Why Are C-section Rates in the USA Skyrocketing?

In just four decades, the c-section rate in the United States has jumped from 4% to nearly 32%. What has caused this rise?

One might immediately consider infant mortality rates. Perhaps the dramatic increase in Cesarean birth has dramatically reduced infant mortality? According to the CDC's numbers, deaths per 1,000 live births has dropped from 25 to 6 in the same time frame, meaning a drop of 2.5% to than .006%. While it's good to see mortality rates have dropped over the years, it wasn't a radical enough change to explain why nearly one in 3 births is now completed by c-section.

A number of social and medical factors may have played into this change in birth norms.

In the medical arena, technology has grown by leaps and bounds, as have insurance premiums and lawsuit fears. Combining the ability to "pre-diagnose" women or unborn babies with potential disastrous problems, and a lawsuit happy culture is a recipe for disaster when it comes to birth. Doctors are often in a catch-22 situation...aggressively "manage" labor medically even when it's unnecessary in order to avoid a life-ruining lawsuit, or refrain from preemptive medical management and hope nothing bad happens. As this situation has developed over several years, natural and unmanaged labors have become something of a surprise even to doctors who have spent many years learning all about birth. If a woman and her baby don't fall within a strict but arbitrary set of conditions (her weight, the baby's weight, due date, length of labor), the red flashing lights and alarm bells go off and a doctor can't feel comfortable with doing nothing anymore.

In my case, my weight, ultrasound estimates of my baby's weights, and going 16 days past my estimated due dates combined in two different pregnancies to give obstetricians nightmares. The pressure to induce, or to just skip it all and go straight to the operating room was intense. I cared about my babies and their health, but I also had a long term view that made me intensely eager to avoid an initial c-section (we are open to a large family, so a c-section early on would likely lead to more surgical births, putting me and future babies at some risk). Although the doctors were not happy about my refusal of aggressive preemptive medical management, they did back off when it was clear I was concerned about my babies and not just "a birth experience". To appease their concerns, I made twice-weekly treks to the hospital to have fetal non-stress tests and bio-physical profiles to insure that my unborn babies were indeed happy and healthy in my womb, not suffering from "overbaking". And I willingly went to the hospital when it was time to give birth, rather than choose the more reactionary route of "unassted birthing". When all was said and done, although both of those babies ended up born at 10 lb. (give or take a few ounces), I was supremely glad to have resisted the pressure for medical management of labor because it's hard to beat 4 hour labors with minimal tearing, even with the best medical intervention.

Medical fears like these can lead to practices like non-emergent induction or augmentation of labor, constant internal or external fetal monitoring, preemptive IV's, "just in case" epidurals....all of which largely restrict a woman to the hospital bed in positions that most birthing women's bodies just do not like, which results in a writhing, fearful woman with a baby who "doesn't like the contractions", and ups the nervousness of her family and caregivers, giving rise to suggestions of one intervention and then another. One has only to view an episode or two of "A Baby Story"² to see this progression happen again and again. Any published or online forum for the telling of birth stories is also rife with the personal experiences of women who have had some variation on this theme. Some are fine with what happened, some defensive, others guilt-ridden, and still others are agitating for change.

These varied reactions of women are part of the social changes that have developed in the generations since birth was viewed as a normal, routine part of life. As Western society has become more individualistic and families have dispersed, many women have lost their "village" which would have surrounded them with known and loved women to teach and encourage them when the time for birth and baby care arrived. Families have gotten smaller and smaller, and thus people can be raised and enter adulthood with absolutely no experience, let alone positive experience, of anything related to pregnancy, birth, or parenting. For many women, birth and mothering have become exceedingly daunting tasks to consider, and they must rely on advice books and on medical professionals, who have their own biases and issues as discussed above. Media portrayals of birth are poor substitutes for supportive community, and tend to feed fears rather than give accurate representations of birth.

Society has also changed it's view of technology, from something amazing and mysterious to something deserving little thought, if any. Reproductive technology promises safe, tidy, clean, quiet solutions to any problem, however small, a woman may run into in her reproductive journey. Why not use fertility treatments? They might result in triplets (or more), but a couple can either have a "simple" reduction abortion, or a "safe and easy" planned c-section. Why not induce at 39 weeks? Why bother with another one or two weeks when the baby is essentially "done"? Why not agree to a c-section for any reason? Particularly if one's obstetrician is placidly insisting that it's no big deal.

The complete list of reasons for our nation's jump in Cesarean births is far too long to examine thoroughly in a short article. Suffice it to say that many seemingly small changes have occurred over decades to prompt the rise, and they are intertwined. For the rates to fall, all of these changes will need to be reversed, or new changes need to be made.

¹Data 360, Infant Mortality Rates
²A Baby Story, TLC