Talk to doulas and childbirth educators today and they'll sigh when you ask about the rates of Caesarean-section births. After a few decades in which natural childbirth was all the rage, the pendulum is swinging the other way, for a variety of reasons.

In the past decade, for example, the U.S. C-section rate has jumped from 20.7 percent in 1996 to 29.1 percent in 2004. Though slightly lower than the national average, Hawai'i's rate is up slightly from last year (see chart).

One reason for rising C-section rates is that more older women are getting pregnant, and older mothers have more health risks, such as diabetes and higher blood pressure. But sources note that C-section rates increased notably when guidelines for obstetricians were changed to require that for a vaginal birth after Caesarean, called VBAC, both a doctor and anesthesiologist must be on hand for the attempt. This excludes many hospitals. Recently, medical guidelines also recommended breech deliveries be delivered via C-section.

"All those (breech births) who may have delivered naturally now are getting C-sections," said Dr. Eesha Bhattacharyya, a local obstetrician.

In addition, there's been a change in attitude about surgery in general, Bhattacharyya said. While many women wouldn't attempt surgery without a reason, others see friends getting breast implants and celebrities choosing C-sections to fit their schedules — though nurses and doctors here say that is frowned upon locally.

"Here in Hawai'i, certainly there are situations it would be reasonable to do (an elective C-section)," Bhattacharyya said. "But most of us don't have a lot of patients asking."

If a mother came to him to ask for a second C-section, Bhattacharyya may suggest she try a vaginal birth, especially if she's planning to have more children. But when a mom who had suffered for two years of severe incontinence after her first birth, then found out she was pregnant again, asked about an elective C-section, he had to wrestle with it. He went to a national meeting with colleagues, where he discussed it and decided hers was a reasonable request.

"I'm not a big fan of elective Caesarean, but if people really understand the issues and have a reason, I wouldn't say no," said Bhattacharyya.

In Hawai'i, the VBAC numbers are falling. In 2005, there were 249 VBACs; in 2006 there were 217 VBACs.

Hospitals have different rates for the procedures, too.

Hospitals' most recent figures, as provided to The Advertiser: At Kaiser, the C-section rate is 23 percent, and the rate for vaginal births after Caesarian deliveries is 29 percent. Kapi'olani has a 25 percent C-section rate and 20 percent VBAC rate. Queen's reports a C-section rate of about 21 percent to 23 percent, and a 12 percent VBAC rate.