Maternal mortality and c-sections on the rise

Birth has been making national news lately because of the release of recent data indicating continuing upward trends in maternal mortality and c-section rates.
Jessica mentioned the recent California report that exposed the rise in maternal morality in the state. But this problem isn’t just in CA, it’s national.
The New York Times reported this week that the US c-section rate has reached an all-time high of 32%. That’s more than almost 1 in 3 women giving birth via surgery. C-section has been the most common surgical procedure in US hospitals for a while now, and the increases don’t seem to be slowing down.
I often get flack for being anti-doctor when I write about birth politics here, but pretty much everyone can get behind a concern about this rate of surgical birth.

The increases — documented in a report published Tuesday — have caused debate and concern for years. When needed, a Caesarean can save the mother and her child from injury or death, but most experts doubt that one in three women need surgery to give birth. Critics say the operation is being performed too often, needlessly exposing women and babies to the risks of major surgery. The ideal rate is not known, but the World Health Organization and health agencies in the United States have suggested 15 percent.

The risks to c-sections are numerous. It’s major abdominal surgery, with it’s resulting possibilities for complications. It presents problems for subsequent pregnancies, and it can be really difficult to find a hospital that will allow you to try a vaginal birth after a c-section (VBAC), meaning once a c-section, always a c-section.
Amnesty International recently released a report entitled Deadly Delivery: The Maternal Health Care Crisis in the US. Amnesty, an organization often focused on highlighting the stark situation of countries around the world, found itself examining what is a crisis among maternal health in the US.
The report exposes the fact that the risk of dying during childbirth is greater here than in 40 other countries, putting us at the bottom of the developing world when it comes to maternal mortality.


The report highlights many conditions that are contributing to the conditions of maternity care in the US, including discrimination, obstacles to care, lack of health care and insurance, bureaucratic delays to care, shortage of providers, lack of standardized protocols.
This is what they had to say about c-sections:

Many women are not given a say in decisions about their care and do not get enough information about the signs of complications and the risks of interventions such as inducing labor or cesarean sections. Cesarean sections make up nearly one-third of all deliveries in the United States – twice as high as recommended by the World Health Organization. The risk of death following c-sections is more than three times higher than for vaginal births.

The NYTimes article touches on some of the reasons why the c-section rate might be increasing, including increases in maternal age, infertility treatments, doctors fears of being sued, policies against VBACs, and increase in inductions.
They also mention briefly a rise in voluntary requests for c-sections. While some women may be requesting c-sections, I think that is often used an excuse for the increases that puts the responsibility unfairly on women themselves. Read more about this in my RH Reality Check piece, The Myth of the Elective C-Section.
The Amnesty report recommends that the Obama Administration establish an Office of Maternal Health to address this crisis, and make good on decades old promises to address the maternal mortality problem.
We need swift action to address this crisis.

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31 Comments

  1. Phenicks
    Posted March 24, 2010 at 4:19 pm | Permalink

    When you compare the reasons why one might need a c-section and the prevelance of those issues in the USA the picture gets clearer. Having Genital herpes is a reason to have a c-section, genital herpes is a very common diagnosis amongst sexually active people in this country. High blood pressure and diabetes are also reason one may need a c-section, there is a higher than average prevelance of those diagnosis as well. Being overweight increases the likelihood of pregnancy complication which in turn increase the chances of needing a c-section, most people (according to BMI) are overweight in this country so it isn’t a far stretch to say that more than likely, most of the pregnant people are overweight or obese. Being in advanced maternal age increases the likelihood of needing a c-section, the age of pregnant persons rise each year in the USA.
    This is all before we factor in multiples, chronic diseases (like HIV), placenta problems, the position of the baby (breech or transverse) and fetal distress.
    I think if we want to see less c-sections we have to have a focus on getting as healthy as possible BEFORE being pregnant and remaining as healthy as possible DURING pregnancy.

  2. JessicaNOWLV
    Posted March 24, 2010 at 5:33 pm | Permalink

    I am proudly anti-doctor, or at least anti-ob. My OB pushed me into a corner (I had no alternatives), successfully forcing a c-section on me for suspected macrosomia. Surprise, surprise, my baby was not macrosomic. After confronting her with information from ACOG and American Academy of Family Physician saying that suspected macrosomia is not a reason for “elective” c-section, she threatened to “call in the lawyers.” Jerk! I ended up with a completely unnecessary c-section.
    The thing is, I don’t think my story is an isolated one. Not by a long shot.

  3. tealy
    Posted March 24, 2010 at 5:45 pm | Permalink

    Actually, merely having genital herpes is not a reason for an automatic c-section. Only if there is an active outbreak at the time of delivery is surgery indicated. Women who have herpes have vaginal births all the time without passing it onto their babies.
    High blood pressure is not a reason for an automatic c-section, it simply heightens the chance of a woman developing a pregnancy-related condition as a result, like pre-eclampsia. But HBP is not, in and of itself, an indication to perform caesarean surgery. Likewise, diabetes is often used as a reason to induce a woman’s labour early because there is a fear of the baby getting “too big,” even when there is nothing else to indicate the baby is macrosomic. Induction of labour significantly increases one’s chances of having a c-section and THAT is more likely the reason that more are being performed. Well, that and doctors’ fear of litigation.

  4. Unnecesarean
    Posted March 24, 2010 at 5:58 pm | Permalink

    “I think if we want to see less c-sections we have to have a focus on getting as healthy as possible BEFORE being pregnant and remaining as healthy as possible DURING pregnancy.”
    I’m not going to knock a healthy pregnancy, but shocking upswing of the national cesarean rate in the last decade can’t be blamed on women suddenly becoming to unhealthy to give birth vaginally.

  5. YellowMellow
    Posted March 24, 2010 at 7:02 pm | Permalink

    Have any of you read the book Pushed by Jennifer Block? It’s absolutely fantastic, and goes into a lot of the reasons for the crappy maternal health care in the US. A big one is the simple fact that OB/GYNs are trained to handle “complicated” or somehow abnormal births, and thus have a tendency to see the birth process in this way, so there is an increased rate of unnecessary interventions (that cause a sort of feedback loop until a caesarean is seen as necessary). In fact, most OB/GYNs haven’t even seen an entirely natural, unmedicalized birth (i.e. the kind where women are free to walk around, eat, shower, change positions, etc.). In my mind more midwives are the answer for low-risk births!
    One other thing…I am always baffled at how little feminists talk about problems with maternity care in this country. It’s a huge women’s issue that gets very little press and even less activist attention/money. Anyone have ideas for why this is or how to change it?

  6. Phenicks
    Posted March 24, 2010 at 7:03 pm | Permalink

    But a fear of litigation is real, so is the fear of messing up. In a perfect world people could deliver 17 pounds babies with no problem and outbreak or no, your vagina would miraculously shield your child from any affect of any disease or infection you may have. Thats not the case, even when you’re NOT having an outbreak you could still pass on herpes during intercourse and even without having an active outbreak you could still pass it on to your child. You’re gambling. You have to weigh the risk of vaginal vs c-section with regard to every factor including whether or not the pregnant person even feels comfortable with vaginal labor.
    Just because the pregnant person or the baby wont die without having the c-section it doesnt make it any less medically necessary.
    I mean condoms are *better* for you than hormonal BC that carries the risk of stroke, heart attack and blood clots but guess what, msot people are more comfortable with hormonal BC because they feel as they its best for them. Apply that same logic to c-sections please.

  7. Phenicks
    Posted March 24, 2010 at 7:04 pm | Permalink

    How much did your baby weigh at birth and how much they believe your baby weighed when tehy scheduled the c-section?

  8. Furiousfemale
    Posted March 24, 2010 at 9:32 pm | Permalink

    One of my fears after discovering I had gestational diabetes was that I would be pressured into getting a C-section. I was using a midwife. Luckily changing my diet and monitoring my blood sugar levels was enough to manage it. I was monitored extensively, getting ultrasounds weekly during my last month and was induced on my due date…not that way wanted it, but my daughter now was an 11/11 birthday and I had the vaginal birth I wanted LOL

  9. PDXHopeful
    Posted March 25, 2010 at 12:22 am | Permalink

    One of the (many) reasons I’m opting out of biological motherhood – I’m not willing to give birth attended by someone with the comparatively limited training of a midwife, and the idea of a fully medicalized birth with a ‘traditional’ OB is equally unappealing.

  10. rebekah
    Posted March 25, 2010 at 2:08 am | Permalink

    because to a lot of feminists the idea of actually wanting and having children is still seen as taboo. We are apparently supposed to denounce motherhood because it ha oppressed women for so long

  11. rebekah
    Posted March 25, 2010 at 2:09 am | Permalink

    most midwifes are not underqualified to handle your labor. They are skilled and trained to be doing what they are doing and they do it well.

  12. damigiana
    Posted March 25, 2010 at 5:46 am | Permalink

    Twin pregnancy IS NOT in itself reason for a c-section, but many hospitals/doctors try to force all twin mothers into having one.
    When it was my turn, I took statistical data from medline, included information such as (but not limited to) the week of pregnancy I had reached and the fact that my sons were both head down, and did a bit of Bayesian analysis. I’m not only a geek, but a mathematics professor in a research university: I figured out I would be safer with vaginal versus cesarean delivery around week 36, and ended up delivering at 38.
    I tried reasoning with them, and when it didn’t work I just refused the c-section and ignored their squeals. Twin homebirth is illegal where I live, but so is forcing medical procedures on nonconsenting adults. I gave birth in a hospital, where an emergency cesarean could have been performed had it been medically necessary.
    PS For the curious, the outcome: 120 minutes from “oops, my water broke – and my belly hurts!” to the second baby safely in my arms. Yes, two hours – including finding a babysitter, driving to the hospital, and filling two copies of the childbirth form. They didn’t have too much time for squealing :-) .

  13. paperispatient
    Posted March 25, 2010 at 8:37 am | Permalink

    I was just about to recommend this book! I read it for a paper a few quarters ago and it was just fascinating, really readable and full of information.
    I wonder if maybe we generally think of abortion rights and access to contraception as more “under fire” or more in danger than the right to give birth how we choose. (Not saying that’s an accurate perception necessarily!) I know that for me personally, those two issues are more relevant to my own life than issues surrounding pregnancy and birth because I do not want children and would not carry a pregnancy to term; I wonder if people are more likely to mobilize around issues they feel personally affect them and if it’s only after having negative experiences that most feminists realize it’s a feminist issue – I know that this was below my radar until I started reading news stories within the past year or so about women being denied VBACs or being forced to give birth early. The question you asked is a really interesting one, and I’m not sure what the answer is or if either of my ideas hold any water, but those were the thoughts that came to my mind.
    Abortion and contraceptive access and the problems discussed in this post really hinge around the same point, respecting women’s rights and ability to make their own choices about their bodies and determine what’s in their best interests.

  14. Gretel
    Posted March 25, 2010 at 9:32 am | Permalink

    This article was in the NY Times earlier this month and highlights a Navajo-administered hospital where the rate of cesarean delivery is half the natural average. It gives a lot of credit to midwives. I was so happy to see a pro-midwife, pro-indigenous article in the mainstream press!

  15. uberhausfrau
    Posted March 25, 2010 at 11:51 am | Permalink

    a past co-worker was told a ultrasound showed her baby was going to be omg!!11!elevensies 11+ pounds! had to have a c-section. little E was born at 7lbs and change.
    and when i was talking with my midwife about her transfer/episiotomy rates, she said she assisted an eleven pound first-timer without tearing. so yeah.

  16. stellarose
    Posted March 25, 2010 at 11:51 am | Permalink

    I am pretty disturbed that you think midwives have “comparitively limited training” in births. You need to look into midwifery a lot further before making this statement.
    Did you know that in almost every other developed country, midwives are the primary attendants of normal pregnancies? And in most other developed countries, the infant and maternal mortality rates are far lower than ours? True, midwives are not surgeons, so if you need surgery during your birth, a doc will need to be called in…however midwives, unlike docs, are highly trained in managing and encouraging the natural process of birth. Which is why hospital units run by midwives and midwife attended homebirths have far lower c-section and instrumental birth rates WITHOUT any uptick in infant or maternal mortality rates.
    Study after study, and example country after example country shows that midwife attended birth with reliable and quickly-accessible hospital/surgeon backup results in the lowest levels of deaths and injuries for low-risk women. That’s why that style of birth is what almost every developed country uses. America is an exception for the same reasons that our healthcare system is exceptional in general.

  17. stellarose
    Posted March 25, 2010 at 12:01 pm | Permalink

    Its true that the general sorry state of health in America contributes to the need to surgical birth. However, the fact remains that the single biggest determinate of whether a woman will have a c-section is the place she gives birth. When a hospital imposes rules like “you may not eat or drink in labor”, “you can only be in labor for 24 hours from admission”, “you may not walk around in labor”, “you must push lying on your back” or hospital staff push pitocin on women unnecessarily resulting in high levels of fetal distress and need for epidurals, the c-section rate goes up BECAUSE OF THOSE PRACTICES and the negative effect they have on the physiological process of birth. Note that none of the practices I have mentioned are evidence-based (i.e., none of them have been shown to improve outcomes and some have been shown to worsen them).
    The fact is, US hospital use a host of non-evidence based practices for financial/liability reasons, and these practices impede normal cervical dialation and vaginal deliveries. Some hospitals are worse than others. Do me a favor and google “the Milbank report” and have a read of that, alone with “Pushed” which a lot of others have recommended.
    On a personal note, I’ve had two vaginal births of two healthy babies, one in Europe and one in my house back in the US, and I know full well that had I been in a US hospital for either, I would have ended up with a c-section.

  18. stellarose
    Posted March 25, 2010 at 12:03 pm | Permalink

    Congratulations! Your story just shows how by being educated consumers of maternity care, we can avoid unnecessary surgical births.

  19. stellarose
    Posted March 25, 2010 at 12:10 pm | Permalink

    When you say “you” have to weigh the risk, who is the “you”? As a feminist, I think the “you” should be the woman in question, NOT her doctor. So when a doc says “you have herpes and thus you need a c-section”, that doc is ignoring the priciple of informed consent and making a decision for that woman.
    I sympathize with the “fear of lit is real” argument, but as a professional myself, I would NEVER do something unethical (i.e., ignore the principle of informed consent and operate on someone under false pretenses) because of my own financial interests (i.e., fear of being sued). OBs have ADMITTED that they make decisions contrary to patient interests because of fear of liability. I think its time they stop minimizing the harm done to 1/3 of US mothers from unec major surgery, step up to the plate as professionals, and change standards. Malpractice liability is based on a “reasonable doctor” standard. As a group, they can change standards.

  20. stellarose
    Posted March 25, 2010 at 12:25 pm | Permalink

    There are some great organizations out there fighting for maternity-care reform and birth rights. Check out Choices in Childbirth, Citizens for Midwifery, ICAN (the International Caesarean Awareness Network) to name a few.

  21. PDXHopeful
    Posted March 25, 2010 at 12:33 pm | Permalink

    I would agree that most midwives are perfectly well qualified to handle the basically low risk pregnancies and deliveries the vast majority of women have, and I should have made that clearer in my comment (which I, of course, realized about 10 seconds after hitting send… gah!).
    However, I would not personally be a low risk patient. I have multiple medical issues that would make pregnancy itself a serious threat to my health, and childbirth an acute one. That being the case, I don’t think wanting an attendant who’s capable of doing an emergency c-sec and so on is unreasonable.

  22. PDXHopeful
    Posted March 25, 2010 at 12:34 pm | Permalink

    Please read my response to Rebekah above. I, due to medical issues, would require an attendant immediately on hand capable of preforming surgery.

  23. stellarose
    Posted March 25, 2010 at 1:05 pm | Permalink

    Understood, and absolutely agree that some people need an OB to manage their entire pregnancy and labor. And totally agreed that having a surgeon immediately available makes sense for some people or that some people might want that even if they are low risk.
    However, its totally possible to have the best of both worlds…i.e., midwife attending you while things are going well and a surgeon in the next room ready to rush in if things take an unexpected turn for the worse. That’s how it is in European hospitals.
    Actually here in the US where OBs are the primary caretakers of preg women, you are more likely to have waiting time for a surgeon to arrive when s/he is needed. In most hospys here, NURSES (less training than hospital MW) attend laboring women, and the doc only comes in during the pushing stage or if the nurses call them in for an emergency. Since OBs do primary care, they are usually not even in the hospy when you are in labor, they are in their offices seeing other women for routine pre-natal apps or at home sleeping. In European hospitals, the OBs hang around the hospital waiting for emergencies and don’t do much else. So they are on the scene to do what they do best when they are needed.
    Here, OBs do what they don’t do best/are not trained to do(i.e., normal labor and routine stuff) as well as what they do best (surgery), so they are stretched thinner. Marsden Wagner (former WHO director of women’s health and an OB) wrote a great article about this phenomena; I encourage anyone who is interested in this topic to read his work.

  24. PDXHopeful
    Posted March 25, 2010 at 1:33 pm | Permalink

    Yes, and I would absolutely support such changes.
    They aren’t here yet though, so until they are my view – that, in the US anyway, I couldn’t get the sort of care I’d want – remains. Unfortunately.

  25. syndella
    Posted March 25, 2010 at 2:20 pm | Permalink

    I hope if I ever decide to have a child, I am able to get an elective C-section.

  26. Phenicks
    Posted March 25, 2010 at 3:08 pm | Permalink

    The state of women’s health without any regard to reproduction has gone down significiantly within the same time span that c-sections have gone up. That can not be ignored or tossed to the way side as a coincidence.
    Women make up the majority of the new HIV/AIDS cases, women are harder to insure and thus women have had a lack of good care, women have been diagnosed with HPV and herpes much more often than before, women are more likely to be overweight or obese, women are more likely to be diabetic and if you have a fmaily history on top of not having good prenatal care or health insurance – an even higher chance of gestational diabetes, women are deciding to give birth later and later in life, women are utilizing ART a lot more often now than before, I could go on and on.
    How could be declare on one hand that women have all these medical needs that are being ignored and pretend as though the only one being affected is the right to an abortion? Women need care and attention before becoming pregnant to have the best shot at a healthy pregnancy with a vaginal delivery. And even for all the healthy there could be, there will still be women who just can not give birth vaginally. I’ve heard of vaginal birth fantics who tell women its ok to be inlabor over 48 hours, don’t give up etc etc. Yeah well guess what? With no mucous plug, being dialated and the membranes no longer intact that risk of infection goes WAAAAY up and varies from woman to woman. Not to mention that being in labor over 48 hours is extremely stressful on pregnant person and fetus with varying long term side effects.
    I think Dr.’s ought to be able to say “these are the risks” and if you decide to take that risk you nor your family can sue the Dr. for allowing you to choose. Right now, a Dr. could lose EVERYTHING, on top of losing your life and that of the unborn baby if they do not err on the side of caution in cases where it seems a c-section is the best medical choice.

  27. Phenicks
    Posted March 25, 2010 at 3:12 pm | Permalink

    Yeah 11 pounds without tearing is not what could be or should be expected of every pregnant person. My godsister had a tear with her 6 pound 7 ounce son, 11 pounds may have killed her. It varies from woman to woman because we are all not the same size and we have varying abilities to stretch.

  28. Athenia
    Posted March 25, 2010 at 3:24 pm | Permalink

    It’s probably not in the news a lot because forcing a woman to have a c-section isn’t “baby killing.” You know, women are stupid and doctors know what’s best for them. [/sarcasm]

  29. stellarose
    Posted March 25, 2010 at 6:44 pm | Permalink

    I support that choice and, even though its the opposite in many ways of what I chose as a homebirth mom, I would fight hard for your right to make it.
    However, I think a lot of people (although not necessarily you) make that choice without being aware of risks and realities of having major surgery as opposed to the risks and realities of vaginal birth. If you do choose to have biological children, and you haven’t done so already, I would really encourage you to do your OWN (i.e., not just asking a doc) research on all your options and their consequences.

  30. MiriamCT
    Posted March 25, 2010 at 8:15 pm | Permalink

    knock yourself out, but having had both a c-section and then a vaginal birth I can assure you that it was the c-section that was more painful and much more diffacult to recover from. in comparsion, the vaginal birth (home VBAC) was SO much better, a walk in the park compared to oh I don’t know, getting hit by a car?
    if you do go for an elective c-section, really educate yourself about what that really means, becouse it does not mean a pain-free and easier birth.

  31. AMM
    Posted March 26, 2010 at 11:58 am | Permalink

    Ah, the politics of childbirth! Guarranteed to get blood pressures up. I won’t bother to argue with so many people who know so much and are so sure of themselves. Instead, I’ll just share my own stories.
    I haven’t kept up with the discussion, as my kids are now in their late teens, but back before they were born, I was about as involved as it’s possible for a non-MD father to be. Even “caught” my second one (not planned, I assure you!) Some of my experiences and conclusions based on them:
    1. #1 was born at home. The attending midwife had attended > 1,000 births, which made her more experienced than most Obstetricians.
    2. In New York State, at least, there are “certified nurse-midwives,” who have gone through a state-approved medical training program and are licensed to attend births. There are also unlicensed midwives, but I haven’t had anything to do with them.
    3. Before the midwife for #1 started with the home-birth practice, she was on staff at a Bronx (New York City) hospital, I forget the name, but it’s the public hospital that’s a Siamese twin with Montefiore. The maternity unit at the public side was run by the midwives, the private (Montefiore) side by Ob-Gyns. IIRC, the public side had roughly a 10% C-section rate, and a mortality and morbidity rate comparable with the private (Montefiore) side, despite serving a much higher-risk population.
    4. When my wife was pregnant with #1, she at first chose an Ob-Gyn practice tied to the local hospital. The MD, like the hospital, had roughly a 30% C-section rate. It was also obvious from our first visit that he was going to be the boss when my wife went into labor, which turned me off right away; it took my wife a few months to decide she didn’t like him.
    I came away with the conclusion that if you want the birth to go a certain way, you’d better find an attendant who is already convinced that they want to do it that way. When you’re in the middle of childbirth, you don’t have a lot of leverage if you don’t like what the doctors and nurses are doing. I remember my mother telling me how, with every birth, she told the doctors not to use a certain anesthetic because of the terrible side effects she experienced, and every time, they used it anyway.
    5. One minor nit: the paragraph quoted in the OP contains the statement “The ideal [C-section] rate is not known, ….” Since the “ideal” rate will be the result of trade-offs, it’s not something you discover, it’s a judgement. So a more accurate phrase would have been “The ideal rate has not been determined,….”

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