Cesarean Birth in a Culture of Fear By Wendy Ponte
Issue 144, September/October 2007
When I tell someone I am working on a story about the escalating rate of cesarean sections in the US, it often leads to a conversation that goes something like this:
"C-section rates are up to 50 percent or higher in some hospitals," I say. "Doctors often feel they must do a C-section to protect themselves from a malpractice suit. And many of them seem to feel that a C-section is actually better than vaginal birth. A lot of women are being given unnecessary surgery."
"I had a C-section," my acquaintance will say. "But in my case, it was necessary."
"Tell me about it."
"Well, the baby's heart rate started to drop on the fetal monitor, and the doctor was worried that she wasn't handling labor very well. So he said a C-section was the safe thing to do."
It's an awkward conversation, to say the least. I would never want to make any woman feel bad about the birth of her child. Women need to be honored for their birth stories, no matter how those stories go. And having been told by both a doctor and a reliable-looking and expensive piece of machinery that her baby could be in trouble, my acquaintance probably made the best decision she could make in that moment. By the time she reached the point when that decision was made, it could, in fact—after hours of beeping noises on the fetal monitor, the suspense of the hospital atmosphere, and loads of chemicals pumping into her body—have been the only choice available.
And yet I also know what hundreds of other birth activists know. Some percentage of women who think their C-sections were necessary—because of fluctuating heart rates, large babies, failure to progress, previous C-sections, difficult birth positions, and on and on—have actually had unnecessary C-sections.
I know this because the World Health Organization (WHO) says that any time a country's cesarean-section rate rises above 15 percent, the dangers of C-section surgery outweigh the lifesaving benefits it is supposed to provide. 1In the US, the overall C-section rate has now reached 30.2 percent.2
That conversation, which I have had all too many times with various women, boils down to this: There are too many C-sections being done—unless it is your C-section. Then, it just isn't so clear. That conversation parallels the one that seems to be happening on a national scale. Although the arguments against the use of C-sections, except when there is no other choice, are clear, and although these arguments are supported by plenty of evidence and statistics, doctors and patients do not seem to be using that information to change birth practices. It doesn't seem to matter that, in the US:
A woman is five to seven times more likely to die from a cesarean delivery than from a vaginal delivery.
A woman having a repeat C-section is twice as likely to die during delivery.
Twice as many women require rehospitalization after a C-section than after a vaginal birth.
Having a C-section means higher rates of infertility, ectopic pregnancy, and potentially severe placental problems in future pregnancies.
Babies born after an elective cesarean delivery (i.e., when labor has not yet begun) are four times more likely to develop persistent pulmonary hypertension, a potentially life-threatening condition.
Between one and two babies of every hundred delivered by C-section will be accidentally cut during the surgery.3
The US is tied for second-to-last place with Hungary, Malta, Poland, and Slovakia for neonatal mortality in the industrialized world.4
Babies born via C-section are at high risk for not receiving the benefits of breastfeeding.5
The risk of death to a newborn delivered by C-section to a low-risk woman is 1.77 deaths to 1,000 live births. The risk of death to a newborn delivered vaginally to a low-risk woman is only 0.62 per 1,000 live births.6
Despite these statistics—which are just drops in the bucket of information available about the dangers of cesarean surgery—the procedure keeps being done. Women are not well enough informed, say birth activists. Medical schools are not teaching doctors how to create optimal scenarios in which successful vaginal birth can happen. Doctors are making decisions based on fear of malpractice suits rather than medical necessity. But even though we know all of this, and even though the statistics are compelling, high-tech birth practices continue, and the C-section rate keeps climbing, with every indication that it will climb higher. Why? "In another century, these birth plans will be perfect time capsules of postmodern maternity," says Tina Cassidy in her recently published book, Birth: The Surprising History of How We Are Born, "for if there is one thing that writing this book has taught me, it is that birth always reflects the culture in which it happens."7 Which made me wonder: In examining the way we give birth today, what would an anthropologist a hundred years from now learn about our culture?
The Mantra of Fear
If an imaginary future anthropologist took a look at our current birth practices, she or he might conclude that we were a very frightened people indeed. In her book, Cassidy reports that many women have a deep feeling that birth is inherently dangerous. "Deliveries at home and in birth centers have been statistically proven to be as safe as those in hospitals, where, not incidentally, one's chances of having a cesarean soar just because you walk through the door. . . . There are, and always have been, trade-offs in decisions about where a child should be born. . . . Weighing those options, women still want to give birth where they feel most safe. And for all but a fraction of those pregnant today, that place is on a bed that can—if necessary—be wheeled into the operating room, surrounded by machines, and attached to electrodes and a catheter that drips anesthetic directly to the spine."8
Just look at the statistics in the 2006 survey "Listening to Mothers II." Only one in four women surveyed had attended a class in childbirth education—however, 68 percent of these women had watched one or more television "reality" shows that depict childbirth.9 With few exceptions, these shows portray births that follow a strictly medical model, usually problem pregnancies in which women and their babies are rescued by heroic medical procedures. Machines beep wildly in the background, and the atmosphere is fraught with tension.
Maureen P. Corry, executive director of Childbirth Connection, which sponsored the "Listening to Mothers" surveys, feels that such shows make women believe that this type of birth is completely normal for all women.10 In the 2006 survey, 72 percent of first-time mothers felt that watching these shows "helped me understand what it would be like to give birth." In other words, being rescued from a dangerous situation by medical technology now seems to them to be a normal part of the birth experience. Even more striking is that 32 percent of first-time mothers felt, on the other hand, that the shows "caused me to worry about my upcoming birth."
Neither position seems likely to prepare a woman for the idea of birth as a normal life process that might actually go well on its own, with little or no intervention—a process that is, in fact, biologically more likely to go well. "Our culture has an 'accident waiting to happen' mentality," says Corry of the survey's findings. "It makes birth go from a normal physiological process to something that resembles intensive care. I think it is indicative of the larger culture in general."
Indeed, we seem to be a people who are just waiting for something to go wrong. You have only to turn on the evening news to get a good dose of what there is to be fearful about. On any given day, you can hear that the supplement you were told last month would add years to your life has now been proven to be toxic. Your chances of developing such-and-such disease have been increased by your living in the town or neighborhood you moved to last year. If you don't send your children to get extra tutoring right now, they will never succeed in their chosen careers.
Certainly, the events of September 11, 2001, and fears of terrorism have increased this tendency—or perhaps it is our fear-filled response to these threats that has caused our lives to become even more anxiety-ridden. For many, it has become impossible to sort out the difference between sensationalism and valuable information. And this very uncertainty itself provokes more anxiety, adding yet another layer of fear.
Our fear-based culture shows up in another birth-related way: the overriding fear of most doctors—even many midwives—of being sued for malpractice. This fear is based on grim reality. Being sued for malpractice can be life-changing and devastating: Doctors can lose their practices, their homes, their life savings. And so, as the normal ebb and flow of labor unfolds, physicians all too quickly resort to responding as if to a worst-case scenario. If a woman is not progressing quickly enough, or if the fetal monitor she is attached to indicates a change in the baby's heart rate, the physician feels the safest route is to use every medical tool available, to show that all the bases have been covered. To protect themselves from the expense of a major, career-destroying lawsuit, doctors pay for malpractice insurance at increasingly outrageous rates—some as much as $200,000 per year.
But why is it that the very things that cause birth-related morbidity rates to rise are seen as the "safe" way to go? Why aren't women and their doctors terrified of the chemicals that are dripped into their spines and veins—the same substances that have been shown to lead to more C-sections? Why aren't they worried about the harm those drugs might be doing to the future health of their children, as some studies are indicating might be the case?11 Why aren't they afraid of picking up drug-resistant Staphylococcus infections in the hospital? And why, of all things, aren't women terrified of being cut open? Again, the response seems totally irrational.
Our future anthropologist might soon conclude that the answer lies in our culture's biggest fear of all—of letting go and allowing natural processes to carry on—and our fascination with and blind faith in science and technology as the ultimate antidotes.
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