A growing number of babies are born by Caesarean section in the central San Joaquin Valley, mirroring a national trend that critics say creates unnecessary risks for both mother and child.
There's no single explanation. Some doctors say women are asking for C-sections for convenience -- so they can pick the delivery date.
But doctors themselves are contributing to the increase, because they fear being sued if vaginal births go wrong, say some women's advocates.
And some experts say doctors are seeing more women with health conditions, such as obesity and diabetes, that can complicate births and require surgery.
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Nationwide, 31% of all births are by C-section -- a record for the U.S. and up 10 percentage points from just a decade ago. In California, the rate has climbed from 21% in 1996 to 27% in 2006, the latest year for which figures are available.
At hospitals between Madera and Tulare, the Caesarean rates range from almost 24% to more than 41%.
All but three of the dozen hospitals in the region have rates higher than the state average. And a half-dozen perform more surgical deliveries than the U.S. average.
Reducing the C-section rate is a national goal. No more than 15% of low-risk births should be by Caesarean, according to Healthy People 2010, an initiative by the U.S. Department of Health and Human Services.
The increasing C-section rate is "a women's health issue," said Errin Woodward, leader of the Fresno chapter of the International Cesarean Awareness Network, a nonprofit group that works to improve maternal health and reduce the number of C-sections performed.
"Until people start to realize the damage that is being done, it's going to continue to go up," Woodward said. "But maybe people will start to realize how much more difficult a Caesarean can be than a normal birth."
With various factors contributing to C-section rates, it's difficult to pinpoint why some rates in the Valley are high and some are low.
"I don't feel like we have any doctors that are doing them unnecessarily," said Patti McCowan, obstetrics coordinator at Tulare District Hospital. But McCowan said she can't explain the hospital's 41.6% Caesarean section rate -- the highest in the Valley.
Madera Community Hospital has similar patient demographics, but it has the second-lowest rate.
Dr. Theodore Nassar, an obstetrician and gynecologist who has practiced in Madera for 30 years, can only cite a conservative approach to surgery for the hospital's percentage of surgical deliveries.
"We try to have patients have labor first," he said.
Any delivery -- vaginal or by C-section -- carries some risk.
C-sections for the most part are safe, experts say. But there are potential complications. A Caesarean section -- during which a baby is cut from the mother's abdomen -- is considered major surgery.
A few women will have increased bleeding, infection, reaction to anesthesia or other medications, injury to the bladder or bowel and blood clots in the legs, pelvis or lungs, according to the March of Dimes Pregnancy & Newborn health education center Web site. Risks to babies born by C-section include breathing problems, the organization says.
Experts say there's no consensus on how much higher the risk is for a C-section compared to a normal birth, but they agree that the surgery is riskier overall. And one recent study suggests the risk of mothers dying may be threefold that of vaginal deliveries.
"It comes down to the risks to the mother," Woodward said. "Women die in C-sections and people don't really realize that, and if the C-section rate keeps increasing, more people are going to die and more people are going to suffer severe complications."
More women would avoid C-sections if they were educated about natural childbirth and the advantages of it over a C-section, Woodward said. But it's hard to inform women. Education takes time, and doctors are too busy, she said.
A C-section can limit how many children a woman can have, Woodward said, because complications increase each time the operation is performed.
Convalescence after a C-section usually takes longer than after a vaginal birth, and women who have surgery are more likely to have trouble breastfeeding, she said. And they are more susceptible to postpartum depression after childbirth.
"When you're in so much pain and it's hard to take care of yourself and a newborn, you can feel really overwhelmed," Woodward said.
For Elizabeth Eos, 27, of Fresno, a C-section in August when her daughter wouldn't turn in the birth canal led to a six-week painful recovery.
"It hurt," she said. "The only thing I was able to hold was her -- just lifting her and holding her -- not anything extra around the house."
The lure of convenience
Yet for some women, C-sections are not only a trend -- they're trendy.
A small percentage of women are requesting C-sections to bypass the ordeal of labor altogether and to fit deliveries around personal schedules, doctors say.
"In general, all of the obstetricians in this community are seeing an increase in demand by women to have a primary Caesarean section, or a Caesarean section without going into labor," said Dr. Roydon Steinke, an obstetrician/gynecologist and president of the medical staff at Saint Agnes Medical Center in Fresno.
And women who want only one or two babies find C-sections desirable, he said. "They see it as a safe form of delivery, and they can plan the date of delivery."
While C-sections on demand remain a small fraction of deliveries, an increase in requests nationwide was enough to prompt a 2006 report by the National Institutes of Health.
A panel of experts assembled by the agency said one study suggested that requests for Caesarean delivery without medical reasons increased from 1.9% of all deliveries in 2001 to 2.6% in 2003.
The panel neither endorsed nor condemned C-sections on demand. The group said more research needs to be done to determine benefits and risks.
But the panel said doctors should carefully discuss the procedure and possible complications with their patients before agreeing to do the surgery.
Some experts say doctors aren't discouraging women from asking for C-sections because the doctors also find them handy.
When doctors do a scheduled C-section, they can be home in time for dinner, said Dr. Marsden Wagner, a former director of women's and children's health for the World Health Organization.
"It is an enormous convenience factor for the busy obstetrician," he said.
But there's little financial incentive for doctors to perform C-sections, said Dr. Conrad Chao, chief of obstetrics and gynecology at the University of California at San Francisco-Fresno Medical Education Program. Chao oversees doctors at Community Regional Medical Center.
Medi-Cal pays the same amount for a C-section as a vaginal delivery, he said. Some private insurance companies pay more for C-sections, but many don't. And much of the obstetrical care in the region is paid by Medi-Cal, the state insurance program for the poor, Chao said.
Doctors have reasons
It's unfair to judge doctors and hospitals solely on Caesarean section rates, doctors say. More women need the surgery.
In-vitro fertilization has increased cases of multiple births. And doctors say there's a trend toward older moms -- which increases the likelihood of high blood pressure and other health conditions and makes a C-section a lifesaver for mother and baby.
Hospitals where high-risk patients are seen by specialists are going to have more C-sections performed, Chao said.
"We're probably doing better than the state average when you consider our patients are much sicker," he said.
McCowan of Tulare said gestational diabetes during pregnancy is on the rise in women of all ages. Diabetes leads to bigger babies who require surgical deliveries, she said.
Legal fears loom large
Doctors say they are likely to do a C-section at the first sign of trouble during labor for fear of being sued if something goes wrong.
To allow a difficult vaginal delivery to continue puts a doctor at risk, said Nassar of Madera. "When you do a C-section, you don't get blamed as much if something bad happens."
Limits on medical malpractice judgments are needed to reduce C-section rates, said Steinke of Saint Agnes.
"That would be the one public health change that would have the biggest impact," he said.
Woodward agreed that more repeat C-sections are a consequence of lawsuits. Legal risks can prompt doctors to discourage a woman who has had a Caesarean from considering a vaginal birth, she said.
The concern is life-threatening uterine ruptures, which require emergency surgery. Doctors who do vaginal births after C-sections follow guidelines established by the American College of Obstetrics and Gynecology.
Doctors and hospitals run the risk of being sued if they don't abide by the recommendations, which call for a doctor to be present throughout labor and an anesthesiologist to be available for an emergency C-section.
One study of California births found vaginal births after C-sections declined from 24% before the guidelines to 13.5% after their release in 1999.
Some malpractice carriers no longer cover doctors who help women have normal deliveries after they've had C-sections, Steinke said.
"The pressure is to not do" the deliveries, he said.
Heather Favelo, 29 and pregnant with her second child due this April, said avoiding another C-section isn't easy.
The Fresno woman spoke with several doctors before finding one willing to do a vaginal delivery.
Two years ago, her son, Noah, was delivered by C-section when there was a risk of infection during labor. She doesn't want another C-section, because it could lessen her ability to safely carry more children. She wants "as many children as God will give us."
Doctors shouldn't make it so hard to have a baby, Favelo said. "I think God made women's bodies to have babies."