Birth, The American Way
One third of babies in this country are delivered by C-sections. A graphic new documentary asks why.
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.
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Member Comments
Posted By: electivecesarean.com @ 02/29/2008 12:01:01 PM
Comment: Susan, the first thing I would like to say is that your persistent use of the adjective MAJOR in front of the word surgery is unnecessary. It goes without saying that cesarean delivery is not equivalent to a more minor surgery such as removing a skin lesion for example.
Secondly, you say: You know for a fact, cesarean surgery has more risks to mom and baby than vaginal birth. I certainly do not know this for a fact, particularly when we are talking about a planned cesarean delivery at 39 weeks EGA for a healthy woman who is planning a small family. If, however, you are referring to all cesarean outcomes ??? including emergency surgery and surgery for medical reasons ??? and comparing them only with successful vaginal delivery outcomes, then that is different. Of course if that is the case, you are also not comparing apples with apples???
You then ask: So why do you feel it is ok for an OB to advise a woman home birth is dangerous, but it is ok for an OB to tell a woman major surgery (c-section) is safe? I don???t believe that OBGYNs in America are advising women that surgery is categorically safe, and furthermore, I think that by accusing them of this, you are at best underestimating, and at worst insulting their professional integrity. It has been my experience that OBGYNs see it as their unquestionable duty to make women aware of both the risks and benefits as they relate to their individual pregnancy health. In fact ironically, it is you making categorical statements on safety: Birth is safe, interference is risky.
I do understand the frustrations of many midwives who feel that there is too much intervention in hospitals, and I can appreciate why they want to be a voice for the women who are unhappy with their cesarean birth outcome. I simply ask that in delivering your argument, you are more careful to clarify the undeniable differences in outcomes between emergency and planned cesareans, and you resist the urge to criticize women who choose CDMR.
Finally, I was disappointed to see that you did not address my comments regarding Holland, obesity outcomes and measuring infant mortality in my previous post, but in any case, I???d like to offer one more thought on this topic. In the UK, where home birth is an option for all women (in fact the government is actively promoting it as a birth choice), the numbers of women who actively make that choice are: Wales 3.53%, England 2.69%, Scotland 1.36% and Northern Ireland 0.39%. The truth is that the vast majority of women choose to give birth in a hospital.
I think the one thing that we can agree on is that women are not homogeneous creatures. You would never choose a cesarean delivery and I would never choose a home birth. What is important going forward is for every pregnant woman???s choice to be supported where possible ??? and more than that - for it to be respected.
Posted By: midwifesue @ 02/28/2008 12:02:19 PM
Comment: I I do not question the need for c-sections, nor do I question the fact that cesarean section is MAJOR SURGERY. I think it is amusing you say " that the rights of the unborn baby should be protected too (e.g. if medical professionals believe that a baby's health or even life will be placed at risk during a home birth due to particular health problems in the pregnancy)." YOU KNOW FOR A FACT, CESAREAN SURGERY HAS MORE RISKS TO MOM AND BABY THEN VAGINAL BIRTH, and yet, you support the womans right to choose inspite of the medical statistics. ACOG made the statement home birth is dangerous and should not be done. This statement is based on no reliable studies but women have trouble getting insurance to cover home birth because OB's say it is dangerous. So why DO YOU feel it is OK for and OB to advise a woman home birth is dangerous, but it is OK for an OB to tell a woman MAJOR SURGERY (c-section) is safe.
I do acknowledge vaginal birth IN A HOSPITAL is becoming much more risky due to interventions. EVERY intervention ( ie, IV's, epidurals, prostaglandan's, pitocin) has associated risks. The bigest risk being an increased chance of needing a c-section! But women are not being told this when they enter the hospital and agree to interventions. If they question them, they are told it will be best for the baby. Do you think it is a coincidence more c-sections are done Monday to Friday between 9am and 5pm. The third leading cause of death in the US is hospital born infection. Who is more likely to develop an infection, someone with major surgery, or someone who has given birth vaginally? And better yet, someone who has given birth vaginally, at home.
Recently, in the news, we heard of two a perfectly healthy women going to the hospital for inductions, and ending up dead (there are many more that were not news worthy.) We also saw the woman in Florida who went in for a normal vaginal birth, and ended up with no arms or legs because she contracted flesh eating skin disease from another patient in the hospital. Hospitals are not the safe place many people believe. Birth is not an illness. It is a normal, physiological process that USUALLY does not need controlling. Birth is safe, interference is risky. Yes, I am thankful we have hospitals where we can take our clients who are having trouble at home and NEED intervention.
Judging from your title, I assume you are for elective c-sections. Well I guess so am I because I believe in a womans right to choose what she does with her body. AS LONG AS SCHEDULED C-SECTIONS ARE DONE ETHICALLY- AND WOMEN ARE GIVEN TRUE INFORMED CONCENT. Funny though, the risk of c-section for both mother and baby is MUCH higher then any potential risk home birth has but OB's push c-sections and say home birth is dangerous.
Susan Scott Gill
Licensed Midwife
Posted By: electivecesarean.com @ 02/26/2008 10:32:20 AM
Comment: Continued...
Finally, when measuring infant deaths, it is far more relevant (when measuring the risks and benefits associated with a specific delivery type) to look at perinatal* or neonatal** mortality rates (which measure deaths *from foetal viability (28 weeks gestation or 1,000g) until the end of 7th day after delivery, and **the first 4 weeks (or 27 days) of life) rather than infant mortality rates (which measure how many live newborns die in their first year of life). This is because infant mortality rates do not take incidences of stillbirth into account, and also there are social factors in the first year of life (that have nothing to do with the birth) which may play a role in the deaths.
Pauline McDonagh Hull
Editor, electivecesarean.com