Then what should we do about the C-section rate?

Inspired by a discussion on my last post with reader Amanda Anderson, I want to talk more about the rate of Cesarean sections in the U.S., and what, if anything, I think ought to be done about it.  Most definitely, the answer is not hanging creepy “awareness” ribbons.  I am not a medical professional—just a rather opinionated C-section mama.

Be realistic about the issueSo the C-section rate in the U.S. is “too high”?  What does that mean?  Let’s look at some numbers: In 2014, 32.2% of all deliveries were by C-section.  However, only 26.9% of low-risk deliveries were C-sections.  That’s still a pretty big percentage, and the U.S. Department of Health and Human Services agrees: they’d like to see the C-section rate for low-risk deliveries get down to 23.9% by 2020.

“Over the past three decades the WHO-proposed caesarean section rate of 10–15% was used as a threshold, despite the lack of concrete evidence to support this statement.”—Ye et al. (2015)

23.9% might be higher than some target numbers you’ve heard.  It’s very common for midwives and company to quote the old 10–15% C-section rate advocated by the World Health Organization (WHO), although the WHO no longer quotes a specific target rate and the original numbers were based on scant data.  It’s clear that 10% is a solid bare minimum, but recent studies show that maternal and neonatal mortality rates continue to drop until C-section rates are at least 20%.  (And bear in mind that death isn’t the only possible negative outcome; oxygen deprivation during birth can lead to severe brain damage, and even less severe effects like a broken collarbone are perhaps not desirable.)

So when I say “be realistic,” I mean this: don’t look at the U.S. C-section rate as being twice as high as it ought to be.  It’s more like a few percentage points higher than the optimum.

Recognize that it’s about risk.  It’s easy to say that if the C-section rate is too high, then some C-sections must be unnecessary, but which ones?  How can we tell in advance?

The reason for my C-section was a breech baby (meaning he was oriented head-up instead of the usual head-down).  Doctors like to avoid breech vaginal births because there’s a chance the baby’s head could get stuck after the rest of its body has already been born, a scary and potentially deadly situation.  But it doesn’t happen that often: for every 111 breech babies delivered the normal way, 1 baby dies.  Meaning, 99.1% of the time, that baby could’ve been born vaginally just fine, and so technically that C-section was “unnecessary.”  But we can’t tell in advance which babies will make it through—are you willing to take that 0.9% risk?

“Obstetricians are sued more frequently than physicians in most other specialties, awards against them can be very large, and they pay more for liability insurance coverage than any other specialty except neurosurgeons.”—Yang et al. (2009)

Risk is also at play when it comes to hospital rules, like how long you’re allowed to push during the second stage of labor, and whether or not you can attempt a VBAC (vaginal birth after cesarean).  For better or for worse, we have a very sue-happy culture in the U.S.  If your local hospital’s medical malpractice insurance doesn’t cover VBACs, they’re kind of stuck.

Don’t demonize doctors.  I’m sure there are obstetricians out there who are overly pushy when it comes to medical interventions in childbirth, and who make women feel out of control.  There are also midwives who are too pushy in the other direction and contribute to maternal and fetal deaths.  Every profession has bad apples, and humans in general are very susceptible to ideology.

But here’s my anecdote as a counterpoint: my OB very seriously warned me about the risks of a C-section and encouraged a version, which is when a doctor tries to turn the baby from the outside.  The specialist who did the version tried and tried, far beyond the expected three attempts, until his arms shook, because it seemed like my baby might turn.  The hospital was as nice of a place as hospitals can be, and the nurses were wonderful throughout.

Moving beyond anecdotes, I believe we shouldn’t put too much blame on doctors because we need them to work with us.  If there are medical practices that need changed, doctors are going to be the ones to do it.  Painting them as scary interventionists who just want to get to their golf games is not only largely untrue, it’s antagonizing to the very people who could be our greatest allies in improving obstetric care.

Focus on maternal health.  Your average media article about the U.S. C-section rate treats it as the problem.  But what if it’s the symptom?  We know that the U.S population has high rates of obesity, heart disease, and diabetes, all conditions that make pregnancy and birth more risky.  We know that income inequality and access to affordable health care are huge issues in this country.  I believe that if we focused on those issues, mothers and babies would be healthier, and the C-section rate could naturally fall.

Speaking from my own experience, U.S. health care is a pain in the butt to navigate.  It’s a maze of insurance and referrals, waiting lists and three-letter acronyms.  And I’m an educated person, with financial and family resources—exactly the kind of person who ought to find it easiest to get good health care.  Imagine a mother who can’t easily take time off for OB visits every few weeks.  Who can’t rest up in late pregnancy because she has to save up all her sick days for after the birth.  Who can’t afford her co-pays.  Her prenatal health is going to be worse, and she’s going to be at greater risk of needing a C-section.

I often see the U.S.’s C-section stats compared to those of countries in northern and western Europe.  You know what those countries have?  Socialized medicine!  Social safety nets!

Support research.  And no, I don’t mean more research about the many possible ways in which C-sections could be scary.  I mean research about the facts of birth.  For instance, a 2014 study showed that with an epidural, it can be safe and normal for the pushing stage of labor to last up to nearly 6 hours, twice as long as the accepted norm.  That’s good, useful information, because it can inform hospital and obstetric policy.  Knowing that, doctors won’t feel like they’re taking as much of a risk letting women push for longer.

We need more data like that.  What is a “normal” labor for women in the U.S., given the current health and demographics of the country?  Can we find more markers of “low-risk”?  Can we develop better technology to measure pelvic widths (to rule out the problem of a too-big head), or to better augment labor when it’s slowing (to keep things going without a C-section)?  The better we can distinguish who’s going to need a C-section before birth, the more we can keep the rate of C-sections where it needs to be.

Make birth centers more available.  One story I hear over and over again is that women didn’t feel like they had any choice about the situation in which they gave birth.  Proper birth centers, that are staffed by proper nurse midwives (CNMs), and that have referring relationships with hospitals, would help with that.  They’re relatively rare, for reasons that I don’t completely know but suspect relate to insurance and perhaps to a general lack of CNMs.  (Midwifery qualifications in the U.S. have several tiers; only CNMs have qualifications on the level of midwives in Europe.)

Birth centers wouldn’t change the underlying health issues faced by many women, or reduce the number of high-risk births, but by offering a choice, they might bring the low-risk C-section rate down that last few percentage points.

And finally…

Stop scaring mothers.  I’ve said this before and I’ll say it again: we have to stop telling women that C-sections are bad.  If we set them up to believe that the surgery will be a bad experience, they’re much more likely to feel that it was.  Now, I know women who’ve had scary C-sections, because they were in an emergency situation and had to suddenly stop pushing and be rushed to the operating room.  I also know women who’ve had scary vaginal births, with stuck shoulders and painful tears.

The burden of changing the C-section rate does not lie on individual women, nor should it.  Women should be free to choose Cesarean if that’s what they want, or if it’s what they feel offers the safest route to a healthy birth.  No woman should be made to feel the need to defend her C-section, chosen or not.

Well, readers, I think that’s all I have to say on this, for now.  What do you have to add?

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One thought on “Then what should we do about the C-section rate?

  1. “The burden of changing the C-section rate does not lie on individual women, nor should it.”

    This, so much.

    The reason doctors (and midwives) go to school so long is to have the expert knowledge to know how to handle a situation. I found an OB that I liked, who I felt listened to me, and I trusted her. I had a rough vaginal birth, and I don’t particularly want to go through that again, but I felt like my doctor was thinking about the best interests of me and my baby. A friend gave birth the exact same day, same doctor (right after us, in fact), and had a C-section because that was safest for her baby.

    I also concur that I’d like to see more concern on pre-natal care and even preventing unwanted pregnancy. We in the US are better at hand-wringing about symptoms than trying to address the sticky underlying problems (for example, our current debate about abortion rather than focusing on strong family planning and the reasons people have abortions). I think you’ve done a good job summarizing ideas that could help us naturally lower our C-section rate and create better outcomes in general.

    Liked by 1 person

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