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An Epidemic of C-Sections » Women's Courage

An Epidemic of C-Sections

February 17th, 2011 by jennawg Leave a reply »

As I was perusing for topics to write about this week, I came across Amelia’s comment on my very first blog post, where she suggested I write about c-sections in the US. I started doing some research and found to my surprise that C-section rates are dangerously high not only in the US but in some developing countries. Surveys by WHO found that in Asia, 27% of births surveyed were c-sections, and in Latin America, 35%. In the US, the percentage is 30. In China, it’s 46. (1) For a bit of perspective, WHO has recommended rates not rise above 15%, and other doctors say even above 5% is generally not justified (2). What are the factors behind these astonishingly high rates? Beyond that, what do they mean for the health of mothers and babies everywhere?

First, another note to frame the issue: I’ve spent a lot of time writing about issues of access to care and how that affects maternal mortality in developing countries. As we all well know by know, a lack of access to obstetric care, emergency or otherwise, is a major factor in the unacceptably high maternal mortality rates that continue in much of the developing world. Thus, it’s critical to note that an even worse statistic than too many c-sections is too few. Rates lower than 1, or even 3 percent “indicate a lack of access to obstetrical care and a risk of maternal death” (2).  Thus it’s unsurprising that rates of c-section remain below 1% in rural areas in Chad, Niger, Mali, Madagascar, Zambia, Haiti, and Nepal.

On the other hand, what is the outcome of too many c-sections? An ecological study of 8 Latin American countries found “overall and elective caesarean section rates to be positively associated with severe maternal morbidity and possibly mortality, as well as with fetal mortality and newborn morbidity,” after accounting for the fact that hospitals attracting higher risk pregnancies would also have higher rates of c-section (3). Given the risks to themselves and their babies, why are so many women choosing c-sections? There is a wide range of reasons, both medical and cultural. Doctors may encourage c-sections in their patients because the procedure is quicker than a vaginal birth (3). Women may choose a c-section because it’s seen as being less violent on their bodies than vaginal birth—a “harmless, painless, and convenient” process (3). There is also the misconception that c-sections are less risky than natural birth. Beyond that, it’s simply convenient to be able to schedule your birth. Yet another WHO study found that some Asian women will plan a surgery so that she can give birth to their child at a time or day a fortuneteller has told her is lucky (1).

In Brazil, a country with c-section rates approximately as high as China’s, socioeconomic factors also play a huge role in women’s choice to have a caesarean. Wealthy women are more likely to have the procedure—in fact, 55% of women with a family yearly income greater than $1000 do—so it is viewed as superior and desired medical care. Beyond that, low SES women are concerned about receiving biased or sub-par care from doctors in a vaginal birth and see a c-section as the solution. What’s interesting is that it’s all about the women’s perspectives of their treatment: the researchers write, “According to some women, a traumatic vaginal birth often occurred because of medical negligence based on social and economic prejudice…Indeed, many of the factors influencing maternal behaviors, such as fear of pain, are meaningful precisely because they are understood to differ by socioeconomic status and to be embedded in discriminating practices.” In this context, the desire to have a c-section is a function of women’s desire to establish some power over their bodies and medical experience. Unfortunately, it’s also reflective of misinformation about the benefit of caesarean sections. (4)

Interestingly, the high and increasing rates of c-sections worldwide are indicative of an over-medicalization of the birth process in developing countries. This statement may seem wrong or ironic given that so many women die because of lack of medical care before, after, or childbirth. However, studies have shown that in developing countries where medical care is available, there is an overuse of obstetrical interventions, notably c-sections but also episiotomies and oxytocin, a chemical used to augment and induce labor. All these practices are life-saving when needed, but may be harmful when used unnecessarily. (2)

Ultimately, distribution of c-sections worldwide indicates the health inequities which plague our world and especially its mothers. In The Lancet, a couple of Brazilian doctors commented on the trends in their country, noting “Within middle-income countries, inequities affect both extremes of the social scale: the rich have too many caesarean sections, whereas the poor have fewer than needed” (3). Indeed, this is the situation worldwide. In developing countries, where resources are painfully limited, prioritizing access, efficiency, and quality in maternal health care is absolutely crucial.

  1. http://www.msnbc.msn.com/id/34826186/ns/health-pregnancy/
  2. http://www.jsieurope.org/safem/collect/safem/pdf/s2938e/s2938e.pdf
  3. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68780-1/fulltext
  4. http://www.bmj.com/content/324/7343/942.full


  1. laurah21 says:

    Hi Jenna,
    This post is very interesting, thanks for sharing!
    You mentioned one ecological study which shows elective caesarean section rates seem to be “positively associated with severe maternal morbidity and possibly mortality, as well as with fetal mortality and newborn morbidity.” I thought that statement was very interesting because, as you mention, c-sections are often considered the safer route to delivery. I would be interested in learning via which mechanisms c-sections can increase maternal and fetal morbidity and mortality. I also wonder if, in the United States at least, the rise of C-sections may be due to obstetricians trying to prevent getting sued. Just to reduce the risk of any potential harm to the baby or maternal complications, physicians may be choosing C-sections. If that is the case, then what does it says about American patient-physician relationship: both sides apprehensive of the other, it would seem.

  2. anna says:

    Jenna – really interesting post. I was first struck by research showing that women may choose a c-section because it hurts them less in the short-term. The thought of giving birth does indeed sound painful, and I can’t say I blame women for wanting to avoid this pain. Perhaps education would play an important role here, by highlighting the risks of unnecessary c-sections to both mother and baby. I don’t know much about the physical consequences of having a c-section, but perhaps in the long run they are harder on the woman’s body than vaginal birth? If so, emphasizing long-term health and well-being over the short-term pain of vaginal birth could be another effective campaign.

    Your discussion of women in Brazil was also really interesting, and again highlights the need for education. I really understand women’s desire to have control over their bodies and medical experience, particularly for an event so momentous as giving birth. We certainly don’t want to take this control away from women, but instead to educate women to steer them toward healthier options for birth (i.e. only c-sections when needed). It’s good for women to want to control their bodies, and they deserve full information to make the best choices for themselves and their children. Physicians likewise need to be educated on when c-section are warranted, when they are unnecessary, and when they are likely to be most harmful. It seems that the whole culture around giving birth needs to change in countries where c-section rates are so high.

  3. Bisi says:

    Hi Jenna!

    I have often thought of having a c-section myself to avoid the pain that comes with childbirth, despite having read all the literature on the increase in c-sections and the harm it poses to both mother and child. Why? In all of the reading I have done, the complications seemed to be more on the side of errors by doctors that can be fixed by investing in safer surgery practices.

    I agree with klstaves’ position that it is not fair to compare the rise in c-sections in developed countries to those in developing countries. To me the problem with both incidences is directly related to quality healthcare and access. If we are to compare both cases, what we need to be clamoring for is improved methods of c-section that do not threaten the mother or child whether the mother elects for it or is in a situation that requires her use of it.

    Improved methods in medicine (and often surgery) requires overthrowing traditions that have been passed on by one doctor to the next, which literally means breaking something that is equated with inheritance. It is tough, but it can and is done (begrudgingly, but done nonetheless).

    Keep up the good work!

  4. klstaves says:

    The issue of access to accurate information surrounding c-sections is an interesting one. On the one hand, doctors are instructed to list out risks for women before they decide to have a c-section (just like for any other surgery). This suggests that women are told about risks of infection, longer recovery time, etc. Assuming that doctors do in fact tell women about these risks, why are there such persistent misconceptions about the relative risks of vaginal delivery vs c-sections? I wonder what this might imply about the way we educate patients about medical risks. Might there be a better way to provide information such that patients are really making well-informed choices about delivery methods?

    The article mentioned by Katie brings up some really interesting points about reasons for increased rates of c-sections in the US. Given the reasons listed in that article, I wonder if it is fair to compare the rise in c-sections in the US to the rise in c-sections in countries in the developing world. While sociocultural factors are probably relevant in both settings, I wonder if they are more important in countries like Brazil than in the US?

  5. kaking says:


    Really interesting post. I just wanted to recommend if you haven’t watched it yet, but an awesome documentary called The Business of Being Born, which is about the high rates of cesarean sections in the US compared to other European countries, and about the relatively low use of midwives in the U.S. The film discusses a lot of the unwanted medical interventions that go on in America’s hospitals and does a great job at tracing the history of American obstetrics. This movie also discusses why some women get c-sections: so that they can get a tummy tuck right after. I was kind of surprised at this, especially because I didn’t think women got c-sections unless they absolutely needed them. Thus I was really surprised to find that it has become an elective procedure – and one that, as you noted, can be harmful to both mother and baby. If you want more information about the documentary you can find information at http://www.thebusinessofbeingborn.com/. It is also streaming on Netflix if anyone would like to watch it.

  6. kjewett says:

    Hey Jennah! Interesting post. You’re right–c-sections are an issue very much overlooked in the U.S. In fact, it looks as if the rate of C-sections for American mothers is rising. The reasons for this seem to be rather unclear. However, it’s important to note, as you did here, when the C-section rate is too low it might be an indicator of inability to access appropriate care. You didn’t explicitly say this, but I think it goes without saying that the rate of C-sections cannot be an absolute indicator of a country’s maternal health. There are so many confounding factors that also come into play when comparing the maternal mortality of one country against another.

    The other interesting point you brought up was how in Brazil, getting a C-section signals higher wealth and status. Women’s preferences in birth vary among countries. The following article talks about how American women often prefer C-sections given the fear of pain, convenience, and for fear that the birth process may complicate the mother’s health. Check out the article here: http://today.msnbc.msn.com/id/17796664/ns/today-today_health/

    Anyway, great post Jennah! It really got me thinking about how our access to health care as well as maternal health in particular compares to other countries.


  7. abui says:

    I find it really interesting and surprising that cesarian sections can increase the risk of maternal morbidity and mortality and it raises many questions. Do you know if there is a reason for that? Could it be due to the incompetence of doctors performing the surgery, which is why I wonder if the same positive correlation would exist in very developed health care systems compared with health care systems in poor countries. I can also understand why women would choose c-sections over vaginal births if they have the option these days because it is a lot less painful and it reduces the risks of tearing, but do doctors realize that c-sections are correlated with higher mortality and morbidity? If so then should they be informing the women of the increased risks associated with c-section as compared to vaginal births. You mention that doctors may encourage C-sections because they are quicker and more efficient than vaginal births, but is time and convenience a priority over safety or is there a relationship between the two? I think this is a very important finding and it would be great to see more research done and start interventions to improve maternal care if needed.

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