hope all this makes sense. I am not quoting studies, although I have read quite a few from AWHONN and ACOG. I am just giving you what you requested, a perspective from an experienced OB and GYN surgical nurse. Hope I helped you some.
I am sure there are more experienced and better- educated people who can chime in here. I would be eager to read their insights.