The recent NIH meeting about "Maternal Request Caesareans" -- covered by Broadsheet here -- seemed to "reinforce the general impression that mothers are fueling the trend toward elective Caesareans, which are at record levels in the United States," according to Women's eNews commentators Gene Declercq and Judy Norsigian.
The problem? That "impression," Declercq and Norsigian say, is difficult to substantiate with actual data. "Although some studies do describe an increase in Caesareans without any medical indication, this may not represent real 'maternal requests' at all," they write. "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."
They cite survey data from earlier this year -- part of a series conducted by Childbirth Connection, which asks mothers directly about their birth experience -- revealing that "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." They continue: "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."
Declercq, by the way, is professor of maternal and child health at the Boston University School of Public Health; Judy Norsigian is executive director of Our Bodies, Ourselves.
While elective C-sections might sound like great "trend" stories -- spawning the classic British tabloid headline "Too posh to push" in 2001 -- they "feed an inaccurate stereotype," Declercq and Norsigian say. "Many stories on maternal request, for instance, feature suburban white professional women, often obstetricians themselves ... Mothers with the highest Caesarean rates in the United States -- African-American women over 35 -- are rarely featured in such coverage."
So what is behind the increase in C-sections? Declercq and Norsigian point, primarily, to changes in obstetrical practice. For one thing, they say, more obstetricians are part of group practices; the doctor who delivers your baby may not be the one you've been bonding with. The writers don't fully explain their insinuation here. Is the implication that a doctor who doesn't know you might be quicker to act on decisions you haven't really processed together? Or, more likely, is it simply that an on-call doc will want you to give birth on his/her schedule, not yours?
Then there's the matter of lawsuits. "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," the authors say, acknowledging that "in cases involving maternal or fetal health risks, a Caesarean can be safer than vaginal delivery." What we cannot say is that elective C-sections are safer, always and categorically, when no health risk is already present. That depends, in large part, by what one means by "safe." For the mom or the baby? For this birth or subsequent ones? And is anyone talking about postpartum pain?
Speaking of which, Declercq and Norsigian also note that some women may have some misconceptions about C-sections. Like, that they don't hurt.
While Declercq and Norsigian could have written with more precision and eloquence, their point is clear: Ask more questions before you blame the mom. "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," they write. "It is not primarily about mothers pressuring doctors to take what they perceive to be the 'easy' way out."