At six hospitals in Massachusetts, forty percent of first-time mothers give birth by cesarean, according to this editorial in the Boston Globe, by Judy Norsigian (Our Bodies, Ourselves) and Timothy Johnson, MD (U Michigan). “Yet none of these hospitals is designated as a high-risk center. So much for the argument that high-risk pregnancies are the reason for these rates.” They also slash through other myths, like that more mothers are too old, too fat, or too posh to push. The C-section rate for women on Medicaid is rising faster than for women with private insurance, they report (which costs taxpayers more). “Considerable media attention has focused on how extreme obesity can raise the risk of having a caesarean, but more emphasis is needed on these system-based approaches,” they write, and go on to recommend that hospitals support vaginal birth after cesarean, restrict labor induction, and offer more nurse-midwifery.

They point out that in Boston, the two hospitals with no midwives had cesarean rates of 37% and 42%, while those with midwives had rates between 27%-35% (though they don’t say what rates the midwives alone achieved). “Enhancing access to midwifery care might well be the most effective approach to safely reducing the overall caesarean rate,” they write. “We must finally make midwives more central in maternity care — as do all other countries whose birth outcomes are superior to ours.” A true and brave statement from an obstetrician, but those numbers suggest that nurse-midwives can only do so much to mitigate a hospital culture that tends toward interventions and surgery. When midwives attend births autonomously outside the hospital setting, cesarean rates are closer to 5%.

Amnesty International minces no words in its new report on U.S. maternity care. Deadly Delivery: The Maternal Health Care Crisis in the U.S.A., reports that more than 2 women die per day in the United States from pregnancy- or childbirth-related complications, a rate that’s worse than in 40 other industrialized countries. “Preventable maternal mortality
is not just a public health issue, it is a human rights issue,” states Amnesty.

“Women in the USA face a range of obstacles in obtaining the services they need. The health care system suffers from multiple failures: discrimination; financial, bureaucratic and language barriers to care; lack of information about maternal care and family planning options; lack of active participation in care decisions; inadequate staffing and quality protocols; and a lack of accountability and oversight.”

The report profiles several women who died or nearly died because of inadequate, inappropriate, or discriminatory care: one woman dies of a blood clot following a cesarean section, which could have been prevented with simple circulation stockings (a standard prophylactic for other major surgeries); another woman bleeds to death following a C-section, even after she and her husband plead with medical staff to address her troubling symptoms; a high-risk woman experiencing complications late in pregnancy is turned away from a prenatal clinic because she can’t afford a $100 deposit; both she and her baby die after care is delayed.

Each death represents dozens of “near misses” that often leave women in worse health; of the 4 million American women who give birth each year, 1.7 million women experience complications that lead to adverse effects. “The US health care system is failing women,” says Amnesty. Read the full report here.

With the historic news that a majority of the U.S. workforce is now female, it’s clear that American women have more power than ever before, says OB/GYN and bestselling author Christiane Northrup, MD. But is that power reflected in the healthcare available to women? No, she writes in an essay for Huffington Post, especially when it comes to childbirth:

“Our so-called healthcare system, which is a direct reflection of the beliefs of our culture, sees the female body and its processes (like labor) as an accident waiting to happen…The truth is that labor and birth need not be the emergencies we think they are. And the medicalization of birth actually does more harm than good.”

Northrup criticizes the rising rates of cesarean section and labor induction, and cites the rising maternal death rate. “Studies have repeatedly shown that in healthy mothers with no risk factors, home birth is as safe as hospital birth. Increasingly, savvy women who trust their ability to birth normally [and, we should add, who have the resources] are opting to avoid the hospital altogether.”

Northrup concludes the essay with a call to action: “When it comes to pregnancy and birth, we as a culture and as individuals need to wake up and claim our right to literally birth right!”

Most of us learn the word “elective” in high school, when we find ourselves with the newfound freedom to take a course like AP music theory, or advanced sculpture, or yoga. Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called “elective” cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature, as did a recent study… (Read the the entire commentary at RH Reality Check.)

Just a week after we learn that babies are suffering from C-sections performed too early — and a large proportion are — another new study finds that serious birth complications are on the rise in U.S. mothers. Nearly twice as many women needed blood transfusions in 2004-05 versus 1998-99, and there were 50% more pulmonary embolisms — life-threatening blood clots that are a direct complication of surgery. There were also more women in respiratory distress and kidney failure following childbirth in the latter group. Researchers made clear that this trend is not related to mothers skewing older in recent years, but rather the rising rate of cesarean birth, which has increased from 21% in 1996 to 31% in 2006. “It was just amazing the consistency,” study coauthor and obstetrician Susan Meikle told the Chicago Tribune, “from vaginal delivery, where the rates [of complications] were lowest, to repeat Caesareans, where we saw an increase, to primary Caesarean delivery, where the increases were the highest.” The overall risk of severe morbidity rose from 0.64% to 0.81%. With 4 million+ births per year, that’s a lot of sick mothers. This is yet more evidence that preventing unnecessary cesareans should be high up on the healthcare agenda.

The New York Times is on a roll this week. One article reports on a study linking the rising cesarean rate to the rise in “late preterm” infants — those born at 34 to 37 weeks, when they are at a higher risk of breathing problems, breastfeeding difficulties, and spending their first days of life separated from their mothers in a Neonatal Intensive Care Unit. Another article blows the whistle on insurance companies denying individual plans to women who’ve previously given birth by cesarean. Treating the first cesarean as a pre-existing condition, the insurers argue such women are at a higher “risk” of having another surgery — which they are, because so many physicians and hospitals are discouraging, or refusing outright, women a vaginal birth after cesarean (VBAC). The Times reports that 500,000 U.S. women anually give birth after previous cesarean, and it has previously reported that at least 300 hospitals have official VBAC bans.

The medical insurers blame physicians and women for a glut of “elective” C-sections, which cost them more; physicians blame women and their own malpractice insurers. “I think there is pressure by patients on physicians to deliver early-ish when someone’s uncomfortable,” said Sarah J. Kilpatrick, head of ACOG’s obstetric practice committee, “and there is medico-legal pressure. Obstetricians are afraid of being sued,” so they may “proceed with a Caesarean to deliver the fetus when the fetus is probably fine.” What Kilpatrick doesn’t say is that the ACOG committee she heads is responsible for the de facto VBAC ban, which plays a huge part in the rising cesarean rate — and, as the study suggests, the rising rate of preterm babies.

The losers in all this, of course, are women and their families: going through unnecessary primary cesareans, then being discouraged or flat out denied normal, physiological birth for their next pregnancy, on top of that being denied health insurance because the repeat cesarean their providers are insisting upon would cost the insurer more money, and having babies at higher risk of being born too early, not to mention the risks of repeated major abdominal surgery for mom. And we call this maternity “care”?

The two most common reasons given for a high C-section rate are that a) more women are having “high-risk” pregnancies, and b) more women are obese. This week’s Washington Post story on the link between rising malpractice premiums and rising cesarean rates suggests (like others before it) that it’s not so much women and their health status that are to blame, but their providers and a system that rewards unnecessary intervention. Nearly 1 in 3 American women are going through major surgery to give birth, but only a fraction of them are “high risk” or obese (and the C-section rate has been rising at a much faster clip than the rates of obesity and multiples).

Take a look at Our Bodies, Ourselves‘ take on the purported connection between obesity and cesarean section. While it’s true that obese women are more likely to have a cesarean, it’s not clear that it’s because they need a cesarean. In fact, many of the women labeled “high risk” are labeled so more because a physician is at risk of losing a hypothetical lawsuit, not because supporting a physiological birth would increase the mother’s or baby’s risk of complications. And that’s unethical. “Any physician who picks up a scalpel and does major abdominal surgery…because that doctor is afraid of litigation, is not practicing medicine but is practicing fear and greed,” Marsden Wagner, MD, told the Post.

“No question…the safest way for most first-time mothers to give birth is via an uncomplicated vaginal delivery.” So begins this USA Today article on the rise in cesareans and concurrent rise in maternal mortality. It’s worth reading. And worth considering the fact that some researchers want to conduct a large study comparing women who are selected at random for unnecessary cesareans to women who are selected for planned vaginal birth. Many experts believe that such a “randomized” study is unethical, because there is so much evidence, nicely summarized in the above article, that cesareans pose an increased risk.

Dear Christina,

I know, I know. You must be getting tons of advice about pregnancy, motherhood, etc. right now. You get the bump, and suddenly everybody feels like butting in. So my apologies straight off for joining the choir. Let me also say that making babies, having babies, not having babies — it’s all about choice. So the way you give birth is ultimately your choice to make, and you have that right. I’m writing this letter because I hear you’ve chosen to schedule a cesarean section…

Read more at Huffington Post.

A large Danish study found that babies born by “elective” or planned cesarean are four times more likely to have trouble breathing than those born vaginally or even by emergency C-section. The study (one of many to show a connection between cesarean section and respiratory problems) is further evidence that babies benefit from normal, spontaneous labor. The researchers conclude: “It is plausible that hormonal and physiological changes associated with labour are necessary for lung maturation in neonates and that these changes may not occur in infants delivered by elective Caesarean sections.” More reason to encourage VBAC — and at the very least not to ban it. Read more on the BBC.