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leo-cullum-expert-witness-new-yorker-cartoon1“Childbirth is something that is primitive, ugly, nasty, inconvenient,” Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo, said. “It takes long, and the idea is we have to make it fast. It’s impolite for doctors to leave cases for the doctors on the next shift–there’s a sense that you need to either accelerate it or do a C-section.”

From an article about C-section rates in Brazil

The World Health Organization has decided that about 6 out of 7 babies should be born “naturally.” How do they know this? Mostly, by making educated (and some less than straightforward) guesses. Fact is that as we doctors have medicalized childbirth, we have complicated the choices women have to make, made childbirth less convenient, and not really improved outcomes all that much. Witness Brazil, where the c-section rate is almost 50% and the maternal mortality rate is 69/100,000 births,  The best country for mothers surviving childbirth is Belarus, where only 1 mother dies per 100,000 births and where 4 out of 5 mothers have a vaginal delivery. Here in the United States, by comparison, 1 in 3 mothers get a c-section, maternal mortality is 28/100,000  and for all we spend we are still #62 in maternal mortality, between Korea and Malaysia.

One school of thought is that all of these c-sections are at least resulting in healthier babies. If only that were true. Although the statistics for infant mortality are a little confusing (some countries don’t count babies below a certain weight and others do), Brazil should have a really low rate with so many of their mothers going to section. By their count, about 12 out of every 1000 neonates die, twice that of America (best is Luxembourg at 1/1000, 3 out of 4 delivered vaginally).

If a high number of c-sections are not particularly good for the mother or the baby, why do so many get done? The National Partnership for Women and Families has debunked some myths and identified some real problems. First the myths:

1) “I want my baby on Tuesday” – Although we would like to believe that consumer choice has something to do with it, only 1% of women who have primary c-sections (a first baby born via c-section) requested that it be done that way.

2) “My doctor says I’m not made for a baby to come out down there” – Though we believe that  women are getting older and more likely to have other medical problems, this is not the case. The evidence is that those women who before 1990 would have had a trial of labor, all things being equal are now being encouraged to go to c-section.

3) “If I do a c-section the patient won’t sue me, especially if things go horribly wrong” – Turns out that the medical system screws up about 1 in every 100 deliveries but only 2% of those lead to lawsuits. Turns out docs are much more influenced by who they chat with in the doctor’s lounge than by actual risk of malpractice claims.

Why so many c-sections? First, women are not encouraged to get in shape for childbirth. We are discovering that the human body deals much better with changes associated with surgery if its owner has it in good shape. This is true for childbirth as well. Women need to be encouraged to be in good physical shape at all times but especially as childbirth approaches. Second, it is important not to rush mother nature. We are finding out that waiting until after the due date to do anything is very important. Obstetrics means “to stand by” and that is what doctors (and patients) need to do. Third is that we are afraid to agree that anything but “once a c-section, always a c-section” is okay. A problem when the primary c-section rate is so high. Fourth, we tend to have a blase attitude towards surgery. We do a lot of surgery in this country and tend to think nothing of it. Obstetricians make a living at it. Along with that  is a belief that nothing bad happens in surgery. Although  c-sections are much safer than they once were, the human womb is not made to be cut open several times and have a baby forcibly removed. Lastly, doctors get paid more for doing a c-section. Less so now in terms of money (it used to be different) but much more so in terms of time (one hour for a c-section as opposed to sitting up with a woman for 12 hours) and increased opportunity cost (ability to do something else with that 12 hours). In the words of one Brazilian who was rushed into a c-section after laboring for 6 hours (less than the average labor takes by half): “He was saying, ‘I was at a birthday party, and I want this done fast because I want to go back and finish my whiskey,’” she said.

To change the c-section rate, then, women will need to take back their bodies from doctors (again). They need to be aware of what the c-section rate is at the hospital they are planning to deliver at and select a doctor and a hospital with a rate below 25%. They need to demand an opportunity to go into labor naturally if at all possible. Mostly, though, they need to prepare for labor physically and mentally. Turns out that only mothers can prevent needless c-sections.