10/19/2018

Why Are More Expecting Mothers Having C-Section Deliveries?

26:47 minutes

A painting of a 17th century pregnant woman and her doctor
“Physician and a Woman Patient,” by Jan Steen. Credit: Public domain, via Wikimedia Commons.

Giving birth through a cesarean section, or C-section, is nothing new—in fact, Pliny the Elder suggested that being born this way is how Julius Caesar got his name. Today, the World Health Organization recommends that the C-section rate should be about 15 percent of births, for optimal outcomes for mothers and babies. But a series of studies published in The Lancet this week shows that rates worldwide are much higher. In the past 15 years, worldwide rates have nearly doubled. In the United States, one out of three children are born through the procedure. At the same time, the rate varies within countries—showing certain communities may have limited access to lifesaving procedures.

Holly Kennedy, a professor of midwifery and one of the authors on that series, and obstetrician-gynecologist Toni Golen discuss the effects C-section can have on mother and child, and what can be done to lower use of C-sections.

Did you or your partner get a C-section? What factored into the decision? What was your experience like? Let us know in the comments below.

Related Links

Interview Highlights

On the disparities of cesarean section rates around the world.

Holly Kennedy: What we found was that over 60 percent of countries overuse C-sections, and 25 percent underuse the the procedure. So there’s a quite a disparity and there are multiple reasons: Part of it has to do with the sort of socio-cultural acceptance of surgery as a normative thing to do; Part of it has to do with insurance and access; A large part of it has to do with women not being able to get a vaginal birth after they’ve had their first cesarean. So, it’s complicated. We’ve seen the rise particularly in North America, Western Europe, Latin America, and the Caribbean. For example, Latin America—it’s gone from 32 percent to 44 percent. And there’s a bit of a paradox when what we would call “too much, too soon” and “too little, too late.” So in the countries that overuse cesareans, they are probably intervening too much in low-risk women that really don’t need the procedure. And in countries such as [the ones] in Africa that don’t have enough access, probably are underusing it. The World Health Organization suggests that 15 percent is about right, so when you think about 1 in 3 women in the United States having had cesareans, we’re way over.

On which demographics are most likely to get a C-section.

Holly Kennedy: Interestingly enough, women that have greater education are more likely to have a cesarean, which is a bit of a paradox in itself because a cesarean is not a low risk surgery. It’s major surgery and there are small but serious risks—with the immediate surgery, and then later in terms of the scar and stillbirth in preterm birth with subsequent pregnancies. And that’s one small piece of the puzzle in the United States for the increasing maternal mortality rate.

[Can babies tell if you’re joking?]

On whether the rising cesarean rate in the United States is caused by women requesting the procedure.

Toni Golen: I think there’s a natural suspicion that this is a major contributor to the cesarean epidemic in the United States at this point. And while it’s true that women can request to have a delivery via cesarean, it turns out that’s not really the most significant driver. In our experience at Beth Israel Deaconess [Medical Center], for example, which is a tertiary care institution and academic hospital in the middle of Boston, it really only contributes to about 1 percent of our deliveries per year. So while some of this could be attributed to patient opinions or patient desires or their perceptions of what’s safer, the truth is that we as healthcare providers need to realize that we are probably the major, major contributors to the rise in cesarean delivery rate here in the U.S.

On the risks of multiple C-sections vs. VBAC (vaginal birth after cesarean) deliveries.

Toni Golen: We see that as our obligation as obstetricians and midwives to really spell out what the risks are. I think we tend to sometimes overemphasize the risk of VBAC. The risk of VBAC can be something quite catastrophic, but it’s rare. The benefit of a VBAC is that for births that happen thereafter it’s highly more likely. So, for example, if someone is going to have a third or a fourth baby, it’s highly more likely that that person would have a vaginal delivery if she’s once had a VBAC. That really is something that contributes to the overall, lifelong health of a woman because the risk of a cesarean delivery is not only related to the hour or so—or even the days or so—that follow a first cesarean delivery, but it traces forward to the years that followed, in some cases decades that follow. Women who have had cesarean deliveries are just more likely to have repeats cesarean deliveries, as your caller almost did, increasing the risk of life threatening complications.

On the challenge of using home birth as a way to promote vaginal birth.

Toni Golen: The important thing to keep in mind, regarding the example of home birth in the United States and that being an extension of the healthcare system and promoting vaginal birth, is that while home births in many countries is a safe option and is a way to promote vaginal birth, we haven’t quite figured that out in the United States. It is important in a healthcare system that promotes home birth to be able to make a really clear connection between home and hospital, and when certain thresholds are reached, then a patient needs to be moved from home to hospital. That’s the part that we haven’t quite figured out here yet. And until we figure that out, I think it’s it’s going to be challenging to really embrace that as an option to promote vaginal birth.

On how using midwives could potentially help lower the C-section rate.

Holly Kennedy: When this Lancet series on C-sections came out, the World Health Organization also issued a new guideline to help help us look at decreasing cesareans. And one of the things that they have recommended is what the U.K. does, which is to have a collaborative midwife-obstetrician model of care where the midwife does most of the primary care. And that’s what happens in the UK—all women have a midwife and some women have an obstetrician too, when it’s really needed. The Lancet also published a series on midwifery, a very extensive review of the evidence, and they found that midwifery was associated with improved outcomes—including decreasing C-sections. And so what I’d like to just mention in the United States, a study came out earlier this year that mapped the integration of midwifery across each state, to see how friendly the state was to midwifery practice. And so if you look at New Mexico, which has the lowest C-section rate of just about 18 percent, 26 percent of births are attended by midwives in that state. Conversely, New Jersey has the highest rate of 33 percent [of C-sections] and only 7 percent of births are attended by midwives. Then they match that with outcomes. And if you look at Alabama, which has some of the worst maternal and infant outcomes in the country and only 1 percent of births are attended by midwives. So, that’s not a causation, it is an association-type study, but it is pause for thought.

On how Beth Israel Deaconess Medical Center lowered their C-section rate.

Toni Golen: Well, first we recognized that we had a problem, and I think that’s step one in trying to solve it. Then we looked toward the evidence—not just our own evidence, but the national evidence about what was contributing to mostly in terms of the indications for cesareans—and focus very narrowly on primary cesarean. [Then, we] looked at the interpretation of how we monitor fetuses while women are in labor. That kind of monitoring, called fetal heart rate monitoring, is very tricky. It’s quite inaccurate—it predicts quite well for us when babies are well, but does not do a good job of telling us when babies are unwell. Obstetricians base decisions on this test. I often say that in no other area in medicine would we make surgical decisions based on such a faulty test. Nonetheless, it’s ubiquitous and people use fetal heart rate monitoring. So we focused on really trying to focus on describing the fetal heart rate tracing using science and objective criteria rather than subjective words. We focused on our documentation, our communication. We also really tried to make sure that people were using scientific, modern definitions for progress in labor. Old definitions assumed that women would move much faster in labor than newer, more modern data really proved to us. We wanted to make sure that people use modern definitions for what we thought was normal labor.

[How to restore maternal microbes to babies born by C-section.]

On whether your hospital may determine whether you get a C-section or not.

Toni Golen: Unfortunately it does. One of the reasons why we know is that we have room to improve on cesarean delivery rates is that if you look from one hospital to the next—even separated by one or two miles from one another, who take care of patients who have similar medical problems, are of similar demographics—their cesarean delivery rates may vary by as much as 10 percent. This is unexplainable by any other reason other than the environment, the unit that you work in, the people that you work with, and the general enthusiasm for vaginal birth.

On whether insurance rates affect the C-section rate in the United States.

Holly Kennedy: Women who are having more money, who are wealthier, will have more C-sections, which implies that they can get reimbursed for that. One of the recommendations that the series made was to not pay more for cesarean, to really level the playing field, in addition to liability reform. In many studies that I’ve conducted, obstetricians have said to me, you know, I won’t get sued if I do a C-section—but I can get sued if I don’t do one in time, or perceived to be in time.

Toni Golen: That’s the issue of reimbursement is interesting here in the U.S., where by and large, physicians and obstetricians do not get a vastly different amount of money for a vaginal delivery than a cesarean delivery. However, the hospital does. And that is something that I think isn’t quite transparent for patients, and probably reimbursement itself doesn’t influence a lot of obstetrician decision-making here in the U.S. The reimbursement is greater, but it really goes more toward the hospital side because of the length of stay.

On whether the type of birth determines what type of parent a new mother will be.

Toni Golen: I think it is important to realize that regardless of how a baby is born, the person who gives birth to the baby becomes a parent after that happens. It’s no less or no more, regardless of what the mode of delivery is. A cesarean delivery certainly makes you just as much as a mother as having a vaginal delivery.

Segment Guests

Holly Kennedy

Holly Kennedy is a professor of Midwifery at the Yale School of Nursing in West Haven, Connecticut.

Toni Golen

Toni Golen is the Vice Chair of Quality in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center in Boston, Massachusetts.

Segment Transcript

IRA FLATOW: This is Science Friday. I am Ira Flatow. For anyone having a baby, the decision to have a C-section is not unusual. But what is unusual is the number of C-sections happening all over the world.

Listen to this. The worldwide rate has nearly doubled from 12% to 21% in the past 15 years. And in the United States, one out of three births is by C-section now.

A series of studies in the journal The Lancet looked at this trend to see what is behind this uptick. What are the effects on mothers and babies? And what interventions can be done to decrease that number. And that’s what we’re going to be talking about, C-section rates globally, also what’s happening here in the US.

And my question for you listeners is, did you or your partner get a C-section? What factored into that decision? What was your experience like? You can phone it in, or you can tweet us. Our phone number 844-724-8255. You can tweet us @SciFri.

Let me introduce my guest. Holly Kennedy is an author on that Lancet series. She’s also a professor of mid-wife wifery at the Yale School of Nursing. Thank you for joining us today Holly Kennedy.

HOLLY KENNEDY: Thank you.

IRA FLATOW: Tell us, the Lancet series looked at 169 countries. And overall, there is a rising C-section rates. Can you give us some of the numbers of different regions? It must have varied around the world.

HOLLY KENNEDY: Well, it does. And what we found was that over 60% of countries over use C-sections, and 25% under use the procedure. So there’s quite a disparity. And there are multiple reasons.

Part of it has to do with the sociocultural acceptance of surgery as a normative thing to do. Part of it has to do with insurance and access. And a large part of it has to do with women not being able to get a vaginal birth after they’ve had their first Cesarean. So it’s complicated. We’ve seen the rise particularly in North America, Western Europe, Latin America, and the Caribbean. For example, in Latin America, it’s gone from 32% to 44%.

And there’s a bit of a paradox when what we would call too much, too soon and too little, too late. So in the countries that overuse Cesarean, they are probably intervening too much in low-risk women that really don’t need the procedure. And in countries such as in Africa that don’t have enough access, probably are under using it. The World Health Organization suggests that 15% is about right. So when you think about one in three women in the United States having a Cesarean, we’re way over.

IRA FLATOW: Well, let’s talk about over about– there’s a statistic, for example, in Brazil, 90% of the women that go into a private hospital are getting C-sections. Are they requesting that before they go in? What is the mechanism? What happens there?

HOLLY KENNEDY: Well, I can’t speak specifically to the interaction. But you’re right, women who are wealthier, who have insurance, are much more likely– the majority of them will have a C-section. And it’s an accepted normative part of the culture in Brazil.

IRA FLATOW: Now, there are big differences within countries. In China, the range is from what, 4% to 62% depending on the province?

HOLLY KENNEDY: Exactly. And again, that has to do with access, and wealth, education. Interestingly enough, women that have greater education are more likely to have a Cesarean, which is a bit of a paradox in itself because a Cesarean is not a low-risk surgery. It’s major surgery.

And there are small, but serious risks, both with the immediate surgery, and then later in terms of the scar, and stillbirth, and pre-term birth later with subsequent pregnancies. And it’s one small part of the piece of the puzzle. In the United States, we’re increasing maternal mortality rate.

IRA FLATOW: You mentioned that in some places, there’s too much, in some places, not enough. What are those not enough places like, and why?

HOLLY KENNEDY: The not enough places are places that don’t have access in particularly in Africa and in countries that have lower resources. So they just don’t have the facilities to do a Cesarean sometimes when a woman really needs it. And I think it’s important to state it at the out site, there are women and babies that it is a life-saving procedure. But it’s not one that should be done for the majority of women.

IRA FLATOW: I want to focus on a little bit about what’s happening here in the US and why C-sections are increasing here. Toni Golen is the Vice Chair of Quality in the Department of Obstetrics and Gynecology at the Beth Israel Deaconess Medical Center in Boston. Welcome to Science Friday, Dr. Golen.

TONI GOLEN: Thank you for having me.

IRA FLATOW: Let’s talk about this. There’s also this idea of planned C-sections, right? Do you have to approach this– do you have– have you seen this in your experience?

TONI GOLEN: It’s quite interesting. I think there’s a natural suspicion that this is a major contributor to this C-section epidemic in the United States at this point. And while it’s true that families, women can request to have a delivery via Cesarean, it turns out that that’s not really the most significant driver. In our experience at Beth Israel Deaconess, for example, which is a tertiary care institution, an academic hospital in the middle of Boston, it really only contributes to about 1% of our deliveries per year.

So while some of this could be attributed to patient opinions, or patient desires, or their perceptions of what’s safer, the truth is is that I think that we as health care providers need to realize that we are probably the major, major contributors to the rise in Cesarean delivery rate here in the US.

IRA FLATOW: When you say health care providers, you’re talking about the doctors who actually are performing it?

TONI GOLEN: Yeah. So certainly the doctors, the obstetricians, they are the ones who make the recommendation for a Cesarean. At the end of the day, that’s who’s responsible. It’s a complex environment to practice obstetrics.

So there are other things that put pressure possibly on obstetricians. We have incomplete, somewhat inaccurate data about health of fetuses during labor that might contribute to our decision making. The progress during labor in terms of those cervical dilation is subjective. So that can contribute to some inaccuracy. There’s other things that happened on our unit that might put pressure on us, other emergencies that might be happening on a labor and delivery unit that might put some pressure on us to make quicker decisions to move toward delivery.

But at the end, it’s really our decision as obstetricians to make that recommendation. And generally speaking, when we make a recommendation like that, patients and families do say yes. And they ask questions, but they generally do say yes.

IRA FLATOW: Holly, what’s your reaction to this?

HOLLY KENNEDY: Well, I would completely agree with her that the culture of the unit where a woman is giving birth is very instrumental. There are a number of strategies we can do to promote a first-time mother having a vaginal birth. But you have to have the staffing. You have to have the commitment to do the kind of care that’s going to help her and her physiology to best achieve a vaginal birth.

IRA FLATOW: Let’s go to the phones. Let’s go to Northern Kentucky. Hi, Lauren welcome to Science Friday.

LAUREN: Hi Ira. Thank you for having me.

IRA FLATOW: You’re welcome. Go ahead.

LAUREN: So, I actually had an emergency C-section at 31 weeks. And I was super thankful for that being available to me. But when I got pregnant for a second time, I really wasn’t given the option of having a vaginal birth after a C-section. I had to do all of that education, investigation on my own.

So I had to look at CDC website. I had to look at rates and what were the risks for me, and my baby, and for future pregnancies. And it really was up to me. It wasn’t– my provider said, do you want to have a repeat? And at the time, I was like, oh, sure. I’ll have a repeat C-section.

But I wasn’t given the risks and benefits of both to be able to make a truly educated decision. And so I think that I was able– I actually had a planned C-section, a repeat. And then I changed my mind at 36 weeks. And my provider was really awesome with that. And I was able to have a VBAC.

But I feel like there wasn’t a lot of information given to me by my provider. I really had to search it out. And a lot of the information was very emotional. And it was really hard to find the facts.

IRA FLATOW: All right, Lauren. That’s a great, great call. Let me get a reaction. Toni, truth be told, I’m a C-section baby. And I’m one of three. Back in the day, everybody had to have one C-section after another. And Lauren was sort of saying, you know, I didn’t know that maybe I didn’t have to have that.

TONI GOLEN: Access to VBAC or a vaginal birth after a Cesarean is going to be– is one of the critical interventions that we all as a health care community are going to have to embrace, indeed to embrace, in terms of lowering the overall Cesarean delivery rate. It’s really a matter of exactly what the caller said, which is grabbing hold of accurate information. We see that as our obligation as obstetricians and midwives to really spell out what the risks are.

I think we tend to sometimes overemphasize the risk of VBAC. The risk of VBAC can be something quite catastrophic. But it’s rare.

And the benefit of a VBAC is that for births that happen there after, it’s highly more likely. For example, if someone’s going to have a third or a fourth baby, it’s highly more likely that that person would have a vaginal delivery if she’s once had a VBAC. And that really is something that contributes to the overall lifelong health of a woman.

Because the risk of a Cesarean delivery is not only related to the hour or so, or even the days or so that follow a first Cesarean delivery, but it traces back and forward to the years that follow, sometimes in some cases decades that follow women who have had Cesarean deliveries are just more likely to have repeat Cesarean deliveries as your caller almost did, increasing the risk of life-threatening complications.

The other thing that’s very interesting about VBAC is that in units– in hospital units, labor and delivery units, where VBAC is embraced, where vaginal birth is something that’s valued, it turns out that the primary Cesarean delivery rate, which has no direct relationship to VBAC because these are women who are having their first baby, and by definition, VBACs are not your first baby, those units who have higher VBAC rates, of even trying to have VBACs, and supporting women in having VBACs, have lower primary Cesarean delivery rates. It really speaks to this idea of the culture of a unit and really valuing the safety of a vaginal delivery.

IRA FLATOW: Lots of callers. 844-724-8255. Let me get to some of the tweets because we have never had so many tweets before. Let me choose out some interesting ones.

Colleen writes, I had three Cesareans, all my three kids. The first was an emergency one. But my concern now are that my children did not receive the bacteria from the birth canal. And I’m seeing possibly weak microbiomes affecting their digestive health. Holly, Toni, what do you think about that?

HOLLY KENNEDY: You know, as Tony was talking about the culture of the unit in VBAC, I think the additional things that are as really important for families to know when they’re trying to make a decision is the value of a spontaneous labor. There’s neurophysiology that prepares the baby to be born, actually contributes to health later in life, but that based on population-base studies. And the travel of the baby through the birth canal does seed the baby with microbiome.

So she’s right, that that does contribute to long-term health. It’s been worked on, we’ve looked at different things to do that with the baby after a C-section. But if you can do it just naturally, that is better.

The other thing is that babies born by C-section tend to have more respiratory distress and particularly, if they don’t have spontaneous labor. So there’s something about that spontaneous labor that contributes to the neurophysiology and the health of the baby.

IRA FLATOW: I’m Ira Flatow. This is Science Friday from WNYC Studios. So many questions. Let’s go back to the phones to Wendy in Portland, Oregon. Hi Wendy.

WENDY: Hi. Thanks for taking my call.

IRA FLATOW: Go ahead.

WENDY: So I’m actually an obstetrician/gynecologist. But I’m working just in a hospital. So I’m an obstetrical hospitalist. And one of the things that I do is just stay in the hospital to manage labor patients. So I think one of the ways the country is responding is that my type of job is becoming more and more popular, so that there are just physicians that are managing labor, and hopefully are allowing VBACs and allowing patients to labor as long as possibly safe.

I’m from Portland, Oregon. And we have the second highest rate of attempted out-of-hospital births. And we have really the best data from our birth certificates looking at transport backs into the hospital.

And I guess my concern is that when I hear– when I hear people talking of the very important things that result from having labor, I have seen some attempts at labor that really should have never been there, and have really resulted in some catastrophic outcomes for both mom and baby. So I love vaginal deliveries. I think they’re great.

But I think there are some moms and some babies that need C-sections. And we need to support that as well. And we provide it when it’s necessary.

IRA FLATOW: Tony Golen, reaction? Thanks for that call.

TONI GOLEN: I couldn’t agree more. Cesarean delivery is a life-saving procedure. And there are certainly many women who should not undergo a vaginal delivery. There’s a number of different conditions that make that unsafe.

The important thing, I think, to keep in mind is also that regarding the example of home birth in the United States, and that being an extension of the health care system, and promoting vaginal birth, while home birth in many countries is a safe option and is a way to promote vaginal birth, we haven’t quite figured that out in the United States.

It is important in a health care system that promotes home birth to be able to make a really clear connection between home and hospital. And when certain thresholds are reached, then a patient needs to be moved from home to hospital. That’s the part that we haven’t quite figured out here yet.

And until we figure that out, I think it’s going to be challenging to really embrace that as an option to promote vaginal birth. We can try to mimic that as best as we can in the hospital setting, and certainly have patients stay at home for as long as is reasonable. But home birth is not yet something in the United States that we have a really great system to support.

IRA FLATOW: All right. We’re going to have to take a break. Lots more questions. We’re going to spend another good 10 minutes on this. So we’re going to talk with Holly Kennedy and also Toni Golen. Our number, 844-742-8255. Stay with us. We’ll be right back after this break.

This is Science Friday. I’m Ira Flatow. We’ve been talking this hour about the increase in the number of C-sections and what that means for women’s health. My guests are Dr. Holly Kennedy, Professor of Midwifery at the Yale School of Nursing, Dr. Toni Golen, Vice Chair of Quality in the Department of Obstetrics and Gynecology at the famous Beth Israel Deaconess Medical Center in Boston.

And lots, lots of folks on the line. Let’s see, we only– gosh, we can’t get to everybody. Let me ask you, Holly. You worked in research midwifery in the UK. How does the approach there compared to what we do here in the US?

HOLLY KENNEDY: Well, it differs in several ways. And actually, when this Lancet series on C-section came out the, World Health Organization also issued a new guideline to help us look at decreasing Cesareans. And one of the things that they have recommended is what the UK does, which is to have a collaborative midwife obstetrician model of care where the midwife does most of the primary care.

And that’s what happens in the UK. All women have a midwife. And some women have an obstetrician too when it’s really needed. And the Lancet also published a series on midwifery, a very extensive review of the evidence. And they found that midwifery was associated with improved outcomes, including decreasing C-sections.

And so one what I’d like to just mention is in the United States, a study came out earlier this year that mapped the integration of midwifery across each state to see how friendly the state was in a regulation and reimbursement independent practice to midwifery practice. And so if you look at New Mexico, which has the lowest C-section rate of just about 18%, 26% of births are attended by midwives in that state. Conversely with New Jersey, who has the highest rate of 33%, and only 7% of births are attended by midwives. And then they map that with outcomes.

And if you look at Alabama, Alabama has some of the worst maternal and infant outcomes in the country. And only 1% of births are attended by midwives. So that’s not a causation. It is an association-type study. But it is pause for thought. And that is what we saw in the UK is that when you have a model of care when women have access to continuity of care with their midwife, their midwife knows them, they feel respected, you have better outcomes.

IRA FLATOW: Toni Golen, you work to drive down, the rate down at your hospital at Yale. And after a decade, it went from 40% to 29% in a decade? What did you do there?

TONI GOLEN: Well first, we recognized that we had a problem. And I think that’s step one in trying to solve it. And then we looked toward the evidence, not just our own evidence, but the national evidence about what was contributing mostly in terms of the indications for Cesareans and focus very narrowly on primary Cesarean.

First looked at the interpretation of how we monitor fetuses while women are in labor. That kind of monitoring, called fetal heart rate monitoring, is very tricky. It’s quite inaccurate. And it predicts quite well for us when babies are well, but does not do a good job of telling us when babies are unwell. And nonetheless, obstetricians base decisions on this test.

I often say that in no other area in medicine would we make surgical decisions based on such a faulty test. Nonetheless, it’s ubiquitous. And people use fetal heart rate monitoring. So we focused on really trying to focus on describing the fetal heart rate tracings using science and objective criteria rather than subjective words. We focused on our documentation, our communication.

We also really tried to make sure that people were using scientific modern definitions for progress in labor. Old definitions were assumed that women would move much faster in labor than newer, more modern data really proved to us. We wanted to make sure that people used modern definitions for what we thought was normal labor. As I mentioned earlier, we focused on improving access and enthusiasm for VBAC and then also some other operations, issues for our unit to change the culture of our unit.

IRA FLATOW: I misspoke. You are with Beth Israel. And I said you were with Yale where Holly is from. So, I apologize for that.

TONI GOLEN: No, I’m here in Boston

IRA FLATOW: So, does this all mean that the hospital you go to determines, more or less, if you’ll have a C-section or not?

TONI GOLEN: Unfortunately it does. And so one of the reasons why we know that we have room to improve on Cesarean delivery rates is that if you look from one hospital to the next, even separated by one or two miles from one another, who take care of patients who have similar medical problems, are of similar demographics, their Cesarean delivery rates may vary by as much as 10%. This is unexplainable by any other reason other than the environment, the unit that you work in, the people that you work with, and the general enthusiasm for vaginal birth.

IRA FLATOW: We have a tweet that’s relevant to this. And Sarah says, I have to wonder how much of the increase has to do with how much money insurance companies make on them versus a typical delivery. Did you study that in your report Holly?

HOLLY KENNEDY: Well, not specifically, except that the recommendation is that the financial strategies– women who have more money, who are wealthier, will have more C-sections, which implies that they can get reimbursed for that. And one of the recommendations that the series made was to not pay more for Cesarean to really level that playing field. And in addition to liability reform, in studies that I’ve conducted, obstetricians have said to me, I won’t get sued if I do a C-section. But I can get sued if I don’t do one in time or perceived to be in time.

IRA FLATOW: Yeah, go ahead, Toni.

TONI GOLEN: The issue of reimbursement is interesting here in the US, where, by and large, physicians or obstetricians do not get a vastly different amount of money for a vaginal delivery than a Cesarean delivery. However, the hospital does. And that is something that I think isn’t quite transparent for patients.

And probably reimbursement itself doesn’t influence a lot of obstetrician decision making here in the US. The reimbursement is greater. But it really goes more toward the hospital side because of the length of stay.

IRA FLATOW: Let’s go to Sarah in Somerville, Mass. Hi Sarah.

SARAH: Hi. I’ve had two C-sections. They were mandated by the doctor due to complications from Crohn’s disease. And so I really appreciate this nuanced discussion. But I just wanted to give a perspective of how this is actually playing out among laypeople and patients.

And I think a lot of the talk about this has become very anti-woman. When I told people that I was having a planned C-section due to my chronic illness complications, I had male friends saying things like, well, are you sure you don’t want to just labor for a little bit? Maybe you could just ask if you could labor for a little bit? And I really interpreted that as questioning can I be a woman if I don’t push the baby out vaginally? And that was really upsetting to me because my two beautiful daughters wouldn’t be here if the C-sections were not available to me.

And I just think it’s really important for those at the academic and provider levels to understand that people are hearing these discussions and I think taking them in inappropriate and different directions. So I’d love to hear the response to that.

IRA FLATOW: All right. I’ve got about a minute, Toni or Holly, which one?

HOLLY KENNEDY: I would completely agree with you that one of the most important things in this conversation is for the provider and the woman to talk through what is important to her so that she can make an informed decision about the best strategy for her. I would completely agree that it’s important that you have that conversation, and the risks and benefits of both diagonal birth and cesarean are fully, fully discussed.

IRA FLATOW: And Toni, what about this charge of sexism here?

TONI GOLEN: Point well taken. I think any extreme is going to be dangerous. I think it is important to realize that regardless of how a baby is born, the person who gives birth to the baby becomes a parent after that happens. It’s no less or no more regardless of what the mode of delivery is. And Cesarean delivery certainly makes you just as much as a mother as having a vaginal delivery.

IRA FLATOW: Great way to end. Holly Kennedy, Professor of Midwifery at Yale School of Nursing, Toni Golen, Vice Chair of Quality in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center in Boston. Thank you both for taking time to be with us today. You’re welcome.

Copyright © 2018 Science Friday Initiative. All rights reserved. Science Friday transcripts are produced on a tight deadline by 3Play Media. Fidelity to the original aired/published audio or video file might vary, and text might be updated or amended in the future. For the authoritative record of Science Friday’s programming, please visit the original aired/published recording. For terms of use and more information, visit our policies pages at http://www.sciencefriday.com/about/policies/

Meet the Producer

About Alexa Lim

Alexa Lim is a producer for Science Friday. Her favorite stories involve space, sound, and strange animal discoveries.

  • Kathleen Winters

    I had an emergency c-section due to complications from preeclampsia. I was induced at 37 weeks and as soon as contractions started my son’s heart rate began dangerously plummeting. We didn’t have a choice due to the severity of the situation. I was heartbroken as, up until the preeclampsia, I had been planning an intervention-free delivery.

  • Angela Hamilton

    At 39, I was having my first child and living in the Middle East. All obgyns that I interviewed said with no hesitation that I would have a c-section, given my age. I ran on a treadmill through six months and continued to workout until I went into labor. After three days of excruciating contractions, my water did not break and I was at 1 cm. The baby’s heart rate had decelerated twice. I was terrified and in a haze of pain. I could not have any pain medication because I wasn’t at 3 cm. I then contacted the doctor and gave in. I wasn’t presented with any options other than waiting probably a few more days with the same or more pain. If we had been in this situation years ago, we probably both would have died.

  • Christie Monson

    My sister has taught natural childbirth classes for more than 30 years, and has worked closely with a midwife during that time. They have both observed that when women speak with a little girl voice –which is more and more common among women in their twenties and thirties— they are far, far more likely to end up requiring a C-section. They both speculate that perhaps these women, who have persisted in talking like little girls, simply don’t believe in their own power as a woman to push a baby out on their own. (Of course, this does not include instances when there are actual medical reasons for the need for a C-section. There is no judgement about that here.) It would be great if someone would do some research in this area.

    • kubajean

      Gosh, I have yet to meet a woman who speaks in a little girl voice and I work in the public…. where do they hide?

      • Christie Monson

        Well, if you are under 40, you may not notice anything unusual, because it has become the new normal.

  • Mieko A Ozeki

    I had a c-section because my daughter was not in the correction position. As much as I wanted a natural birth and tried hard to have her moved in the right position, I needed to get a c-section. This should be a last resort and not an elective surgery.

  • Kelly

    I had a c section 24 years ago after it became apparent that my son(10 days post due date) was breech and my water broke. There was fear of a prolapsed cord and other issues that come with an (unproven pelvis”.All went well. Two years later my OBGYN was all for and supportive of me having a VBAC which I did. I realized later that my children born in a window where doctors and insurance companies were supportive of VBAC births. I feel like insurance companies are part of the issue.

  • Nicholas Abram

    What about postpartum depression following a cesarean compared to vaginal?

  • Deanna Janes

    I have had 2 c-sections, the first because my son was transverse and couldn’t be turned. The second because at a monitoring appointment showed that our second child was not doing well, so he was delivered via emergency section at 36 weeks, and unfortunately he passed away shortly after birth due to a hemorrhage through the placenta, we had intended to try for a VBAC with his birth. Now I will have a 3rd C-section in January, because we waited less than a year to have another child and our hospital will not allow a trial of labor due to the risk of uterine rupture.

    • kubajean

      hope all goes well for you, that is so sad. Again, do what keeps your sanity/health, it really really won’t matter to your child down the line. My kids are happy adults now who speak to me regularly :). I did however breast feed both kids…that is probably the most important in terms of parent/child relationship!

  • Kathy Duffy

    I had an emergency c-section following an attempt at a VBAC. My uterus ruptured during labor. I nearly lost my life and my daughter was born with severe brain damage. She died eight days later. That was 20 years ago. The possibility of such an experience may be small, but when it happens to you it is 100%.

    • kubajean

      so sorry for your loss, that must have been terrifying.

    • kathleen74

      I’m sorry your experience was so sad. Thankfully that outcome is rare, but it’s a risk. Many home birth providers won’t do VBACs. But given the right conditions, VBACs can be safe. There are risks to c-sections too. Every family needs to be informed and do what they think is best.

  • Jenny

    I am an out of hospital midwifery student in the state of Minnesota. I completely disagree with your guest regarding transpots to the hospital being a barrier to the safety of out of hospital birth in the U.S. Any responsible out of hospital midwife has a relationship with their local hospital and a direct line to their obstetric unit in able to coordinate rapid transport to the hospital, when necessary. Many OOH midwives have liability insurance which dictates the distance from a hospital, in miles, that they can attend women. The practice I am studying under has had the local EMT staff come for a tour of the birth center to discuss smooth transport. And, the Minnesota midwifery org has created guidelines and is reaching out to all state hospitals for optimal transport safety. Midwives are doing a lot of work on this end, and the next step is for hospital providers to meet them in the middle to make transports smoother for safety of mother and baby.

    • RudyTooty

      It is good to hear that midwives in Minnesota have insurance so there is potential for recourse when something goes wrong.

      What percentage of licensed midwives in MN are coverage by a malpractice insurance policy?

      Is it required by state law?

  • kubajean

    30 years ago, in France, after having had a miscarriage and then tubal pregnancy, my doctor told me it would be ‘at least’ a forceps and probably C-section …pointing out that in France C-sections were not so common but that it was advisable in my case due to baby’s head size and my small size (no financial interest for him or hospital). I did not want to risk this hard-won child and all went well …that 10 day completely free hospital stay in a private room with food delivery and baby by my side was heaven. Several years later I had my son here in the States-was not offered any alternative to C-section, was booted out of hospital after 24 hours and then proceeded to have pulmonary embolism 2 weeks after delivery…I am lucky to have survived. My embolism was probably aggravated by surgery but I had been studying while pregnant so very sedentary and then suddenly moving shortly before (because we literally moved and did it ourselves while pregnant at 8 months). Emboli are not so uncommon during pregnancy but who knew, no one warned me! Both children now adults are fine–although did my daughter develop mild asthma due to lack of microbes?…. It would have been nice to have been informed about alternatives but my OBGYN here was completely disinterested in giving advice and I hope that has changed for women now. I am curious about long term issues for women post C-section… Women need to view this as something they do based on sound information if planned in advance, but quite frankly whether you adopt or give birth vaginally or C-section, when you are a parent, you are a parent ..this shouldn’t be a competition, and who cares so long as the baby and you are healthy.

  • Amanda Morris Johnson

    I had two registered nurse midwife home births. They are the most memorable great experiences in my life. I felt so strong, so much in my nature, and recovery was really quick. I believe Western Medicine is really good at crises. Birth IS NOT A CRISIS. C-Sections ARE for crises. Change the point of view that birth is somehow unnatural because it doesn’t happen all the time, for both medical professionals and mothers-to-be, and you will change C-Section rates, imo.

  • Liz Leyden

    The WHO admitted in 2015 that the 15% “ideal” cesarean rate was pulled out of thin air. They also said it shouldn’t be used to deny cesareans to women who need them.
    http://www.who.int/reproductivehealth/topics/maternal_perinatal/cs-statement/en/

    • RudyTooty

      Yes – when I hear this number it creates further questions for me.

      What is the rate of perinatal mortality relative to the cesarean rate?

      For instance, if the perinatal mortality rate is higher with a 15% rate than with a 20% rate – is that really optimal?

      • stemium

        This paper in JAMA suggests that maternal and neonatal mortality rates are inversely correlated with cesarean rates up to 19%. I guess that supports the idea to keep access open but not sure how things change if you get into the 20%+ range. From the “mom” perspective I was definitely not a fan of the C-section delivery experience.

        https://jamanetwork.com/journals/jama/fullarticle/2473490

        • RudyTooty

          I would assume that the ‘optimal’ rate of cesarean birth – would vary depending upon the country, hospital, population, medical resources available, etc.

          Declaring an optimal world-wide rate of cesarean is kind of absurd considering how different health care systems are. If we had a homogenous population, and a homogenous global health care system, maybe this number could be standardized world-wide.

          And maternal preference, of course, is an important consideration. There are plenty of women who prefer to avoid cesarean surgery. There are others who prefer to avoid vaginal birth.

          Though the choice to opt for a cesarean is limited in countries and places where surgical and medical resources are limited and relatively expensive.

  • Linda Rosa

    Some of the increase in C-sections appears to be related to older women, increased obesity, diabetes, etc. The main thing to consider is the outcome. Is this the best way to get the healthiest baby?

    Also something that is often not included in calculations is that planned home births are increasing. These are attended almost always by lay midwives who are infamous for using very unconventional practices such as “Power Birth” (urging the woman to begin pushing when her cervix is only halfway dilated). They have little training or experience in emergencies. Lay midwives are known for delaying the transfer of women having complications to the hospital, because that is considered a “failed delivery.” Instead of being able to head off a problem in its early stages, ER and hospital personnel may be presented with a woman in serious condition and no known history – with a C-section perhaps the only alternative.

Explore More

The Hidden Beauty Of The Human Placenta

Though discarded after birth, the placenta builds the first vital connection between mother and fetus.

Read More