The cesarean rate in the United States hit an all-time high of 31 percent in 2006, a record likely to stand only until figures are released for 2007, and then only until new numbers arrive for 2008. But are one-third of women actually unable to birth without high-tech support? And is there an endpoint in sight? I know of one large community hospital that is revamping its labor floor for a 50 percent cesarean delivery rate.
In a recent essay on the subject of childbirth, surgeon and author Atul Gawande makes a case for the standardization of obstetrics. He lauds the obstetricians whose names live on in the many life-saving maneuvers to usher babies into the world, but observes, “Obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the cesarean section.” While this is a fascinating perspective on the changing of obstetrical practice, industrialized childbirth conjures up images of the factory floor. In fact, cynical staff at hospitals serving large numbers of well-insured upper-middle-class women often refer to their institutions as baby factories: these are the places in which cesarean rates are highest.
And here’s the paradox: women with higher incomes, higher levels of education, and commercial insurance have higher rates of cesarean delivery. If cesarean section is a response to any perceived risk, why would women at statistically lower risk of a poor outcome have higher cesarean delivery rates? New Jersey has the highest cesarean rate among states but no lower levels of maternal or perinatal mortality. What it does have, however, is the highest median household income.
Perhaps this paradox reflects a profound misunderstanding of risk. I have seen, over years of practice in maternal-fetal medicine, an odd and unsettling pride among women who announce that they have a “high-risk pregnancy.” Although the inherent literal meaning of the term “high-risk pregnancy” is one that entails a greater risk of a poor outcome for mother or baby, the subtext seems to be that high risk equals high value. In some cases it is difficult to persuade a low-risk woman to continue her care with a general ob-gyn practice. “I’m high-risk,” she’ll say. But does she really mean, “I’m high-status”? We now see perfectly healthy, low-risk pregnant women requesting cesarean delivery upfront.
Curiously, this vaunted right to choose stops at the door of the labor room: women are implicitly allowed — or encouraged — to make only those choices that increase the power of the physician.
IS CESAREAN SAFER?
For developing or low-income countries, where access to safe maternity care is an issue, a rise in national caesarean rates from 0 percent to 8–10 percent is accompanied by a drop in stillbirths, neonatal deaths, and maternal deaths. But across the developed world, there is no additional benefit of further increase in cesarean sections: Slovenia, with a 12 percent cesarean rate, has the same maternal mortality ratio as the United States. Nordic maternal mortality ratios are only a fraction of the American, with a 50 percent lower cesarean rate. Infant mortality rates as low as 4 per 1000 are achieved at caesarian section rates of 15 percent in a number of countries, contrasting favorably with the U.S. infant mortality rate of 7 per 1000: the American system results in infant mortality that is nearly twice as high, despite having twice as many cesareans. (Among other benefits, vaginal delivery may provide the baby with bacteria necessary for a strong immune system.)
But maybe — just maybe — a backlash is coming. A generation of American women fed their infants artificial formula because they were told it was modern, convenient, and better for their babies. Decades of medical progress later, two-thirds of mothers at least attempt breast-feeding. Perhaps women who appreciate Slow Food and cage-free eggs will “just say no” to the quick-fix cesarean culture. They will come to understand that real autonomy does not mean cesarean-on-request but a spectrum of birth options that honor women’s authentic choices.
Reprinted from the International Journal of Feminist Approaches to Bioethics from the Indiana University Press. (http://inscribe.iupress.org/loi/fab)