TAMPA — Lisa Dimitris' doctor told her in March that she would deliver her baby on June 9. She and husband Kirk marked the calendar and lined up a babysitter for Madeline and Ella, their 20-month-old twins.
On the appointed day, Lisa and Kirk arrived at St. Joseph's Women's Hospital at 5:30 a.m. Right on time at 7 a.m., Brock was delivered by caesarean section, a healthy 8 pounds, 2 ounces.
Dimitris, a registered nurse, said she never questioned whether Brock, like his big sisters, would arrive via C-section.
"It was just more of a given," Dimitris, 29, said as she held the sleeping Brock last week in her hospital room.
In hospitals across the country but particularly in Florida, surgical births are becoming a given. Nearly 40 percent of Florida babies were born by C-section in 2008; in the Tampa Bay area, the rate is 38 percent. The U.S. rate in 2007 (the most recent year available) was 31.8 percent.
A decade ago, the national rate was 21 percent and Florida's was 23 percent.
The increase, doctors say, is fueled by three main factors:
• Obstetricians fear malpractice suits if mother or baby is injured during a protracted labor and delivery.
• More pregnant women than ever are obese. Larger moms tend to have larger babies, complicating births.
• More women who have had one C-section are having subsequent babies the same way.
C-sections are the most commonly performed medical procedure in U.S. hospitals. At $12,000 to $20,000 each, they cost about twice as much as vaginal deliveries, according to state figures.
Caesarean rates have been rising around the world, but more slowly. Canada's rate is 26 percent, Great Britain's is 23 percent; Japan's is 21 percent. The World Health Organization has said the C-section rate should be no higher than 15 percent.
As the nation's leaders scrutinize medical costs and practices to reform the health system, the C-section rate will be getting more attention than ever.
It's already a hot topic in Miami-Dade County, the most expensive health care community in the country, judged by Medicare spending. More than half of all babies there arrive by C-section.
Procedure was once rare in United States
A caesarean is the delivery of a baby by surgical incision through the abdominal wall and uterus. The procedure used to be rare, accounting for just 4 percent of U.S. births in 1965. But advancements such as electronic fetal monitoring and improved neonatal care have made them safer.
Caesarean rates began to climb when it was believed that many cases of cerebral palsy were caused by traumatic vaginal births in which the baby was deprived of oxygen.
But that also led to another trend: an increase in the number of malpractice lawsuits against doctors. Before 1970, delivery-related litigation was rare.
Today, "Obstetricians tend to opt for the method of childbirth most likely to withstand a legal challenge,'' said Dr. Robert Yelverton, a Tampa physician and board member of the Florida Obstetric and Gynecologic Society.
A few decades ago, doctors assisted in difficult births with techniques such as forceps or vacuum extraction delivery. They would manually turn babies that were arriving feet first. Now many doctors automatically opt for C-sections, said Yelverton, who also is chief medical officer for Women's Care Florida, a group of more than 100 obstetrician-gynecologists from Tampa to Orlando.
The fear of lawsuits is real. One study showed that 76 percent of American obstetricians reported at least one litigation event, with a median award of $2.3 million for negligence in childbirth. Monday in Chicago, members of the American Medical Association booed loudly when President Barack Obama told the group he would not help them with their top priority — reforming the medical malpractice system.
But vaginal births are actually less risky for both mother and child. The maternal mortality rate for C-sections is three to seven times greater than for vaginal deliveries, according to the American College of Obstetricians and Gynecologists.
Obesity's role in driving C-section rates
More than one-third of American women of childbearing age are overweight or obese, another factor driving the C-section rate.
One study found that patients who had C-sections had an average body mass index (BMI) of 53, compared to an average BMI of 31 for women who delivered vaginally.
Obesity puts women at higher risk of gestational diabetes, pregnancy-induced hypertension and delivering premature babies. Obese women are more likely than others to have larger babies (over 9 pounds, 15 ounces). In such cases vaginal births can be risky for both mom and baby.
Of course, obesity isn't the only high-risk factor. Conditions such as diabetes, heart disease, STDs, hypertension and carrying multiple babies can make doctors decide against vaginal births.
St. Joseph's Women's Hospital in Tampa delivers more babies than any other hospital in the Tampa Bay area. Many of the pregnancies are in the high-risk category, and that contributes to a C-section rate of 43 percent, said Merrianne Furlong, director of women's health.
Several years ago, St. Joseph's created a family-centered delivery program for mothers who have C-sections. The centerpiece is a special recovery room where mother, father and baby can be together just minutes after surgery. Dimitris said it was one of the reasons she chose St. Joseph's.
Some women insist on caesarean sections
In the late 1990s, nearly 30 percent of women gave birth vaginally after a previous C-section. But by 2005, the rate was just 7.9 percent — another fallout of litigation, doctors say.
Complications from a vaginal birth after a caesarean are rare (less than 1 percent), said Dr. Patrick Duff, a professor at the University of Florida's Department of Obstetrics and Gynecology. But those complications can be so serious to both mother and baby, many doctors automatically schedule a C-section for such moms. Lisa Dimitris said a vaginal birth for Brock was never discussed as an option.
Some women opt for a vaginal birth after a C-section. But other women insist on C-sections even when there's no real medical reason to do one, said Yelverton.
Whether these woman want C-sections for convenience, fear of pain, fear of damaging their baby, or some other factor has not been studied.
Some doctors say too many C-sections are performed in this country.
"The rate is probably higher than can be justified on the basis of maternal or infant safety," Duff said.
"I personally think that the rate has gotten to be higher than it needs to be," said Dr. Roger Freeman, a retired ob-gyn from California, who chaired a 2000 task force that examined the soaring C-section rate.
But others say it should be solely up to doctors and parents to decide how a baby is born — mirroring the overall health care reform debate.
"We pretty much take our patients as individuals,'' Yelverton said. "And we don't try to use statistics to make a decision as to how best to safely approach a birth of an individual.''
Times researcher Caryn Baird contributed to this report. Richard Martin can be reached at firstname.lastname@example.org or (727) 893-8330