Women in the United States are giving birth by Cesarean section far more often than is necessary to keep maternal and neonatal mortality rates low.

Around the world, a C-section rate of approximately 19 percent seems to be ideal for the health of both women and newborns, according to an analysis of childbirth in 194 countries published Tuesday in The Journal of the American Medical Association.

In the United States, however, about one in three births happen by C-section, a rate that has risen dramatically over the past few decades, from 5 percent in 1970 and 20 percent in 1996. By contrast, about 16 percent of births in Finland and 24 percent in the United Kingdom are from C-sections.

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“As countries increase the number of C-sections they provide, mortality goes down” — but only to a point, said Dr. Thomas Weiser, an assistant professor of surgery at Stanford School of Medicine and one of the study’s authors. When the C-section rate tops 19 percent, benefits for maternal and infant health plateau.

The implication: “We have higher overall rates than are medically necessary,” said Katy Kozhimannil, a women’s health researcher at the University of Minnesota who wasn’t involved with the study.

And all the surgery isn’t producing better outcomes.

The maternal mortality rate in the United States has climbed in the past two decades to 14 deaths per 100,000 live births. That’s considerably higher than the rate in other wealthy countries such as Germany, Canada, and the United Kingdom, according to the World Bank.  The infant mortality rate in the United States is also grim; it stands at about six deaths per 1,000 live births, double the rate of countries like such as Japan, Finland, Portugal, and the Czech Republic, according to the Centers for Disease Control and Prevention.

So why are there so many C-sections in the US?

Technology is raising more alarms during labor

Experts chalk at least part of it up to technological advances. Specifically, they point to continuous fetal monitoring, which tracks a baby’s vital statistics once a pregnant woman enters a hospital. That might seem helpful, but there hasn’t been extensive research on how to interpret the readings.

“Without any evidence at all to suggest continuous fetal monitoring improves outcomes, it has become a standard of care,” said Dr. Terrie Inder, a neonatologist at Brigham and Women’s Hospital in Boston who was not affiliated with the study. And when there’s a blip in the reading — if a baby’s heart rate goes up or down — that can trigger a C-section, even if it’s not clear the baby is truly in distress.

Doctors watching the monitor are “seeing a pattern that they are determining is ‘not reassuring’,” Kozhimannil said. “But if you watch any kind of pattern for a stretch of time you find something that’s not reassuring.” Some malpractice insurers will actually reduce doctors’ rates if they take courses on how to read those fetal monitoring scans properly, Kozhimannil said.

Other labor ward policies aren’t always backed up by science, either. Mothers carrying babies that are deemed too big to deliver vaginally often get C-sections, but there’s no simple test to determine a baby’s size so that’s often a guessing game, Kozhimannil said.

Similarly, different obstetricians often have very different policies on how long a woman should spend pushing before she gets a C-section, and how long after her water breaks she should be permitted to try for a vaginal birth.

“It’s an arbitrary cutoff that varies in different places,” Kozhimannil said.

Obstetricians in the US are sued a lot

The idea of defensive medicine — doctors giving the most aggressive care possible to avoid a negligence lawsuit — permeates labor wards across the US.

“If a baby is born via C-section and there’s a bad outcome, you can say everything was done,” said study author Dr. Alex Haynes, a surgeon at Massachusetts General Hospital. “But born vaginally, it could be asked why you didn’t do a C-section.”

Much of the evidence on defensive medicine is anecdotal, but there are slightly higher C-section rates in states that have higher caps on malpractice settlements, a 2009 study found. Doctors aren’t the only ones at fault; there are financial incentives for hospitals to have higher C-section rates, Kozhimannil said.

“Pointing your finger just at the obstetrician and saying ‘Stop doing so many C-sections’ is kind of like looking at the symptoms rather than also the root causes,” Kozhimannil said.

Some women choose C-sections for more control

Unlike in many countries where surgery is a challenge, women in the US can elect to have a C-section. It gives them a lot more control over childbirth than waiting to go into labor naturally.

“Women can choose the day, they can choose the surgeon, they know exactly how it will happen,” Inder said. Doctors are divided on whether purely elective C-sections should be permitted, Inder noted.

It’s a noteworthy but relatively small factor — a 2010 study by the National Institutes of Health found that truly elective C-sections accounted for just under 10 percent of all of the scheduled procedures in the US.

The numbers don’t show nuance

A C-section rate of up to 19 percent improves maternal and neonatal mortality rates, but that benefit plateaus after 19 percent.
A C-section rate of up to 19 percent improves maternal and neonatal mortality rates, but that benefit plateaus after 19 percent. JAMA

On a clinical level, the 19 percent C-section rate touted in the JAMA article doesn’t have much meaning. But on a policy level, the authors said, having a target rate can help policymakers decide how to allocate resources for care and research.

Yet even the authors acknowledge that their study has limitations. For one thing, the 19 percent target is a global average that doesn’t take into account local realities of prenatal care and surgical expertise — much less the needs of individual women.

“There are a lot of countries doing too few C-sections and a lot doing too many,” said Dr. George Molina, another study author from Massachusetts General Hospital. “The findings apply to countries at large; they don’t apply to just hospitals in Boston or a particular expectant mother or a certain OB-GYN practice.”

In some cases, experts said, high C-section rates are appropriate. That makes the “ideal” average cited in the JAMA study less meaningful.

“A hospital could have a 70 percent C-section rate if it was specialized to treat extremely high-risk women,” Kozhimannil said. “What we want is for all women who need a C-section to get one, and all those who don’t to not get one.”

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  • What about Brazil? They have a very high elective Csection rate. Some women dont even try natural childbirth. Travesty

  • My OB definitely pushed Csections, so she could get her rotation done. She told me “You can get this done/ with your parents here- or come back in 1 week and do the same painful procedure.” Talk about convience.

  • C-sections are better for the baby. Mystic reasons aside (e.g. “the baby not born through the vagina never learns to overcome difficulties”), what are the benefits of natural birth for the baby. None.
    Therefore, it is for the woman to decide. She is the one undergoing labour, she is the one to live with the postpartum body. If she wants the scar on lower abdomen and not on her vagina, if she does not fancy the hours of contractions but would rather accept longer recovery and the risk of intestinal adhesions – IT’S UP TO HER.
    Why do some people feel they have a right to tell women what to do with their bodies?

    • C-sections are not better for the baby. A vaginal delivery offers a squeeze to the chest the helps the baby breath better and they are less likely to go to the NICU for breathing difficulties. Several studies show that vaginal deliveries are actually better for the child unless a c-section is medically necessary. C-sections in the U.S. are done 2-3 times more than medically necessary and often kids end up in the NICU for breathing issues because of this. Courtney Wells NICU nurse

    • Yeah, wet lungs. Not frequent and not a big deal compared to much more detrimental possible consequences of vaginal deliveries. Cerebral palsy, brain damage due to asphyxia, fractured bones… Not unheard of in vaginal, almost unheard of in elective c-sections. Really, you are trying to make a claim that birth trauma for the baby is NOT lower in elective c-sections?

    • The benefits to the baby are fewer breathing complications, lower risk of exposure to spinal anesthesia which may delay feeding, mother is able to care for the child more quickly after birth, higher rates of breastfeeding among women who give birth vaginally, and, while it’s still being researched, statistically lowered risk of food allergies.

      Benefits to the mother include reduced risk of infection and blood clots, lower rates of embolism, faster recovery time, less blood loss, lower rates of pain-managing medications, and (again, still being researched) a lowered statistical rate of PPD.

      It’s not about telling women what to do. It’s about ensuring women are making informed choices. I’ve had both c-section and vaginal birth; I can tell you for sure that c-section is not the “easy way out.” Unless you’re talking about being easier for the physician, in which case… yeah, c-section is easier than vaginal. There are a lot of myths out there about both c-section (it’s easy! you can schedule it whenever you want! you are in control of everything!) and vaginal birth (you’ll tear to your bum! your vagina will never be the same/will get stretched out! it’s the worst pain of your life!) that make it hard for women to make an informed choice. We need articles like this to cut through the crap regarding c-section rates and let women know what it really means on the national level.

    • I think you miss the point. The study shows a rise in risk when you go over 19%. I’m sure this is within the margin of error, so platou was the term used. The reality is, if you don’t need a c section, you are increasing risk to mother and baby by having one! From a policy standpoint Americans could improve child birth substantially

  • Come on lets be honest… for all the talk out there, that women can take the pain, I call bullshit. They just want to be knocked out, carved up, and wake up with a baby. No pain, but then use labor and child bearing as an excuse for the rest of their life about why they are 100lbs over weight.

    • Yea c- cections are gross ….I don’t understand why some women would elect it and then complain that they are fat because of it ….well of course because their uterus gets sliced up

  • It’s a travesty to have 1/3 of all children to be born by Csection. Unnecessary and unnatural in manyour instances . Safety is of the utmost importance : Perform C sections when vital for woman and child. Elective C sections and women being pressured into one is an outrage

    • Agreed. I hear of all these women who had “emergency” c-sections and I cannot imagine that all of them/their babies were in mortal danger. Yes, they save lives, but as this article says, they’re done far too frequently. And they are detrimental to the mother and far from ideal for the baby if they’re not necessary.

    • It’s vain for a woman to get a c- section when she doesn’t require it. Some of these women get one so that their vaginal canals do not get stretched. How f___ing vain.

    • It is also disgusting that the doctors in the United States are not trained in the art of delivering breeched. They just don’t have the skill anymore. In other countries this still exists.

    • 2 Bekkah:
      Lol, sounds like it’s coming from someone with a hopelessly stretched vagina 🙂 If the unwillingness to stretch her vagina is relevant to a woman, she has a right to get a c-section. It’s her body and her choice, not yours, Bekkah.

    • I have seen many women in their early to late 20’s instructed by their OBGYN to get a C- section and then given some obscure medical reason why it was necessary. I have had 4 children, 2 natural vaginal births and 2 C- section births. Both C- section births were medically necessary. While every birth is different I did notice some differences that are maybe not so obvious. The first of which was the effect that delayed breast feeding and bonding had on my baby. If you plan to breast feed (and I highly recommend doing so) C- section is not the best option for you. The drugs used for C- section will prevent you from being able to breast feed for several hours after birth. Despite my best efforts to keep the nurses from bottle feeding in the nursery, they did it any way. When I could breast feed, my baby was not hungry and was already nipple confused. Babies take to bottle feeding much faster than breast feeding because it is easier for them to cup their tongue around the nipple. It is a popular misconception that breast feeding is easier because it is natural. That is not the case. I highly recommend contacting your local Laleche League and going to some classes for breast feeding, it really helps. Not being able to breast feed immediately after or soon after birth definitely affects bonding with your baby. Babies need that skin to skin contact in order to bond. Babies are omniscient and empathic. They feel their way through everything at first, so that initial skin to skin contact is very important. The difference for me was having a baby that was colicky and sometimes inconsolable versus a baby that was content and happy. Pregnancy, labor and childbirth is a journey. I believe our society has become so focused on the destination, they have forgotten about the journey! One of the most important parts of becoming a mother is the journey. It helps us to bond with our babies, both in utero and after birth. Women’s bodies were designed for childbirth. We have a higher tolerance to pain for childbirth. Our bodies are designed to go through vaginal childbirth and then transition back to our pre childbirth bodies. Maintaining a healthy diet and exercise routine during pregnancy will help postpartum. Breast feeding also helps a lot as it reduces the size of your belly. If labor and delivery were such terrible experiences, women would only have one child! Now this is for all the woman that are considering getting a C- section so that their vagina doesn’t get stretched out or tear during childbirth. Like I said before, your body was designed to do this and recover and there are various different techniques to do so. I recovered from both of my vaginal births fairly quickly and was back at my pre pregnancy weight within a few months. A C- section is major surgery and can take some people up to 2 months for their body to recover from just the surgery and that’s assuming there are no complications. Then you will also have a harder time losing that belly. A C- section causes you to have a pouch of weight right at the scar line or just below that most women are never able to get rid of. Ok so the baby came to fast during vaginal childbirth and you tore, big deal, the Doctor will sew it up and you can even ask him to put an extra stitch or two in for good measure. Don’t deny yourself the full journey. Yes it’s scary, yes it’s painfull, but if that was all we remembered about the experience I would not have 4 children!

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