Abstract: From 1965 to 1979 the cesarean section rate in the United States increased 264 percent. An analysis in 1979 identified several contributing factors, including fear of malpractice suits, the custom of repeat cesareans and operative delivery for breech-presenting infants, increased diagnoses of dystocia and fetal distress, physician training, economic incentives, and the concept of “premium babies.” From 1979 to 1987 the cesarean section rate increased 48.8 percent to an annual rate of 24.4 percent. Current analysis finds the same factors still interacting to continue the upward trend. Growing use of vaginal birth after a previous cesarean, increased recognition of the imprecision of electronic fetal monitoring, greater public awareness, and professional peer review activities are beginning to slow the rate of increase.