The Myth of the Elective C-Section

Miriam Pérez

When the media covers the rising rate of c-section, it’s often ready to lay the blame at the feet of a woman we’re come to know well over the last few years -- the busy career mom scheduling her delivery between important business deals. But while some moms may be requesting surgical birth, research shows that has little to do with the overall increase in c-section rates nationwide.

Cesarean sections have been
hitting headlines a lot lately. We’ve been hearing about the rising c-section
rate, now above
30% and rising
, for months, and in early June we learned that women
have been denied
health insurance coverage because of previous cesareans
. A few days later,
the March of
Dimes reported
that 92% of preterm births were delivered by c-section.

When the media covers the
rising rate of c-section, it’s often ready to lay the blame at the feet of a
woman we’re come to know well over the last few years — the busy career mom
scheduling her delivery between important business deals, penciling in labor
and delivery the way she pencils in a client meeting. As criticism of surgical
birth mounts, the idea that mother-initiated c-sections are spurring an overall
increase in the practice has only become more popular.

In mid-April
(coincidentally also Cesarean Awareness
Month
), Time Magazine claimed that Choosy
Mothers Choose Cesareans
. Euna Chung, a child psychiatrist in Los Angeles, told Alice Park that she planned her c-section before she was even pregnant. Park wrote of Chung,
"a combination of having watched traumatic vaginal
deliveries in medical school and hearing about her mother’s difficult emergency
caesarean experience after trying to deliver vaginally helped make up her
mind." Chung told Time, "I had a fear of going through labor and ending up with
an emergency C-section anyway. I know that’s rare, but I didn’t want to deal
with it." A recent Today show
segment
picked up on this supposed phenomenon, referring to the trend as
"babies on demand." Dr. Judith Reichman, the expert obstetrician on the show
reported National Institutes of Health Statistics that approximately 2% of all
c-sections nationwide can be considered "cesarean deliveries on maternal
request."

While the media likes to use these
stories of maternal demand as attention-grabbing hooks for their reporting on
the rise in c-section rates, other birth advocates and birthing rights
organizations take issue with the "mother’s choice" frame. Our Bodies Ourselves’
recently released book "Pregnancy and Birth" explains that the studies which
produce data like what Dr. Reichman referenced is flawed and not at all
conclusive:

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Although some
studies describe an increase in caesareans without any medical indication, the
authors of these studies are clear that these may not represent real ‘maternal
request.’ The studies, based on birth certificates or hospital billing records,
have no way of documenting whether the caesarean was initially sought by the
mother, whether it was based on physician advice or pressure, or whether there
was simply poor record keeping.

These
advocates argue that while there invariably are some women who are choosing casareans without medical reasons, they do not represent a significant enough
percentage to account for huge increase in c-sections in the last decade. In
other words, some moms may be requesting surgical birth, but that has little to
do with the overall increase in c-section rates. Childbirth Connection’s most
recent survey Listening
to Mothers survey reports
that just one woman in 1600 actually reported
having a first c-section because she chose and planned it ahead of time without
any medical reason – a rate far lower than the 2% suggested by Dr. Reichman on
the Today Show.

Does it do any harm when the media,
doctors and others point to mother’s choice as the reason behind higher c-section
rates? These advocates argue that it takes away attention from the how decisions
related to pregnancy and childbirth are really made: often, under intense
pressure from the woman’s physician.
Childbirth Connection explains, "There is a change in practice standards
that reflects an increasing willingness on the part of professionals to follow
the cesarean path under all conditions. In fact, one quarter of the Listening
to Mothers survey participants who had cesareans reported that they had
experienced pressure from a health professional to have a cesarean." Even if
women are reporting a choice for cesarean, Childbirth Connection and others
argue that women aren’t making decisions about their mode of delivery in a
vacuum; rather, they are deeply impacted by the opinions and guidance of their
providers. Lamaze
International explains
, "What women hear from obstetricians
powerfully influences what they think. Some obstetricians think so little of
the risks, pain, and recovery of cesarean surgery that they feel that ‘convenience,’
‘certainty of delivering practitioner,’ and ‘[labor] pain’ justify performing
this major operation on healthy women."
When physicians talk up convenience and don’t give air time to possible
complications resulting from c-section, it’s no wonder women make decisions in
the same terms.

What makes these advocates the
angriest, though, is the implication that doctors who support a woman’s right
to elect a c-section do so because they believe in supporting all of women’s
choices around how they want to give birth. Quite the opposite, says Lamaze
International
:

Obstetricians champion a woman’s right to choose elective
surgery on grounds of ‘patient autonomy’ but deny her right to refuse one.
Access to vaginal birth after cesarean (VBAC) has declined precipitously in
recent years and is currently unobtainable in whole regions of the United
States…Until such time as obstetricians support a woman’s right to refuse as
well as choose surgery, the promotion of ‘maternal request’ cesarean must be
viewed with extreme suspicion.

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