All along, Julia Maeda knew she wanted to have her baby naturally. For her, that meant being in the hospital, vaginally, without an epidural to ease the pain.

This is her first pregnancy. Although she was a nurse, she was working with cancer patients, not mothers or babies in labor. “I really didn’t know what I was doing,” said Maeda, now 32. “I didn’t do much preparation.”

Her home state of Mississippi has the highest cesarean delivery rate in the U.S.—nearly four in 10 women who give birth there do so by caesarean section. Nearly two weeks past her 2019 due date, Maeda was one of those when doctors came to her bedside during her labor.

“‘You’re not in pain, and your baby isn’t in pain — but we don’t want that for you, so we need to think about a C-section,'” she recalls her doctor saying. “I was totally defeated. I just gave in.”

C-sections are sometimes necessary and even life-saving, but public health experts have long argued that too many are performed in the United States. They see it as a major surgery with huge risks and high prices.

Overall, 31.8% of all births in the U.S. are Caesarean section in 2020According to the latest data from the Centers for Disease Control and Prevention, that was only a slight increase from 31.7% the year before. But that’s close to the 2009 peak of 32.9%. In many states, especially in the South, the rate is much higher.

These high rates have persisted—and even increased slightly—in some states, such as Alabama and Kentucky, despite ongoing calls to lower them. Although the pandemic has brought new challenges for pregnant women, research shows U.S. caesarean section rates not affected by COVID. Instead, obstetricians and other health experts say high rates are a tricky problem.

Some states, such as California and New Jersey, have reduced C-section rates through various strategies, including sharing C-section data with doctors and hospitals.But change has proven difficult elsewhere, particularly in the South and Texas, where women are often less healthy prior to conception and where maternal and child health problems are among the highest in the U.S.

“We have to recalibrate how we think about caesarean sections,” said Dr. Veronica Gillispie-Bell, an obstetrician and medical director of the Louisiana Perinatal Quality Partnership, a group of 43 birthing hospitals working to reduce caesarean section rates in Louisiana. “It’s a life-saving technique, but it’s not without risks.”

A C-section, like any surgery, creates scar tissue, including in the uterus, that can complicate future pregnancies or abdominal surgery, she said. C-sections also often lead to longer hospital stays and recovery periods, and an increased chance of infection. Babies are also at risk. In rare cases, they may be scratched or cut during the incision process.

Although C-sections are sometimes necessary, public health leaders say the procedures are overused in many places. Black women, in particular, are more likely than any other racial group in the country to give birth by caesarean section. Often, rates vary widely by hospital or even by region and cannot be explained.

“If you deliver Miami-Dade County, your chances of having a cesarean section are 75% higher than in northern Florida. ” William Suppenfieldan obstetrician and epidemiologist at the University of South Florida, who has studied the state’s high C-section rate.

Some doctors say their costs are determined by the mother who requested the surgery, not by the doctor. But Dr. Rebecca GeeThe obstetrician-gynecologist and former secretary of the Louisiana Department of Health said she saw a sharp rise in caesarean section rates at 4 p.m. and 5 p.m. — around the time doctors want to go home.

She has led several initiatives aimed at improving birth outcomes in Louisiana, including standardizing Medicaid payments to hospitals for vaginal births and C-sections. In most places, C-sections are significantly more expensive than vaginal births, making high C-section rates a concern not only for pregnant women but for taxpayers as well.

Medicaid pays for 60% of all births in Louisiana, according to KFC, and about half of all births in most southern states, compared with 42 percent nationally. This is one of the reasons why some states, including Louisiana, Tennesseeand Minnesota – Attempts to address high C-section rates by changing what Medicaid pays for. But Ji said payment reform alone will not be enough.

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“One person in central Louisiana does more C-sections and early elective births than anyone in the United States,” she said. “When you have a culture like this, it’s hard to get rid of it.”

Linda SchwimmerMany hospitals and doctors don’t even know their C-section rates, said the president and CEO of the New Jersey Institute for Quality in Healthcare. Sharing the data with doctors and hospitals — and making it public — made some providers uncomfortable, but it worked in the end, she said.New Jersey Cesarean section rate Once the country began sharing these data, along with other initiatives, the percentage of low-risk mothers fell to 26.7 percent six years later, from 33.1 percent in 2013.

The New Jersey Institute for Healthcare Quality and other similar groups across the country are focused on reducing the subset of caesarean sections known as “nulliparous, term, singleton, apex,” or first-time full-term mothers who deliver one head down in the womb baby.

NTSV C-sections are important for tracking because women who have C-sections during their first pregnancy face a 90% chance of getting pregnant again in subsequent pregnancies. Across the U.S., the rate of these caesarean sections was 25.9% in 2020 and 25.6% in 2019.

PhD. Eliot LordMaternal Fetal Specialist at Stanford University and Medical Director of the California Partnership for Maternal Quality Care, Co-authored a paper, published last year in JAMA, outlines interventions by the collaboration to reduce the NTSV caesarean section rate in California from 26.0% in 2014 to 22.8% in 2019. Nationally, the rate did not change over the period.

He said it was important to have women work longer before undergoing surgery.

Before a woman gives birth, the cervix must dilate by 10 cm. In the past, the threshold for “active labor” was a cervical dilation of at least 4 cm.However, in recent years, the start of active labor has been changed to 5 to 6 cm.

“People show up in the hospital prematurely,” said Tony Hill, president of the Mississippi Midwives Union. “If you show up in the hospital with 2 to 3 centimeters, you can go for weeks with 2 to 3 centimeters. I don’t even think about that kind of labor.”

Many times, women who are in the early stages of labor end up having their labor induced and delivered by caesarean section, she said.

“It’s almost like, at this point, C-sections are handed out like lollipops,” says Doula LA’Patricia Washington in Jackson, Mississippi. Doulas are trained non-medical workers who help parents before, during and after childbirth.

Washington, in partnership with a nonprofit, A Safer Childbirth Experience in Jackson, pay doula fees to help expectant mothers in the area.Some state Medicaid programs, such as Medicaid in New Jersey, reimburse services through Doula because research shows They can reduce caesarean section rates.California has been trying roll out the same benefits for its Medicaid members.

In 2020, when Julia Maeda became pregnant again, she bought a doula out of her own pocket to assist in the delivery. The experience of giving birth to a son by C-section the previous year was “emotionally and psychologically traumatic,” Maeda said.

She told her OB-GYN that she wanted a VBAC, short for “vaginal birth after cesarean.” But, she said, “he just shook his head and said, ‘That’s not a good idea.'”

Anyway, she has VBAC. Maeda credits her doula for making this happen.

“Maybe it was just her presence that communicated to the paramedics that this was something I took seriously,” Maeda said. “They want you to have kids during work hours. Biology doesn’t work that way.”

Kaiser Health News is a national health policy news service. It is an independent editorial project of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.