The Myth of the Elective C-Section

By Miriam Pérez, RH Reality Check. Posted July 15, 2008.

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:

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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Miriam Pérez has worked with various Latino community reproductive health organizations in Pennsylvania, helping pregnant immigrant women access prenatal care and health insurance. She is a trained doula.

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