Can We Please Stop Blaming Women for C-Sections?


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 the
recent study in this month’s New England Journal of Medicine,
"Timing of Elective Repeat Cesarean Delivery at Term and Neonatal
Outcomes."

The large study made headlines last
week in papers large and small, was mentioned on NPR, went viral on
the web, and even made national TV news. It found that when babies
are extracted prior to 39 full weeks in the womb, they are less
likely be born breathing on their own, more likely to start life in a
neonatal intensive care unit, and more apt to have infections and
lingering health problems.

We already knew this from previous,
smaller studies, and the American College of Obstetricians and
Gynecologists’ recommendation is to wait until the 39-week mark. But
the study, which culled subjects from the National Institute of Child
Health and Human Development network—presumably those hospitals
most likely to follow best practices—found that a whopping 36
percent of scheduled, repeat cesarean sections were booked before
39 weeks.

Ah, but these are "elective" repeat
cesareans, so women must be requesting them early! That’s what the
study’s authors tell us: lead researcher Alan Tita, MD, said that
women "usually" want to deliver "as soon as they hit" week
37. "Women should wait to have an elective cesarean until 39
weeks," he told Time magazine. Study coauthor Catherine
Spong, MD, elaborated for the Washington Post: "Sometimes
a patient is bonded to their physician…and says, ‘Can we schedule
it when you’re in town?’…Sometimes her in-laws are coming at a
certain time."

And the media dutifully followed the
physicians’ pointed fingers—toward mothers: "Thousands of
women put their babies at needless risk of respiratory problems,
hypoglycemia and other medical ailments by scheduling C-section
deliveries too early…" began an L.A. Times story. "The
findings could help diminish a widely popular practice…in which
mothers choose to schedule c-sections, or surgical removal of the
baby," reported the Wall Street Journal. "Some women
opt to deliver a little earlier for a variety of reasons, including
being eager to see their baby, being tired of pregnancy or for
convenience," explained the Washington Post. Time
magazine castigated those mothers: "Today, a trend toward elective
cesareans is presenting doctors with another problem—women who
insist on delivering earlier than they should, with potential
risks to the newborn" (emphasis added).

To be clear, the researchers did not
survey the women in this study—they were looking strictly at the
health outcomes of newborns. And previous surveys of women have found
no evidence of a "trend toward elective cesareans." But in
classifying the deliveries as "elective," they imply
patient-choice. "These are all elective repeat Caesareans
without a medical indication and without labor," Spong told
reporters.

It’s true: scheduled, repeat cesareans
are not "medically indicated," at least not according to the
research evidence. After a cesarean birth, a woman is left with a
scar on her uterus, and there’s a small risk of that scar rupturing
in subsequent deliveries, which has led to concerns about vaginal
birth after cesarean (VBAC). But a VBAC baby has excellent odds—the
risk of severe harm or death is 1 in 2000—the same odds as for a
baby born vaginally to a first-time mother.

However, in spite of the true risk,
VBACs are often vehemently discouraged. In fact, many obstetricians
now refuse to attend them, and hundreds of hospitals have officially
banned them. And malpractice liability fears are a strong motivation
to schedule the surgery early, so as to avoid the possibility of
labor—and vaginal birth. The fact is that VBAC is inaccessible to
most women.

So, if a woman with a scar from a
previous cesarean goes to her OB and is recommended to schedule a
repeat cesarean—and is told that a vaginal birth would be risky,
and that anyway it won’t be done by this doctor, this practice, or
this hospital—can the surgery possibly be called "elective?"

There are risks to VBAC and risks to
repeat C-section—even those done after 39 weeks—and women should
be weighing the risks and benefits with objective care providers who
will support their decision. But this is not what’s happening. In a
survey conducted in 2005, more than half of women seeking VBAC could
not find a willing provider or hospital.

This is not about women "electing"
to put their babies at risk. This is about women being backed into a
corner and told what’s best, then publicly shamed for "asking for
it."

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  • http://womantowomancbe.wordpress.com invalid-0

    I can’t even begin to recount the number of women who have been told they can’t have a VBAC, or can only have one if they (among many other criteria) go into labor prior to their already-scheduled C-section date, which is at 38 weeks. I’ve blogged about this story here, on my blog.

    I’ve often said we need to have more categories for C-sections instead of those we have: elective, emergency, or medically indicated. All in-labor C-sections are called “emergency” which leads a great many women to fear a future trial of labor lest it lead to the same “emergency” (which sounds like your house is burning down) for their baby.

  • invalid-0

    Kudos to you, Ms. Block! You are one of the few journalists to see what’s wrong with childbirth in America. I applaud your efforts to educate the public about how mothers and babies are put at risk by habit-based medicine and bullying by the profit-driven American medical system (some individual docs notwithstanding)! Thank you.

  • http://www.breedermama.wordpress.com invalid-0

    Most of the time a repeat c-section should be called “coerced” rather than “elective”. If someone who is trained to protect your health and well being tells you that you are “putting yourself and your precious unborn child at risk for no reason” and you decide to follow that MD’s professional advice, how is that really “elective”. Is not like women are being presented with a even choice in that situation, it’s more of a “you can have a nice safe c-section or you could possibly kill your baby”. Seriously, the fact that we have a reason to discuss this in this country makes me absolutely ill.

  • invalid-0

    My first pregnancy was normal, I went into labor on my own, went to the hospital an procee to attempt to birth my daughter vaginally. From the beginning the dr. was “agaisnt” that effort. I had my water broken, received an epidural, then pitocin, then finally a c-section. All the while being told by my dr that this was all fine, this was the way she did it. My second pregnancy I used a miwife and again had a normal pregnancy and went into labor on my own no problem, tried to have my daughter vaginally. After many hours of labor an getting only to about four or so centimeters we went to the hospital for another c-section. Now my third pregnancy HAS to be a c-section (which I expected) an I was told it would be scheduled for 9-11 days before my due date to be sure I would not go into labor on my own (which I did not expect at all). My due date ( which we are not completely sure about) is April 4 they wanted to have the c- sec on March 24. I did get them to push it back to the 1st. But that was my wish, the first date I was told was the 24th I had to ask to have it closer to the due date. Some women do want to have c-sections as a matter of convienience, but many more are pressured into all of the medical crap that goes on when you are in a hospital which then result in a c-section, and many, many dr’s and some states will not allow you to even try again vaginally. They do not give you a choice and they belittle concerns that may be had. My dr., when I asked her about being sure the baby was ready to be born told me most babies can be born anytime after 37-38 weeks safely. I am convinced that Dr’s and hospitals have become obsessed with c-sections as a matter of convienience to themselves with barely so much as a care to what is actually best for baby. After all if something is wrong they just admit the baby NICU or keep it in the hospital longer and make even more money that way. It is a win win situation for them.

  • invalid-0

    Great article. I’m pregnant for the first time and have been researching c-section rates at our local hospitals in order to evaluate which would be best for me. My mother was in labor with me and had an emergency c-section, and then another “elective” c-section with my younger sister. As a result, I have always had a fear of not being able to deliver vaginally, and I’ve wanted to ensure that I wouldn’t be unnecessarily coerced into a cesarean. I found that while two of our local hospitals have average cesarean rates (27% and 29%, respectively) one had an unbelievably high rate (37%). I also found that all three hospitals have an average repeat c-section rate of about 91%. I would imagine that many more than 9% of our local women want to attempt VBAC, and I’m sure that the other 91% don’t appreciate their cesareans being labeled “elective.”

    One more thing- the local hospital with the 37% cesarean rate sees many more Medicaid patients than the other two, making their higher cesarean rate even more suspect. I work in reproductive health, and I know from experience that Medicaid reimburses around $470 for a vaginal delivery but $1060 for a cesarean.

  • invalid-0

    You cannot choose that which you cannot refuse.

  • invalid-0

    This type of information will never make a big show in mainstream media because there is just too much money to be made from birthing mothers and babies and those like ACOG and their cronnies have the power to protect their own interests – in any way they see fit. THAT is the bottom line.

    It is truly frightening just how far the medical establishment’s agenda is from what is actually healthy for mother and child. Do a tiny bit of research into common practices – outside the mainstream sources, that is. try Marsden Wagner’s Born in the USA.

    Many women are attempting to arm themselves with information so that they might be able to navigate the ridiculous and harmful aspects of the “care” available. But all too often, rather than develop an honest relationship with such women, OBs see them as too much of a threat. These women find themselves threatened, abused and shunned.

    A few women decide to sidestep this flawed system and go with a homebirth. The medical establishment goes after this situation with all they’ve got. They imprison midwives, attempt to take babies from women, whatever works. This is not because homebirths are dangerous, in fact in all but the most dire situations, they have been proven to be just as safe if not SAFER. But despite with wonderful outcomes, they are a threat to a very flawed, very shakey system.

    The OB community is not beyond vindictiveness, in fact, it very often outright PUNISHES dissenters. Do you see that reported anywhere? Will you? Not until the medical establishment pushes its own interests so far, squeezing the current system so dry, that it all explodes in their face and countless women and babies are damaged or die. And then, of course, they will blame it on the women. Think I’m going too far? Wait…

  • invalid-0

    Part of the difficulty is that we Gen-Xers have grown up with a medical mentality for childbirth, and also are generally respectful of physicians in general. So, when we are told, by someone that we have trusted with the care of our unborn child for months, that a C-section is necessary, or “best”, then we are going to acquiesce, without much research.

    After all, few of us, especially when seven or eight or nine months pregnant, has the time or energy to research options re: labor and delivery.

    When I was pregnant with my first, he was a transverse breech. We tried everything (except for a version, because my doctor felt that was as dangerous for the baby as a C-section) to get him to turn, and he didn’t. So they scheduled my C for 39 1/2 weeks. My Bradley teacher tried to get us to switch doctors to the ONLY OB in the community who would try to turn and/or vaginally deliver a breech baby. But that was really hard for us to imagine. I had spent 8 months building a relationship with my doctors, and I really liked and trusted them. In my head I knew that I could switch doctors and it would be ok, but my heart, I couldn’t do it.

    So, with a second pregnancy, I did switch to that other doctor, because he is also well versed in VBACs. Didn’t work this time either, but I feel like I had the best trial. The unfortunate part is that first C…if I had switched doctors and he had been able to turn and/or deliver the baby vaginally, the second pregnancy might have turned out differently. Maybe not, but maybe.

    Hard to second guess yourself though. Even harder to second guess the doctors. I guess what I am saying is that I feel like I had VERY good patient care, and a doctor who listened to me, both times. And I never felt pressured. And yet I still wound up with both of my pregnancies ending in C-sections. WOW. I can’t imagine how someone who IS pressured feels like.

  • invalid-0

    Sounds like a rape apologist to me. She should have known better, not to trust the judgement of so and so. You just can’t expect so and so to control him/herself around women. She elected to be around him/her so it’s obviously the mother’s fault for not knowing the current research, never mind that doctors are legally obligated to give unbiased information on the material risks of any birth intervention before it’s performed. She shouldn’t have exposed her body and baby to him/her.

    Well. What we have here is a problem of doctors knowing about the risks of inductions, c/s, and early deliveries, and GOING AHEAD AND COERCING WOMEN INTO THEM ANYWAY. Sometimes even forcing these instances of assault and battery on families during “routine” vag. exams and performing AROMs and stretch and sweeps without so much as a by your leave.

    And there is the separate issue of non-consensual interventions and gential contact during term labors. This would include when a patient is too drugged to be able to advocate for themselves, and may not even realize that they were assaulted. Hmnn, birth-date-battery drugs for all hospy patients! Epidural anyone? Gas? Pethidine?

    Selkie, as someone who has been “pressured”, said “no”, and was battered anyway, I feel like pulping their fingers with my Louisville Slugger. Of course, if I did, it would not be MY fault, they should have known better. But, as I’m not a criminal, I sent in a very detailed complaint to my state’s Healthcare Commission. The OB involved gave up the (Australian) AMA power position he/she held, but has not yet responded to the complaint after 7 months. Anytime anyone else complains to the Commission about the parties who were named in my complaint, their names and my complaint will pop up-talk about the straw that breaks the camel’s back, too many complaints and you are without a license.

  • invalid-0

    Those of us opting to try VBAC are truly backed into a corner. If we go with the “safer” hospital-attempted VBAC, there are policies which severely limit the progression of labor, the time frame in which we are permitted to go into labor naturally, and the time during which our labor must progress. I will not even mention the atmosphere of fear, and of tacit (and not-so-tacit) pushing of interventions. (Yes, you *must* have the hep-lock, yes you *must* be strapped to fetal monitor and stay within 3 feet, the Dr is outside the door sharpening her knives in case you don’t progress. . .) With a midwife, we would have a greater chance of successful vaginal delivery than with an OB; but even our midwives are backed into a corner by hospital policy, their liability insurance, and their relationship with insurers.

    We’re even cornered financially, as insurance in our state will not cover the use of direct-entry midwife. It will cover CNMs, but only within a hospital, not at home or in a birthing center. Again, putting us into a situation where repeat and *unnecessary* c/s is likely. And very risky.

    So many of us are choosing to birth at home, to bargain with the midwife so we can afford it, to hope that if we need to go to the hospital we will not receive hostile treatment (not uncommon).

    We need a maternity hospital, staffed primarily with midwives, where we won’t put ourselves and our children at risk for hospital acquired infection, where we can labor at our own pace–when the baby is ready, and where babies and mothers are really put first, are not pressured and are not rushed to surgery for no reason.

  • invalid-0

    you’re amazing. time and again you tell it to us straight, and are right on about what matters when. thank you.

  • invalid-0

    I suspect there are some hospitals out there who have stopped doing VBACs because they can not afford the insurance coverage to offer this option. Plantiff’s attorneys consider bad outcomes after an attempted VBAC a “slam dunk” and they get a 30-40 % of the 25 million dollar verdict. Insurance underwriters simply tell hospitals stop doing VBACs. The American College of Nurse-Midwives took up this issue a few years ago, does anyone have any updated information?

  • invalid-0

    OB doctors and hospitals hide behind malpractice as a reason not to do the right thing. It is far less of a factor in the problem than the old boys club that is ACOG, AMA, etc and what is easiest, most convenient and most lucrative for the establishment. They could change things, they don’t want to. They go hand in hand with the insurance compnaies much of the time. AND they do actually injure quite a lot of women and babies with their non-evidence based, non science based, all-for-themselves practices, so the “problem” isn’t something they didn’t bring on themselves, it is just an easy excuse for what they’d do/have done anyway. THE DOCS/HOSPITALS ARE SO NOT THE VICTIM HERE. But let’s just keep providing htem with excuses for their abhorent behavior.

  • http://momstinfoilhat.wordpress.com invalid-0

    Women are absolutely bullied into repeat cesareans. When I was training as a midwife at a freestanding birth center, we had women transfer to our care late in pregnancy all the time because their doctors were forcing them into a repeat (or primary!) cesarean without medical indication. In fact, we had one mother who said the doctor told her she had to go see a psychiatrist because she was literally crazy for requesting a trial of labor.

    A close friend of mine had a doctor tell her she had to bring her husband in to her next visit so they (the male doctor and her husband) could talk some sense into her when she wanted to try for a VBAC. She was successful with her trial of labor, and now is an activist with ICAN.

    Now that I am in medical school, we had a Women in Medicine Physician’s Panel. On of the doctors told us that she was assured by her doctor in Michigan that, after her cesarean for her twins, that she would have no problem going for a trial of labor with a subsequent pregnancy. Well, she moved down her to South Florida, and was denied by every doctor she approached, even though she is a physician! She finally found a concierge obstetrician who was willing to let her, with a hefty additional fee.

    When I held a journal club meeting for our Student Association of Obstetrics and Gynecology on an article about the success of repeat VBACs, our faculty adviser said he had no idea why I picked that article, because “no one was doing VBACs anymore”.

  • invalid-0

    As far as abortion goes, my own convictions fall no where close to this site’s ideological bent. But how can I help from expressing my profound gratitude to RH Reality Check for running a piece like this? It strikes both a personal and political cord with me and, I’m sure, for countless other women.
    I saw my sister through two cesarean deliveries. The first was an “emergency” cesarean because her membranes ruptured and-ding!ding!ding!-the times-up, 24-hour alarm went off. The second actually went into her chart as an “elective” cesarean . . . a laughable name considering that it happened at a hospital with a VBAC ban.
    A revolution is occurring, and the curtain is closing on the many injustices of modern maternity practice. Will the last evidence-free physician kindly turn out the lights?

  • invalid-0

    I got almost 15,000, the first few pages were 80 % attorneys looking for “Vbac victims.”

  • invalid-0

    I got almost 15,000 hits, the first few pages were 80 % attorneys looking for “Vbac victims.”

  • invalid-0

    We all know there are heeps of attorneys ready and willing to sue for ANYTHING. The medical establishment is willing to hide behind this excuse instead of changing their ways and improving their practices. Again, THEY ARE NOT THE VICTIMS. Their practices are heinous and they go practically UNCHECKED. Read Marsden Wagner. Please. He does a far better job explaining it than I and he does it from the inside. He addresses this issue very pointedly.

  • invalid-0

    as mentioned above…. no VBACs in S. Florida because they have the highest ob malpractice rates in the USA

  • invalid-0

    Hi Jennifer,

    May I ask where you got the 1 in 2000 for serious harm or death figure? I had heard something like that but can’t remember where I found it in terms of medical literature. I have a friend who is starting to freak out about VBAC (ironically, her doctor is not), and she was looking for reassurance. Most of us have read the stats on rupture, but what we really want to know is how often the results are catastrophic. I would love to pass on this reassurance to her. E-mail me privately or post here – thanks so much!

  • invalid-0

    Can we get a reference on the VBAC uterine rupture as 1 in 2000 being the same as for a first time mom? I’d really like to use that!

  • invalid-0

    “Vaginal delivery was attempted by 17,898 women, and 15,801 women underwent elective repeated cesarean delivery without labor. Symptomatic uterine rupture occurred in 124 women who underwent a trial of labor (0.7 percent). ”

    http://content.nejm.org/cgi/content/abstract/351/25/2581

    Dec 2004

  • http://organic-birth.com invalid-0

    Thank you for writing this, Jennifer. Your voice is much needed in a time when medicalization of childbirth is becoming overwhelming.

    I was lucky… after my first was born by a cesarean that I was slowly directed towards from the moment I checked into the hospital, I was able to have hospital VBACs. In the 1990s, this was promoted as the best way to handle births after cesareans. I went on to have 3 hospital VBACs, and 4 homebirth VBACs without incident.

    Many states don’t allow homebirth midwives to do VBACs like they do here in my state of Oregon. Without these options, women truly are backed into a corner. I hope we can all band together and change the direction birth is going in this country.

    Thank you for all you do.

  • invalid-0

    This artical finally gives me hope to continue searching for practioners who will help me through a VBAC.
    After calling over 15 practices and speaking privatly with about 25 MDs, my problem is not in finding a hospital who is willing, but finding a doctor.
    In the medical records from my c/s (9/11/07), many things were incorrect. They state that
    1)my child was born a female (wrong last time I looked),
    2)I was induced because the doctor feared that the baby’s size was too big for my pelvis (when he actually induced over 10 women that week, due to his upcoming vacaton and my baby was an average 7lbs.2oz.), and
    3)that the baby failed to decend and that the reason for c/s was stalled labor (which was never even discussed).
    My water was broken at about 7am without my knowning why, exactly, the so-called “routine examination” was hurting so bad. i didn’t find out until about half an hour later what had happened. And i was preped for surgery at 2pm, when i was dialated to a 7. Therefore, i was only in “active labor” for 7 hours, and was progressing fine, except that 1/2 hour went by with no change. I don’t know about you, but I think that had to do with the fact that i could not get up and move around. That was due to the practically forced epi ( i was afraid of being paralyzed), the susequent cathiter, and the constant fetal monitoring.
    Now, every doctor looks at that medical record, and, despite my pointing out the many dicrepencies, gives me an automatic no. One doctor even went so far as to say that he had seen “many dead mothers and dead babys because of hard-headed women like you,” and when I told him that I just wanted a chance, “Why go your whole pregnancy on a hope and a dream when that’s all it is. I can tell that you’re not going to be able to do this.” And that was when that appointment was over.
    If anyone could give me a better approach as to how you convinced your doctor, or ways to find maybe a list of VBAC friendly hospitals/doctors/midwives, whatever. It would be greatly appreciated.

  • invalid-0

    The responsibility lies with the doctors. If they are refusing women VBACS, they need to at least do the c-sections safely. Saying, “Well this woman wants a VBAC, but I think it’s unsafe so I won’t do it” and then turning around and saying “this woman wants her elective c-section at 37 weeks because she thinks the last few weeks are uncomfortable and that’s ok with me even though the baby will probably have a rougher start” is NOT ok. I hate hearing doctors say “I don’t like to do it but if the parents/patient wants it….” NO! You don’t HAVE to do anything you think is unsafe no matter how much they beg you! The pedi my daughter had in the NICU told me how much he hated doing circs and was glad he didn’t have to do them at the hospital and I couldn’t help but think, “Why would you do them anyway? You don’t HAVE to!” When it’s judgment based on convenience or aesthetics, you don’t have to do it. If a doctor suggest to a woman that her c-section should be before 39 weeks for medical reasons, she should STILL be given all the info on risks and be allowed to make the decision herself. As for “choosing” to have the baby before 39 weeks…most women would not “choose” to have the baby early for selfish reasons if they knew the risks. So again, responsibility lies with the doctors to inform them and also choose not to do anything unsafe. Now doctors not “allowing” women to VBAC is a whole ‘nother story…