There are many births in the documentary film "The Business of Being Born," including a scene of former talk-show host Ricki Lake giving birth naked in her tub. But the image that viewers may find most shocking is that of a baby being cut out of a woman's abdomen via Caesarean. This, according to Lake, the executive producer of the film, and Abby Epstein, the film's director, is the right reaction: one of their messages is that C-sections should only be performed when needed to guarantee the well-being of the mother and infant, and should not be a first choice for healthy mothers. New research into the risks associated with elective Caesareans supports their view. In a study, published in October's British Medical Journal, of 97,000 deliveries in 410 Latin American hospitals, perinatal specialist Dr. Jose Villar found the risk of death for mothers who had Caesareans, while slight (.01 percent of the women who delivered vaginally died vs. .04 percent who had elective C-sections), was triple that of those who delivered vaginally. "The C-section increases risk because it's major surgery," Villar says. Mothers who had undergone a Caesarean were also more likely to need blood transfusions and stay in the hospital more than a week after delivery. The risk of death for infants delivered via C-section—who are more likely to have a low birth weight—was double that of vaginal births, and C-section babies were more likely to have respiratory problems. According to a study published in the journal Birth, labor clears liquid from the infant's lungs, preparing the baby to breathe outside the womb. Caesareans impede this process. Yet the rate of Caesareans is spiking: in 2006, C-sections accounted for 31.1 percent of births nationwide, a 50 percent increase over the past 10 years. Natural birth—without drugs or interventions—whether at home or in a hospital, remains a rarity (despite the fact that home births don't have an appreciably higher risk rate than hospital births).
Amid the controversy over what constitutes an ideal birth experience, doctors, researchers and natural-birth advocates agree: Caesareans save lives when medically necessary. But defining medical necessity is complicated. Natural-birth advocates cite a "cascade of interventions" caused by hospitals' practice of using the drug Pitocin to stimulate labor. The drug can cause painful contractions, which doctors treat with an epidural painkiller. The epidural can then retard contractions and lead to more drugs, fetal stress and the doctor's recommendation of a Caesarean. Natural-birth advocates say that hospitals, driven by profits and worried about malpractice, are too quick to intervene. "I compare it to a restaurant. If you have customers who sit at a table and don't order anything, you're not making any money," says Jennifer Block, author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care." Normal labor, Block says, isn't profitable (according to "The Business of Being Born," a Caesarean can cost three times as much as a normal birth). If something does go wrong, in the eyes of the courts "a normal birth is a risk. The courts reward action," Block says.
Some doctors say the increased rate of Caesareans is partially attributable to maternal demand: busy mothers may want to schedule their deliveries. The phrase "too posh to push" predates Posh Spice, but reports that celebrities such as Posh (Victoria Beckham) and Britney Spears had Caesareans have popularized the procedure, some doctors say. And some women are scheduling them early. According to the March of Dimes, late preterm delivery (34 to 36 weeks) increased from 7.3 percent to 8.9 percent between 1990 and 2004 in the United States. "No one knows how much of that is maternal choice," says Ann Stark, head of neonatology at Texas Children's Hospital. "There are certainly women who want timed, elective delivery surgically." According to a recent study, attendance at Lamaze classes, which teach women how to manage labor pain without drugs, dropped 14 percent between 2000 and 2005.
Although the United States has one the highest rates of Caesareans—and of infant mortality—Villar says the rest of the developed world is catching up. But opinion differs on how to respond. Doctors such as Stark say we need a better sense of what goes on while the baby is still in utero. "One of the knowledge gaps is a clear understanding of the indications for C-sections," she says. (Known indications include breech position of the fetus, and pre-existing medical conditions such as extreme hypertension in the mother.) Naomi Wolf, author of "Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood," blames insurance companies and hospitals, who she says deny women information about their choices. Wolf and other natural-birth advocates say we need a better idea of what normal birth looks like, as movies and TV usually depict the process as painful and bloody. "We all have this idea that normal birth is a woman lying in a hospital bed screaming," says Block. If nothing else, "The Business of Being Born," with its indelible image of a naked, exhilarated Ricki Lake cooing "Hi there!" to her seconds-old son in her bathtub, will give them another view.