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Reproductive Justice: Interventions in pregnancy and birth: C-sections

**NOTE**

Medical advancements have saved the lives of women and babies at risk for injury or death during pregnancy and birth.  This site is not about the doctors who properly use interventions to save lives; it is about those who use them unethically for profit or convenience.   Improperly used interventions have led to harm and death of women and babies and obstetrics  is the only field in which mortality rates are rising and non-medically needed interventions such as c-sections are related to 66% of maternal deaths. 

**NOTE**  This site is designed to share valid evidence for those working to change the maternal healthcare system who do not have access to databases of peered research. 

Chronological order allows users to find new data.  It also begs the question of why, when we have known for decades that such practices are harmful, do they not only continue to be used but are increasingly used.

NON-MEDICALLY PERFORMED C-SECTIONS

“C-sections are the most common major surgery performed on human beings anywhere in the world and the most common in the U.S. They have become 500 percent more common over the last generation of moms” (Rappleye, 2016).   They should only be performed when medically necessary with an acceptable rate being 10 – 15% (WHO, 2021)

Rates increase with country development and adoption of western ideas.    2018 rates by region (WHO, 2021)

     Africa 9.2%

     Asia 23.1%

     Europe 25.7%

     Americas 39.3%     Oceania  21.4%

C-sections Increase the risk of harm to both mother and baby and should only be performed to preserve the health/lives of mothers and babies. 

Mother

•     Infection of the incision or the uterus.

•     Heavy blood loss and blood clots.

•     Injury to the mother or baby.

•     Problems from the anesthesia. These may include nausea, vomiting, and a bad headache.

•     A longer hospital stay than after a vaginal birth.

•     Risks for a future pregnancy. A woman who has had a C-section has a small risk of the scar tearing open during labour if she has a vaginal birth. She also has a slightly higher risk of a problem with the placenta, such as placenta previa  (MyHealthAlbert.ca, 2022)

Babies born by C-section are at risk for complications that are less likely to occur with normal birth

• May be born early (prematurely) which can cause problems for baby at birth and later in life date (due dates are arbitrary). There is a margin of error in determining fetal maturity which may lead to premature birth putting baby at a higher risk  of death or illness.

•     May have breathing problems, especially if delivered before the natural due date. If the mother did not  labor, babies are more likely to have difficulty breathing on their own. With a scheduled cesarean, babies are more likely to be born preterm, before the lungs have fully developed. Respiratory complications can be serious enough to require admission to a special care nursery.  During labor with each contraction less oxygenated blood crosses placenta,  babies heart rate slows, baby produces catecholamines that prepare the baby to breathe on its own at birth.   Other breathing issues can develop that may be life-threatening

•May be injured (cut) by surgery  (March of Dimes, 2022)

•Vaginal birth colonizes the babies gut with beneficial bacteria from the mother’ birth canal which helps to  create a healthier system

•More than doubles the risk of asthma (Verbanas, P. 2020). Babies were more likely to have a certain kind of bacteria in their intestines if they were born  by cesarean. Babies with bacteria have a greater risk for developing allergies or asthma later on.

C-section makes breastfeeding more difficult.  Terreri, C. (2018). Babies are less likely to have skin-to-skin contact immediately after birth. Pain medications affect the newborn’s ability to latch on and breastfeed. American Academy of Pediatrics encourages all maternity care providers to collaborate to support breastfeeding by avoiding common, often unnecessary procedures that interfere with breastfeeding and that may traumatize the newborn. Routine procedures after a cesarean birth such as suctioning the newborn’s mouth, esophagus and airways can also make it more difficult for babies to begin and continue breastfeeding. (Raihana, et al, 2021)

As the rate of Caesarean section has increased in the U.S., maternal mortality has also increased.  The U.S. has the highest rate of maternal mortality of all developed nations.  Many attribute the increase in mortality to the increase in unnecessary medical intervention.   Pregnancy and births for low-risk women guided by a midwife have much lower rates of C-sections  (Geising, A, 2016)

How many in the U.S.?

So, even though we know that they can cause problems such as bleeding, fetal distress, hypertensive disease, and infants in abnormal positions,  C-sections are associated with complications in future births and are not without risk. The surgery is also associated with adulthood obesity, diabetes, respiratory infections, and delay in microbiota development for babies born this way. Yet they continue to be done for non-medical reasons and 66% of maternal deaths are related to c-sections.

Per the CDC rates of c-section births range from 22.9% (23.7% in 2014) in Alaska to 38.2% (37.7% in 2014) in Mississippi. (CDC, 2022).

New York State Average is 33.6% in 2022 (12th highest in the nation). Not much change since 2014 when it was 33.9%. (CDC, 2022).

WHAT DOES THE LITERATURE SAY?

2023

Ledbetter, A. (2023).  C-Section rates are way to high: We need to hold doctors and hospitals accountable.  Accessed https://www.scientificamerican.com/article/c-section-rates-are-way-too-high-we-need-to-hold-doctors-and-hospitals-accountable/

  • During my 17 year career, first as a labor and delivery nurse and then a certified nurse-midwife, I have grown frustrated watching patients like this one face the downstream consequences of an unnecessry surgery and have become disheartened by a lack of will to hold healthcare systems accountable.  We need to name this problem for what it is: widespread, unchecked medical malpractice.

2022

California Healthcare Foundation (2022).  Reducing unnecessary c-sections in California.  Accessed https://www.chcf.org/project/reducing-unnecessary-c-sections/

  • From article:   Unnecessary c-sections are a health equity issue since c-section rates are higher among people of color. Nearly 36% of Black infants, 32.3% of American Indian and Alaska Native infants, and 31.3% of Asian and Pacific Islander infants were delivered by c-section between 2018 and 2020.    Overuse of c-sections matters because, while often lifesaving in limited circumstances, the surgery also brings serious risks for babies (such as higher rates of infection, respiratory complications, and neonatal intensive care unit stays, as well as lower breastfeeding rates) and for mothers (such as higher rates of hemorrhage, transfusions, infections, and blood clots).

CDC., (2022). Cesarean Delivery Rate by State. Accessed https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm

  • Concluded:  site gives c-section rates by state in the U.S.  All states are above the acceptable percentage of C-sections established by the World Health Organization

Ibrahim, B. B., Vedam, S., Illuzzi, J., Cheyney, M., & Kennedy, H. P. (2022). Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean. PloS One, 17(9), e0274790–e0274790. https://doi.org/10.1371/journal.pone.0274790

  • Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes.

Lisa, K. (2022). Legislation seeks to address New York’s high cesarean section birth rate.   Accessed https://spectrumlocalnews.com/nys/central-ny/politics/2022/08/23/legislation-pushes-back-on-new-york-s-high-cesarean-birth-rate

  • “The path to progress on maternal mortality must address racial disparities in outcomes through an integrated approach that spans the entirety of the health care system,” State Health Commissioner Dr. Mary T. Bassett said about the report’s findings, stressing DOH is working with community partners to address the issues
  • “This includes expanding access to maternal care and services, increasing access to birthing centers, doulas and midwifery centers and providing postpartum coverage for all individuals eligible for Medicaid while pregnant from 60 days to one year after they give birth,” Bassett added. “In addressing the persistent disparities experienced by pregnant New Yorkers and specifically, Black New Yorkers, we will work to change them.”  

March of Dimes (2022).  Having a C-section. https://www.marchofdimes.org/pregnancy/having-a-c-section.aspx

  • CONCLUDED:  “If your pregnancy is healthy and you don’t have any medical reasons to have a c-section, it’s best to have your baby through vaginal birth.   If there are problems with your pregnancy or with your baby’s health, a c-section may be the safest way for you to have your baby.  A c-section should be for medical reasons only.  If  you’re planning to schedule your c-section, talk to your provider about waiting until at least 39 weeks of pregnancy.  A c-section is major surgery, so it may have more complications for you and your baby than vaginal birth..

Milbeck, S. (2022). C-section birth associated with numerous health conditions. National Center for Health Research. Accessed https://www.center4research.org/c-section-birth-health-risks/

  • CONCLUDED: “The rate of Caesarean sections (C-sections) in the United States is on the rise and has increased over 50% since the 1990s. [1]   In 2018, 31.9% of all births were C-sections [2] which is 3 times higher than the World Health Organization’s “ideal rate” for use as a necessary medical procedure to reduce maternal and newborn mortality. [3] As the rate of C-sections has grown, the incidence of certain chronic and immune system-related medical conditions has also greatly increased.[4] Experts are asking whether this is a coincidence or do babies born via C-section have weaker immune systems”

My Health Alberta (2022). Childbirth: Thinking About Having a C-section for Non-Medical Reasons? https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=abp8154

  • CONCLUDED:    In the past 40 years, the rate of caesarean (C-section) deliveries has jumped from about 1 out of 20 births to about 1 out of 3 births.  This has caused experts to worry that C-sections are being done more often than needed.   Because of the risks of C-section, the Society of Obstetricians and Gynecologists of Canada recommends that planned C-sections generally be done only for medical reasons.”

2021

American College of Obstetricians and Gynecologists Alliance for Innovation on Maternal Health (2021) Safe Reduction of Primary Cesarean Birth.  Accessed https://saferbirth.org/psbs/safe-reduction-of-primary-cesarean-birth/

  • Goals include guidelines for promotion of vaginal delivery and decreased cesarean section delivery through education of healthcare teams on approaches which maximize the likelihood of vaginal delivery

American Pregnancy Association (2021). C-Section complications for mother and baby.  Accessed https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/c-section-complications/

  • CONCLUDED:  Discusses risks and complications for baby as a result of C-sections.

Negrini, R., da Silva Ferreira, R. D., & Guimarães, D. Z. (2021). Value-based care in obstetrics: comparison between vaginal birth and caesarean section. BMC Pregnancy and Childbirth, 21(1), 333–333. https://doi.org/10.1186/s12884-021-03798-2

  • Results   A total of 9345 deliveries were analyzed. The C-section group had significantly worse rates of breastfeeding in the first hour after delivery (92.57% vs 88.43%, p < 0.001), a higher rate of intensive unit care (ICU) admission both for the mother and the newborn (0.8% vs 0.3%, p = 0.001; 6.7% vs 4.5%, p = 0.0078 respectively), and a higher average cost of hospitalization (BRL14,342.04 vs BRL12,230.03 considering mothers and babies).   Conclusion  Cesarean deliveries in low-risk pregnancies were associated with a lower value delivery because in addition to being more expensive, they had worse perinatal outcomes.

World Health Organization (2021). Statement on Caesarean Section Rates Frequently Asked Questions.  Accessed https://www.who.int/news/item/10-04-2015-who-statement-on-caesarean-section-rates-frequently-asked-questions

  • CONCLUDED:  C-section for non-medical  reasons should be avoided and rates should decrease.  No evidence of benefit when rates rise above 10%.

WHO (2021).  Caesarean Section Rates continue to rise amid growing inequalities in access. https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access

  • CONCLUDED:   “Caesarean sections are absolutely critical to save lives in situations where vaginal deliveries would pose risks, so all health systems must ensure timely access for all women when needed,” said Dr Ian Askew, Director of WHO’s Department of Sexual and Reproductive Health and Research and the UN joint programme, HRP . “But not all the caesarean sections carried out at the moment are needed for medical reasons.  Unnecessary surgical procedures can be harmful, both for a woman and her baby.”

2020

Niethammer, C. (2020). Coronavirus exposes the business of safe birth.  Accessed https://www.forbes.com/sites/carmenniethammer/2020/05/14/coronavirus-exposes-the-business-of-safe-birth/?sh=1dfb19a154da

  • CONCLUDED: (from article) “Whether serving in hospitals, birth centers, or homes, midwives are providing vital health care services. Yet, over the past decades this group of “essential” professionals is said to have been squeezed out by market forces in many advanced economies where women think that cesarean sections performed at a hospital are safer. Moreover, there is the supply of surgeons and hospitals who make more money when they bring out the scalpel.  Then there is a certain prestige that comes with having a “just in time” cesarean section like a celebrity. Though medically not advisable, some even consider a ‘tummy-tuck special’ to be part of the C-section package.”

Slabuszewska, A., Szymanski, J. Ciebiera, M., Sarecka-Hujar, B and Jakiel, J. (2020). Pediatrics Consequences of Caesarean Section –  Systematic review and meta-analysis.  Accessed https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662709/

  • This systematic review of literature and meta-analysis shows, that cesarean section may be associated with several pediatric complications. The results of the studies included indicated that children delivered by cesarean section more commonly developed respiratory tract infections, obesity and the manifestations of asthma than children delivered vaginally. The risk of developing diabetes mellitus type 1 or neurological disorders in offspring after caesarean section is still under discussion. Due to a high number of reciprocally exclusive study results concerning long–term pediatric sequelae it is recommended to conduct a multicenter prospective study comprising the concept of epigenetic influence of cesarean section.

Verbanas, P. (2020). C-section delivery prevents babies from receiving beneficial germs in their mother’s microbiome, which, in turn, affects immune system development, says Rutgers researcher  https://www.rutgers.edu/news/hidden-reason-children-born-c-section-are-more-likely-develop-asthma#:~:text=The%20researchers%20found%20that%20delivery,composition%20of%20the%20gut%20microbiota

  • CONCLUDED: “Researchers at Rutgers University, the Copenhagen Prospective Studies on Asthma in Childhood and the University of Copenhagen have described for the first time how delivery by caesarean section interferes with a baby’s ability to obtain beneficial germs from the mother’s microbiome, and how this can lead to early childhood asthma.”

2019

ACOG (2019). Safe prevention of primary cesarean section. Accessed  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2014/03/safe-prevention-of-the-primary-cesarean-delivery

  • From article: the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused.

Hayes, T. and McNeil, C. (2019).  Maternal mortality in the United States. Accessed https://www.americanactionforum.org/insight/maternal-mortality-in-the-united-states/

  • C-sections put women at risk for infection, postpartum hemorrhaging, blood clots, and surgical injury, and for that reason they are not recommended as the primary option over vaginal delivery.[13] A recent study found that women who had c-sections were 80 percent more likely to have complications than those who delivered vaginally, and for women aged 35 and older the risk for severe complications was nearly three times greater.[14] Improper postpartum care can exacerbate complications following surgery, and many complications left untreated can lead to death.

OECD (2019). Caesarean Sections.  Health at a Glance 2019: OECD Indicators.  Accessed https://www.oecd-ilibrary.org/sites/fa1f7281-en/index.html?itemId=/content/component/fa1f7281-en

  • CONCLUDED:  (from site) “Caesarean sections can be a lifesaving and necessary procedure. Nonetheless, caesarean delivery continues to result in increased maternal mortality, maternal and infant morbidity, and increased complications for subsequent deliveries. This raises concerns over the growing rates of caesarean sections performed across OECD countries since 2000, in particular among women at low risk of a complicated birth who have their first baby by caesarean section for non-medical reasons. The World Health Organization concludes that caesarean sections are effective in saving maternal and infant lives, but that caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates at the population level. Nevertheless, caesarean sections should be provided based on need, rather than striving to achieve a specific rate.” 

Tianyang Zhang, Anna Sidorchuk, Laura Sevilla-Cermeño, Alba Vilaplana-Pérez, Zheng Chang, Henrik Larsson, David Mataix-Cols, & Lorena Fernández de la Cruz. (2019). Association of Cesarean Delivery With Risk of Neurodevelopmental and Psychiatric Disorders in the Offspring: A Systematic Review and Meta-analysis. JAMA Network Open, 2(8), e1910236–. https://doi.org/10.1001/jamanetworkopen.2019.10236  Accessed https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2749054

  • CONCLUDED:”Our study findings suggest that birth by cesarean delivery is associated with certain neurodevelopmental and psychiatric disorders. The results appear to further add to the known adverse health outcomes associated with cesarean delivery and suggest judicious use of cesarean delivery.1,3,4 Statistical heterogeneity was high in the meta-analysis of some specific outcomes despite the use of strict inclusion criteria and our attempts to address the source of heterogeneity in subgroup analyses and meta-regression. This finding might suggest that other confounders, such as indication for cesarean delivery, could contribute to explaining some of the variation across studies. Future research should include further adjustment for potential confounders and consider genetically sensitive designs, such as sibling comparisons or twin and adoption studies. The mechanisms underlying the observed associations remain unknown and require empirical investigation to examine whether cesarean delivery plays a causal role in the development of neurodevelopmental and psychiatric disorders.”

Wagner. (2019). Choose And Lose: Promoting Cesarean Section And Other Invasive Interventions. In Born in the USA (pp. 37–69). University of California Press. https://doi.org/10.1525/9780520941748-004  eBook available at https://ebookcentral.proquest.com/lib/plattsburgh-ebooks/detail.action?docID=470994&pq-origsite=primo

  • CONCLUDED (description) “In this rare, behind-the-scenes look at what goes on in hospitals across the country, a longtime medical insider and international authority on childbirth assesses the flawed American maternity care system, powerfully demonstrating how it fails to deliver safe, effective care for both mothers and babies. Written for mothers and fathers, obstetricians, nurses, midwives, scientists, insurance professionals, and anyone contemplating having a child, this passionate exposé documents how, in the most expensive maternity care system in the world, women have lost control over childbirth and what the disturbing results of this phenomenon have been. Born in the USA examines issues including midwifery and the safety of out-of-hospital birth, how the process of becoming a doctor can adversely affect both practitioners and their patients, and why there has been a rise in the use of risky but doctor-friendly interventions, including the use of Cytotec, a drug that has not been approved by the FDA for pregnant women. Most importantly, this gripping investigation, supported by many troubling personal stories, explores how women can reclaim the childbirth experience for the betterment of themselves and their children. Born in the USA tells: * Why women are 70% more likely to die in childbirth in America than in Europe * What motivates obstetricians to use dangerous and unnecessary drugs and procedures * How the present malpractice crisis has been aggravated by the fear of accountability * Why procedures such as cesarean section and birth inductions are so readily used”

World Health Organization (2019). Caesarean sections should only be performed when medically necessary says WHO.  Accessed  https://www.who.int/news/item/09-04-2015-caesarean-sections-should-only-be-performed-when-medically-necessary-says-who

  • From article “Since 1985, the international healthcare community has considered the ideal rate for caesarean sections to be between 10-15%. Since then, caesarean sections have become increasingly common in both developed and developing countries. The WHO statement published today says that when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10% there is no evidence that mortality rates improve. Across a population, the effects of caesarean section rates on maternal and newborn outcomes such as stillbirths or morbidities like birth asphyxia are still unknown and more research on the impact of caesarean section on women’s psychological and social well-being is needed.”

2018

Arboleya, Suárez, M., Fernández, N., Mantecón, L., Solís, G., Gueimonde, M., & de los Reyes-Gavilán, C. . (2018). C-section and the Neonatal Gut Microbiome Acquisition: Consequences for Future Health. Annals of Nutrition and Metabolism, 73(Suppl 3), 17–23. https://doi.org/10.1159/000490843  

  • CONCLUDED: (from intro) “This review discloses the clinical parameters for correct CS recommendation. Moreover, the major microbial changes in the infant gut microbiome acquisition as a consequence of delivery mode and medical practices surrounding it, as well as, the early and long-lasting effects for both mother and babies are discussed.”

Dahlen, H. (2018). How birth interventions affect babies’ health in the short and long-term.  Accessed https://www.westernsydney.edu.au/newscentre/news_centre/expert_opinion_stories/how_birth_interventions_affect_babies_health_in_the_short_and_long_term

CONCLUDED:  (from intro) “

  • Medical and surgical intervention during birth continues to rise in much of the world. Nearly one in three women who give birth in Australia have a caesarean section and around 50% have their labour induced and/or augmented (sped up with synthetic hormones).  Our new research, published today in the journal Birth, found babies born via medical or surgical intervention were at increased risk of health problems. These include short-term concerns such as jaundice and feeding problems, and longer-term illnesses such as diabetes, respiratory infections and eczema.  Intervention will sometimes be required in childbirth, but should only occur when medically necessary.

Keag, O., Norman, J. and Stock, S. (2018). Long-term risks and benefits association with cesarean delivery for mother, baby and subsequent pregnancies: Systematic review and meta-analysis.  Accessed https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002494

  • CONCLUDED: (from intro) Maternal preferences are an important influence on decisions about mode of delivery. At present, evidence of longer-term complications of cesarean delivery has not been adequately synthesized to allow fully informed decisions about mode of delivery to be made. The aim of this systematic review and meta-analysis is to summarize the evidence about long-term risks and benefits of cesarean delivery for women, children, and the associations with future pregnancies.

Kingdon, C., Downe, S., & Betran, A. P. (2018). Non-clinical interventions to reduce unnecessary caesarean section targeted at organisations, facilities and systems: Systematic review of qualitative studies. PloS One, 13(9), e0203274–e0203274. https://doi.org/10.1371/journal.pone.0203274

  • Results:  8,219 studies were identified. 25 studies were included, from 17 countries, published between 1993–2016, encompassing the views of over 1,565 stakeholders. Nineteen Summary of Findings statements were derived. They mapped onto three distinct themes:   Health system, organizational and structural factors (6 SoFs); Human and cultural factors (7 SoFs); and Mechanisms of effect to achieve change factors (6 SoFs). The synthesis showed how inter- and intra-system power differentials, and stakeholder commitment, exert strong mechanisms of effect on caesarean section rates, independent of the theoretical efficacy of specific interventions to reduce them.

Raihana, S, Alam, A., Huda, T. & Dibley, M. (2021) Factors associated with delayed initiation of breastfeeding in health facilities… International Breastfeeding Journal. Accessed https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-021-00360-w

  • CONCLUDED: “Over the last decade many programs in developing countries, including Bangladesh, have promoted birthing at health facilities. Further, caesarean delivery at a health facility is a valuable tool to save the lives of women and their newborns in emergency obstetric situations [29, 47]. However, as we see from this analysis, the overuse of caesarean delivery in Bangladesh is associated with a higher likelihood of delaying breastfeeding initiation. Research also suggests that delayed initiation is likely to increase the risk of mortality and morbidity, especially in the newborn [5] and early newborn period ”  (material omitted)

Rosenberg, & Trevathan, W. R. (2018). Evolutionary perspectives on cesarean section. Evolution, Medicine, and Public Health, 2018(1), 67–81. https://doi.org/10.1093/emph/eoy006  Accessed https://academic.oup.com/emph/article/2018/1/67/4911519

  • CONCLUDED: (material omitted) “Although medical intervention is welcome and necessary in some cases, cesarean section has reached levels that cause concern in many parts of the world. In support of the concern, we have presented evidence of both the risks to mother and infant of unnecessary surgical delivery and benefits to both the mother and infant of vaginal delivery. One factor that contributes to the high rates of elective cesarean section may be maternal attitudes towards birth that include both a misperception of the safety of surgical delivery as well as the extreme fear of vaginal delivery.”

Sandall, J., Tribe, R. M., Avery, L., Mola, G., Visser, G. H., Homer, C. S., Gibbons, D., Kelly, N. M., Kennedy, H. P., Kidanto, H., Taylor, P., & Temmerman, M. (2018). Short-term and long-term effects of caesarean section on the health of women and children. The Lancet (British Edition), 392(10155), 1349–1357. https://doi.org/10.1016/S0140-6736(18)31930-5

  • CONCLUDED:  “Almost every woman who has a CS increases her risk of certain morbidities in her subsequent pregnancies. The axiom once a caesarean, always a caesarean is not evidence-based, but once a caesarean, always a scar reinforces the maxim that women with a previous CS should be considered to be at increased risk of obstetric complications and poorer outcomes for mother and baby. The discussed evidence shows the complexity in achieving an initially favourable result from an operative intervention and, consequently, potentially severe complications in subsequent pregnancies. There is a need to consider the long-term outcomes for women and children when planning the mode of birth in high-resource and low-resource settings. We have identified evidence about CS and its effects on short-term maternal and infant outcomes compared with vaginal birth, but more evidence is needed from low-resource settings. The evidence regarding outcomes of CS for women, infants and children is complex, often of poor quality, and carries uncertainty in establishing causality over the longer term. In parallel with the strengthening of this evidence base, interventions after birth that are aimed at improving lifelong health for CS infants and children should be developed and evaluated ” (material omitted)

Terreri, C. (2018).  What to know about babies born by c-section – and what you can do. https://www.lamaze.org/Giving-Birth-with-Confidence/GBWC-Post/what-to-know-about-babies-born-by-c-section-and-what-you-can-do

  • CONCLUDED: Increasingly, researchers are finding that c-sections are linked to both short and long-term health problems for baby. Short-term problems include breathing difficulty, risk of head/facial laceration from surgery, breastfeeding difficulties, and delayed bonding. Long-term problems possibly associated with cesarean are increased risk of asthma, obesity, and developmental delays.

The Lancet. (2018). Stemming the global caesarean section epidemic. The Lancet (British Edition), 392(10155), 1279–1279. https://doi.org/10.1016/S0140-6736(18)32394-8

  • CONCLUDED: (from site) “When medically indicated, such as in placenta preavia, fetal distress, or abnormal positioning, caesarean sections save the lives of women and babies. Underuse due to lack of access clearly exists in some areas, and is associated with maternal and perinatal harms. But overuse and its implications are now of growing concern. Population rates above 10–15% are considered excessive. Women who do not need a caesarean section and their infants can be harmed or die from the procedure, especially when done in the absence of adequate facilities, skills, and comprehensive health care.”

World Health Organization. (2018). New WHO guidance on non-clinical interventions specifically designed to reduce unnecessary caesarean sections.  Accessed https://www.who.int/publications/i/item/9789241550338

  • CONCLUDED: “A caesarean section is a surgical procedure that, when undertaken for medical reasons, can save the life of a woman and her baby. Many caesarean sections are undertaken unnecessarily however, which can put the lives and well-being of women and their babies at risk – both in the short and the long-term.   Worldwide, caesarean section rates have been steadily increasing, without significant benefit to the health of women or their babies. In recognition of the urgent need to address the sustained and unprecedented rise in these rates, WHO has today published new guidance on non-clinical interventions specifically designed to reduce unnecessary caesarean sections

2017

Ariadne Labs. (2017). Study tracks long-term health risks to women after having a C-section.  Accessed https://www.ariadnelabs.org/resources/articles/study-tracks-long-term-health-risks-to-women-after-having-a-c-section/

  • CONCLUDED:  Study authors concluded that the results support policies and clinical efforts to prevent cesarean deliveries that are not medically necessary. The Delivery Decisions Initiative led by Shah is working to identify the key drivers of dangerously high C-section rates and to develop a health-system level solution to the problem

Dekkar, R. (2017).  Friedman’s curve and failure to progress; A leading cause of unplanned c-sections. Accessed: https://evidencebasedbirth.com/friedmans-curve-and-failure-to-progress-a-leading-cause-of-unplanned-c-sections/

  • CONCLUDED:  (from site)  “The definition of a “normal” length of labor that has been used since the 1950s is obsolete. The new, evidence-based definitions of normal labor, labor arrest, and failed induction should be adopted immediately, and the vague term “Failure to Progress” should be abandoned. As long as the laboring person and baby are both healthy, and as long as the length of labor does not qualify as an arrested labor, laboring women should be treated as if they are progressing normally. Pregnant people who are being medically induced should be given more time to complete the early phase of labor. Importantly, six centimeters—not four centimeters—should be considered the start of the active phase for most people and caregivers should keep in mind that normal early labor (before six cm) sometimes includes a “resting” period in which there may be no change in dilation for hours. People may decide, together with their caregivers, to delay hospital admission until active labor. In the end, if more care providers begin using evidence-based definitions of labor arrest and failed induction, we will begin to see fewer of these diagnoses, and a simultaneous, safe lowering of the Cesarean rate.”

2016

Betrán, A. P., Ye, J., Moller, A.-B., Zhang, J., Gülmezoglu, A. M., & Torloni, M. R. (2016). The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014. PloS One, 11(2), e0148343–e0148343. https://doi.org/10.1371/journal.pone.0148343

  • CONCLUDED: “Current rates of CS, except for the least developed countries, are consistently higher than what is considered medically justifiable [23, 42]. The scientific, public health and medical community have raised concern about this global epidemic while the search for ideas and interventions to reduce unnecessary CS is on-going [33, 34]. However, the rational and responsible reduction of unnecessary CS is not a trivial task and it will take considerable time and efforts. Monitoring both CS rates and outcomes is essential to ensure that policies, practices and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.”

Consumer Reports: The Biggest Risk In C-Section: May Be The Hospital You Use. (2016). The Hartford Courant.  Accessed https://www.consumerreports.org/c-section/biggest-c-section-risk-may-be-your-hospital/#:~:text=While%20being%20overweight%2C%20diabetic%2C%20or,reproductive%20biology%20at%20Harvard%20Medical

  • Concluded (from article) “While being overweight, diabetic, or older can make it more likely for a woman to have a C-section, the biggest risk factor is “the hospital a mother walks into to deliver her baby, and how busy it is,” says Neel Shah, M.D., an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, who has studied C-section rates in the U.S. and around the world.

Gesing, Alexandria, “The Medicalization of Childbirth Within the United States” (2016). https://digitalworks.union.edu/theses/150?utm_source=digitalworks.union.edu%2Ftheses%2F150&utm_medium=PDF&utm_campaign=PDFCoverPages

  • CONCLUDED:  (from abstract)  “The World Bank rates the United States last amongst developed countries for maternal mortality, with 14 deaths per 100,000 live births compared to Canada and the Netherlands with 7 deaths per 100,000 live births, and the UK with 9 per 100,000 live births. This paper argues that these deaths are strongly linked to excessive use of Cesarean sections, resulting from increased access to technology, and explores the attendant medicalization of childbirth in the United States. Drawing on interviews with patients, midwives, and physicians, in addition to participant observation of hospitals and private practices within the Tristate area; I compare the medical or physician-led model to the midwifery model. In doing so, I describe distinct aspects of care each model provides to expectant mothers today, and consider the historical evolution of midwifery in the American health care system. I contend that we can improve women’s birthing experiences, regulate the provision of care, improve health outcomes, and reduce high Cesarean section rates through education.”

National Partnership for Women and Families (2016). What Every Pregnant Woman Needs to Know about Caesarean Birth. Accessed https://www.nationalpartnership.org/our-work/resources/health-care/maternity/what-every-pregnant-woman-needs-to-know-about-cesarean-section.pdf

  • Which is safer: vaginal birth or C-section? Vaginal birth is much safer than a C-section for most women and babies. Sometimes a C-section is the only safe option, like when the baby is positioned side-to-side in the belly (transverse lie) or the placenta is covering the cervix (placenta previa). In other situations, having a C-section might have some possible benefits, and these need to be weighed against possible risks. You have the right to know these possible harms and benefits, and only you can decide how important they are to you.

Rappleye, E. (2016). The most common surgery in the world is often unnecessary – and this physician is out to fix it. https://www.beckershospitalreview.com/hospital-management-administration/the-most-common-surgery-in-the-world-is-often-unnecessary-and-this-physician-is-out-to-fix-it.html#:~:text=C%2Dsections%20are%20the%20most,the%20last%20generation%20of%20moms.

  • CONCLUDED:  (from interview)   ” C-sections are the most common major surgery performed on human beings anywhere in the world and the most common in the U.S. They have become 500 percent more common over the last generation of moms. We really have no idea why rates are skyrocketing. Not only are they really high, but it’s hard to believe 1 in 3 humans need major surgery to be born. There is also incredible variation in C-section rates from hospital to hospital. It ranges from 7 to 70 percent of births, which indicates the greatest risk factor for a woman to have a C-section may be the hospital she goes to — not her own risks or preference — but which door she walks through.  Additionally, about half of C-sections are not necessary in retrospect. As many as 20,000 surgical complications could be avoided that cost $5 billion and a lot of unnecessary pain and suffering”

Reducing Early Elective Deliveries. (2014). In New York Times (Online). New York Times Company. Accessed https://www.proquest.com/docview/2213655240?parentSessionId=xTWaNIxKzwiO8BqqTt8%2BNhokQ3IzMVmuJFL%2FD%2Fgew5c%3D&pq-origsite=primo&accountid=13215

  • CONCLUDED:  (from article) “Until four years ago, it seemed like early elective delivery was a textbook example of evidence widely ignored. These are induced or cesarean section deliveries after 37 completed weeks but before 39 completed weeks of gestation, when not medically necessary. The reason is usually convenience — the family is coming in for Christmas or the obstetrician will be off next week.  Delivery at 37 or 38 weeks was widely considered benign — but it is not. Infant mortality is at least 50 percent higher for babies at 37 or 38 weeks than at 39 or 40 (at 41 weeks the rate rises again). These babies are also more likely to suffer breathing, feeding and developmental problems.”

2015

Curran, O’Neill, S. M., Cryan, J. F., Kenny, L. C., Dinan, T. G., Khashan, A. S., & Kearney, P. M. (2015). Research Review: Birth by caesarean section and development of autism spectrum disorder and attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Journal of Child Psychology and Psychiatry, 56(5), 500–508. https://doi.org/10.1111/jcpp.12351 

  • CONCLUDED: “Conclusions: “Delivery by CS is associated with a modest increased odds of ASD, and possibly ADHD, when compared to vaginal delivery. Although the effect may be due to residual confounding, the current and accelerating rate of CS implies that even a small increase in the odds of disorders, such as ASD or ADHD, may have a large impact on the society as a whole. This warrants further investigation. Keywords: Autism spectrum disorder, attentiondeficit/hyperactivity disorder, Caesarean section.”

World Health Organization Europe. (2015).  Childbirth: Myths and Medicalization. Accessed https://www.euro.who.int/__data/assets/pdf_file/0007/277738/Childbirth_myths-and-medicalization.pdf 

  • CONCLUDED: (from site)  Perhaps the greatest myth about childbirth is that it is in the best interest of mother and baby that birth takes place in hospital. The past several decades have witnessed a largely consistent and persuasive argument that the hospital is the best and safest place for babies to be born. Subscription to this overriding single policy has led to little choice for women in terms of place of birth and has resulted in almost complete elimination of homebirth services in many countries.

World Health Organization (2015). Caesarean sections should only be performed when medically necessary says WHO.  Accessed https://www.who.int/news/item/09-04-2015-caesarean-sections-should-only-be-performed-when-medically-necessary-says-who

  • CONCLUDED: “Since 1985, the international healthcare community has considered the ideal rate for caesarean sections to be between 10-15%. Since then, caesarean sections have become increasingly common in both developed and developing countries. The WHO statement published today says that when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. When the rate goes above 10% there is no evidence that mortality rates improve. Across a population, the effects of caesarean section rates on maternal and newborn outcomes such as stillbirths or morbidities like birth asphyxia are still unknown and more research on the impact of caesarean section on women’s psychological and social well-being is needed’

World Health Organization (2015). WHo statement on caesarean section rates.  Accessed https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf

  • From executive summary “Since 1985, the international healthcare community has considered the ideal rate for caesarean sections to be between 10% and 15%. Since then, caesarean sections have become increasingly common in both developed and developing countries. When medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure. As with any surgery, caesarean sections are associated with short and long term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care”

2014

Levine, & Lowe, N. K. (2014). Nurse Attitudes Toward Childbirth: A Concept Clarification. Nursing Forum (Hillsdale), 49(2), 88–99. https://doi.org/10.1111/nuf.12040

  • CONCLUDED: “Nurses have the most patient contact of all healthcare providers. While other providers (physicians or midwives) write orders that direct certain aspects of patient care, nurses have the freedom to implement independent nursing actions (e.g., continuous electronic fetal monitoring, activity, labor support, and maternal positioning). These nursing interventions place nurses in a position of great influence. Nursing research findings demonstrate that nursing care has the power to encourage, support, and nurture women toward the goal of a vaginal birth, or to hinder it, and contribute to a labor process that leads to eventual cesarean birth (Gagnon et al., 2007; Radin et al., 1993). The TPB is an appropriate theoretical framework for future research involving this concept. Nurse researchers have demonstrated that attitudes can predict nurses’ intention to provide nursing care and nurse behavior. RN attitudes affect patient care and therefore patient outcomes. These nursing care actions may be a predictor of or protector against unnecessary cesarean birth. This concept analysis suggests a middle-range predictive nursing theory. Future theory development regarding “nurse attitudes toward childbirth” should include testing of the TPB for appropriateness in intrapartum nursing.”

National Partnership for Women and Families. (2014). Cesarean Prevention Recommendations from Obstetric Leaders: What Pregnant Women Need to Know. Accessed https://www.nationalpartnership.org/our-work/resources/health-care/maternity/new-cesarean-prevention.pdf

  • In March 2014, the two leading obstetric professional organizations in the United States issued a landmark joint consensus statement (available online at acog.org/Resources_And_Publications/ Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery). The statement says that cesarean birth is overused in the United States. More and more cesareans – now one in three births – have not led to better health for mothers and babies. While this procedure offers clear benefits in some situations, it appears to pose greater risk for quite a few problems in women and babies in low-risk pregnancies. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine identify many ways to safely reduce the chance of cesarean birth. They focus on preventing “primary” or initial cesareans in pregnant women who have never had a cesarean and on preventing cesareans that offer no clear benefit for women and babies.

Visser. (2014). Women Are Designed to Deliver Vaginally and Not by Cesarean Section: An Obstetrician’s View. Neonatology (Basel, Switzerland), 107(1), 8–13. https://doi.org/10.1159/000365164 

  • CONCLUDED (from abstract) “Worldwide, there is a rapid increase in deliveries by cesarean section. The large differences among countries, from about 16% to more than 60%, suggest that the cesarean delivery (CD) rate has little to do with evidence-based medicine. In this review, the background for the increasing CD rate is discussed as well as the limited positive effects on neonatal outcome in both term and preterm neonates. Negative effects of CD, including direct maternal morbidity, complications of subsequent pregnancies and iatrogenic early delivery resulting in increased neonatal morbidity, are discussed in addition to long-term implications for the offspring involving altered development of the immune system. The ‘battle’ to lower the CD rate will be difficult, but we should not forget that women are designed to deliver vaginally and not by cesarean section.

2012

Lavender, T., Hofmeyr, G. J., Neilson, J. P., Kingdon, C., & Gyte, G. M. L. (2012). Caesarean section for non-medical reasons at term. Cochrane Database of Systematic Reviews, 2012(3), CD004660–CD004660. https://doi.org/10.1002/14651858.CD004660.pub3

  • From abstract: The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and a greater risk of stillbirth and neonatal morbidity. The differences in neonatal physiology following vaginal and caesarean births are thought to have implications for the infant, with caesarean section potentially increasing the risk of compromised health in both the short and the long term.

Minkoff, H., Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY. (2012). Fear of litigation and cesarean section rates. Seminars in Perinatology, 36(5), 390-394. doi:10.1053/j.semperi.2012.04.025

  • CONCLUDED: “It is in that regard that the ethical obligations of the obstetricians cannot be forgotten in any discussion of factors that drive patient care behaviors. Putting the welfare of the patient first is a cornerstone of professionalism. The European Federation of Physicians, the American Board of Internal Medicine, and the American College of Physicians have jointly defined primacy of patient welfare as one of the tenets of professionalism.29 It imbues the physician with the altruism that fosters a therapeutic relationship with the patient. If self-interest was perceived to have compromised that tenet, it would seriously undermine the esteem of our discipline, and physicians, contrary to some beliefs, are still held in high regard.30 Although physicians fear of suit may never fully abate and substantive changes in physicians’ beliefs about their liability exposure may only occur in the wake of meaningful tort reform, physician must continue to balance an understandable tendency to revert to cesarean section as one of many acts of defensive medicine, with their professional obligation to serve their patient’s interests primarily”

2010

Geller, Wu, J. M., Jannelli, M. L., Nguyen, T. V., & Visco, A. G. (2010). Neonatal outcomes associated with planned vaginal versus planned primary cesarean delivery. Journal of Perinatology, 30(4), 258–264. https://doi.org/10.1038/jp.2009.150

  • CONCLUDED: “Planned vaginal delivery led to more meconium passage and low 1 min Apgar but less NICU admissions, oxygen resuscitation and jaundice. Multicenter trials are needed to assess rare but serious outcomes based on planned route of delivery.”  

2007

BERGERON. (2007). THE ETHICS OF CESAREAN SECTION ON MATERNAL REQUEST: A FEMINIST CRITIQUE OF THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS’ POSITION ON PATIENT-CHOICE SURGERY. Bioethics, 21(9), 478–487. https://doi.org/10.1111/j.1467-8519.2007.00593.x

  • CONCLUDED: “The unique position of childbirth at the nexus between medical ambitions, gender-based discrimination and social perception of motherhood and femininity demands that it be approached with careful consideration for its multi-dimensional aspect. In rooting the ethics of CDMR in patient autonomy and informed choice, the American College of Obstetricians and Gynecologists reveals a superficial understanding of childbirth that gives no consequence to its sexist past and its future implications.” (material omitted)

2005

Beckett. (2005). Choosing Cesarean: Feminism and the politics of childbirth in the United States. Feminist Theory, 6(3), 251–275. https://doi.org/10.1177/1464700105057363  Accessed https://www.researchgate.net/publication/249744564_Choosing_Cesarean

  • CONCLUDED: “Although childbirth has become comparatively safe for most women living in developed countries, some contemporary obstetrical practices pose serious threats to women and newborns and, by consuming significant medical resources, contribute to inequities in health and health care. Furthermore, Western obstetrical practices are aggressively promoted around the globe, and, if adopted, contribute to the injudicious use of health care resources in even more profound ways. While the essentializing and moralistic rhetoric of the alternative birth movement should be abandoned, its critique of contemporary obstetrics, commitment to women’s and children’s health, and thoughtful use of health care resources are essential to the reconstruction of a feminist politics of and theoretical approach to childbirth.”

1989

Sachs, B. (1989). Is the rising rage of Cesarean sections a result of more defensive medicine?  Accessed https://www.ncbi.nlm.nih.gov/books/NBK218656/

  • From article “The high cesarean section rate in the United States is a major public health problem, one that is having and will continue to have a major impact on health care delivery. If the $800 million that could be saved by reducing the cesarean section rate by 5 percent were spent instead on prenatal care and preventive programs, dramatic effects on maternal and child health would be seen. This shift, in my opinion, is very unlikely to occur, given the current medical-legal environment, which has resulted in a siege mentality among clinicians. If one also considers that less than 20 cents on the dollar paid for malpractice premiums is given to injured parties, our current tort system is clearly very expensive, inefficient, and, because of its adverse effects on the delivery of maternity care, dangerous