Cesarean deliveries can save lives. When there’s a medical need, that is.

When there isn’t, they cause unnecessary risk to mother and baby. They also drive up healthcare costs.

Experts have warned for decades that the cesarean rate is too high in the United States.

According to the Centers for Disease Control and Prevention, 1 in 3 births in the United States is by cesarean delivery, up 60 percent since 1996. The rate has declined slightly in the past several years, but it’s still much higher than it should be.

Studies show that when cesarean rates rise toward 10 percent, fewer mothers and babies die, according to the World Health Organization. When rates go higher than that, there’s no additional benefit.

In 2010, 54 countries had cesarean rates below 10 percent while 83 countries had rates above that.

Read More: History of the Cesarean Section »

Why Are Cesarean Rates so High in the United States?

There are valid medical reasons for cesarean delivery.

Problems with the placenta, multiple births, and chronic health conditions may make vaginal delivery risky. Complications of delivery may include breech positioning, fetal distress, and umbilical cord prolapse.

But in some cases, there is no medical need.

The March of Dimes is working to reduce early elective cesareans that aren’t medically indicated. The organization helps mothers, doctors, and hospitals understand the risks of early elective delivery.

One factor may be that mothers are not getting the information they need.

Women who have had previous cesareans may be unaware that they can try a vaginal birth after cesarean (VBAC). Others may be uninformed of the risks of the surgery.

For hospitals, planned cesareans are more efficient than an unpredictable labor. They’re also more profitable. A 2013 study showed that average total payments for maternal and newborn care with cesarean births were about 50 percent higher than those of vaginal births.

Providers may also fear the legal ramifications of not recommending a cesarean should something go wrong.

Jessica Mason Pieklo, senior legal analyst at RH Reality Check, is following the case of Michelle Mitchell. The Virginia woman says she was forced into having a cesarean delivery. Mitchell claims she was threatened with having her child taken away if she refused consent for the surgery.

Pieklo told Healthline there are no data on how many women say they’ve been coerced into cesareans.

“She is the first to really articulate that that kind of coercion is an assault separate and distinct from any potential violation of her constitutional rights,” said Pieklo. “The trick of course is getting the courts to agree.”

Pieklo said there are many factors that may push a provider into recommending a cesarean. “But none should demand them or threaten to take their child away for refusing the procedure. Fears of medical malpractice claims for a poor birth outcome is one factor, but if a physician properly obtains consent and refusal from their patient, then they should be protected,” she said.

“Not trusting patients to drive their own care is another and one that is more deeply rooted in paternalism and traditional medicine,” said Pieklo.

Read More: First-Time Cesareans Can Lead to Health Complications »

Mothers Taking Control

Childbirth is more than a physical experience. There are complex emotions involved. Some women may welcome a planned cesarean, but others feel let down, especially when it follows a long labor.

Dede Cummings of West Brattleboro, Vermont told Healthline her first child was born via cesarean after a 36-hour labor. The baby’s head was too large to fit through her pelvic opening.

“I was so happy to have my baby born healthy,” said Cummings. “But for years I felt like I didn't have the childbirth experience I wanted. My thoughts would invariably turn to the fact that I felt like a failure.”

For her second child, Cummings worked with a midwife. She felt more empowered and supported. After 21 hours of labor, she delivered her baby vaginally.

“This birth experience was amazing,” she said. A third child also arrived by vaginal birth.

Read More: C-Sections: Which Part Will Surprise You? »

Doctor Explains Why Rates Are Dropping

Dr. Jason James, medical director at FemCare Ob-Gyn in Florida told Healthline that recognizing that cesareans are not as safe as vaginal deliveries has driven a push to lower rates.

Cesarean delivery is major surgery. Bleeding, infection, and surgical complications are immediate risks. In the long term, it increases the dangers for future deliveries. James said patients who have had a C-section have higher likelihood of complications that could preclude a vaginal birth.

He explained that guidelines from some of the governing bodies in healthcare, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Patient Safety Foundation, have encouraged hospitals to take steps to cut down on C-sections. Numbers are now available to the public. That factors into these organizations’ reputation, ratings, and accreditation.

“Coupled with better access to VBAC, more permissible use of operative deliveries (vacuum and forceps) as well as changing the definition of ‘arrest of labor’ to allow patients to labor longer before deeming the labor a failure, are all techniques that can lower the number of patients who end up with a cesarean section,” said James.

Babies tend to do better with vaginal delivery, too.

“Those born via cesarean section may have a slightly higher risk of respiratory complications due to not having been squeezed through the birth canal,” said James. “And recent studies suggest a possible protective effect of exposure to the vaginal flora in terms of preventing future infections.”

James thinks the increased use of midwives is probably helping. A 2015 paper published in Obstetrics & Gynecology shows that he may be right.

Researchers analyzed cesarean rates in California’s Marin General Hospital. Study authors linked changing from private practice to a collaborative midwifery-laborist model to lower cesarean rates and higher VBAC rates.

James believes women have also become more empowered. They’re taking a more active role in choosing the course of labor to achieve more natural childbirth experiences.

Read More: Number of Women Who Die from Childbirth Drops Dramatically Worldwide »