Declercq and Norsigian

BOSTON (WOMENSENEWS)–"Too posh to push."

That catchy phrase originated in 2001 headlines of British tabloids and has been echoing through the news media ever since. It suggests a trend toward an increasing number of medically elective Caesarean sections requested by upper-class mothers.

In late March, the National Institutes of Health held a meeting called "Maternal Request Caesareans."

While dropping the emphasis on "posh," the title of the conference and its draft report seem to reinforce the general impression that mothers are fueling the trend toward elective Caesareans, which are at record levels in the United States.

Problem: No systematic evidence of this is available. In addition, focusing on maternal request obscures a more complex story concerning changes in obstetrical practice.

Although some studies do describe an increase in Caesareans without any medical indication, this may not represent real "maternal requests" at all. These studies, based on birth certificates or hospital billing records, have no way of documenting whether the surgery was sought by the mother or based on physician advice.

Childbirth Connection, a New York-based national nonprofit with whom we have each separately collaborated in the past, has conducted the only representative national studies, "Listening to Mothers," that directly survey mothers about their birth experience, including those who had a Caesarean section. The first study was published in 2002, initial findings of the second were completed in March.

In the most recent survey carried out in January and February 2006 among 18- to 45-year-old women who gave birth in U.S. hospitals to a single infant last year, only 1 in 252 women (0.4 percent) who had a primary Caesarean section without a medical reason actually chose this option herself.

Although there are undoubtedly some women who do seek elective Caesareans, they are hardly enough to increase the number of Caesareans by 400,000 nationally since 1996.

Great News Story

With Caesarean rates at an all-time high–accounting for 1.2 million surgeries and 29 percent of all births in 2004–reporters and editors are naturally interested in seeking explanations and "patient choice" makes an attractive news story.

Such stories often include human interest elements, such as following one woman’s decision to elect a Caesarean. They also involve broader ethical issues, such as whether individuals should have the right to choose elective surgery and, if so, who should pay for it.

The news coverage, however, too often gives a skewed impression of who is electing to have a Caesarean. Many stories on maternal request, for instance, feature suburban white professional women, often obstetricians themselves.

These stories may be interesting, but they feed an inaccurate stereotype. Mothers with the highest Caesarean rates in the United States–African American women over 35–are rarely featured in such coverage.

So if it’s not maternal requests, what then is causing the increase in Caesareans?

Answer: Primarily changes in obstetrical practice.

Long gone are the days when a single obstetrician handled a caseload of women to whom he or she made the extraordinary commitment to attend her birth no matter when that woman went into labor.

Now, the overwhelming majority of obstetrical practices are group-based, substantially reducing that individual bond with a mother.

In Childbirth Connections’ 2002 survey, 19 percent of mothers reported they had never met the person who delivered their babies and another 10 percent indicated they had only briefly met their birth attendants.

Reality of Lawsuits

Another factor is the increasing concern about malpractice and the reality of lawsuits that may be brought even in instances when an obstetrician is not really to blame for a bad outcome.

It is not surprising that in the gray area of clinical decision-making during labor, many obstetricians have substantially lowered the threshold for when they would perform a Caesarean.

In cases involving maternal or fetal health risks, a Caesarean can be safer than vaginal delivery. But the core question in elective C-sections is whether they are safer when no medical risk is involved. That answer depends on many variables.

Are we are talking about the baby or the mother? Are we talking about this birth or the risks associated with future births (the more Caesareans a woman has the greater her risk of future delivery complications). Are we talking about short or long-term morbidity for the mother? Are we considering postpartum pain as part of the equation?

Caesareans, especially those that are scheduled and not matters of emergency, allow obstetricians to exercise their surgical skills, appear to decrease the likelihood of malpractice suits and provide more control over the scheduling of hospital and office hours.

Lack of Evidence

Advocates of medically elective Caesareans will also cite an array of health benefits for mothers and infants from Caesareans, although the National Institutes of Health conference made clear that solid evidence of such benefits is not available.

Nonetheless, as we know from survey findings, many women do hold erroneous assumptions about elective Caesareans.

For example, they may think of Caesareans as reducing the pain that they will experience. However, while regional anesthesia such as epidurals can reduce the experience of pain during vaginal deliveries, this pain often pales in comparison to the substantial long-term pain after birth experienced by women who have undergone Caesareans.

There is much we still don’t know about the impact of Caesarean or vaginal birth on health outcomes, either for the mother or the baby or both.

We do know, however, that Caesareans cause more respiratory-lung problems in the infant, even with technology to avoid births before 39 weeks when this risk is higher. At the NIH meeting one pediatrician described a rapid rise in the occupancy rates of neonatal intensive care units in Brazil, where some city hospitals are said to have 90 percent Caesarean section rates.

Thus, the information now available makes clear that the growth in Caesareans–which includes mothers of all ages, races and across all medical conditions–is the result of a complicated shift in professional practice that deserves careful scrutiny. It is not primarily about mothers pressuring doctors to take what they perceive to be the "easy" way out, as contemporary media coverage would have us believe.

Gene Declercq is professor of maternal and child health at the Boston University School of Public Health. Judy Norsigian is executive director of Our Bodies Ourselves.

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For more information:

Childbirth Connection–
NIH Cesarean Conference: Interpreting Meeting and Media Reports:

NIH Medline Plus: Caesarean Section:

Our Bodies, Ourselves:

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