Who's too posh to push?

Are C-sections on the rise because women are lazy or because healthcare providers and insurers are lazy?

Published May 17, 2007 5:17PM (EDT)

Has Posh Spice become the poster girl for modern childbirth? News of yet another study chronicling a rise in C-sections brought back those old familiar pangs. Two years ago, the National Center for Health Statistics found that nearly a third of all U.S. births in 2004 were via cesarean section. (That may sound high, though not compared with private hospitals in New Delhi, where C-section rates reportedly approach 65 percent.) Now a paper published in the British Journal of Obstetrics and Gynecology has found that the number of C-sections in western Australia almost doubled between 1984 and 2003. What's interesting is that the western Australia study controlled for high-risk pregnancies and other factors that can make C-sections medically necessary, and found that older, more affluent mothers were more likely to have cesareans. Among the wealthiest women, the rate of planned C-sections was triple that of their poorer counterparts. The researchers concluded that more affluent women are having C-sections for "societal reasons," prompting headline writers to dredge up one of our least favorite expressions: "Too posh to push."

No doubt there are women who elect C-sections to maintain their work schedules or avoid excruciating pain, but as someone who planned on having exactly two incense-scented natural childbirths accompanied by Tibetan drones, only to wind up with two bloody C-sections without so much as a snatch of Muzak, I hesitate to conclude that rising C-section rates come only from women treating childbirth like a bikini wax. In my experience, the subtle influence of doctors and hospital staffs is hard to overestimate.

The recent Australian study did not consider whether doctors' preferences had any influence on the rise of C-sections, but an older study from the Syracuse University School of Citizenship and Public Affairs suggested that fear of malpractice lawsuits prompted nearly 20 percent of all cesareans. And as doctors and hospitals become more concerned about profit margins, there are financial incentives to schedule C-sections rather than attempt riskier vaginal births (which might result in emergency C-sections, anyway).

My second birth offers a prime example of why many hospitals are performing more scheduled cesareans. It was to be a VBAC (vaginal birth after cesarean, which carries a small risk of uterine rupture), so a doctor (as opposed to simply a midwife or nurse) needed to be on call in case my labor resulted in an emergency C-section. That meant that for the 20-something hours that I was laboring, the doctor couldn't perform more lucrative operations or procedures. By the same token, VBACs typically require an anesthesiologist be on call, something many hospitals can no longer guarantee, since the anesthesiologists are often free agents and get paid only when they administer drugs. My hospital's strong midwifery practice allowed me to give it the old college try (although I ended up getting sliced open and gutted like the Christmas goose), but it's an option I wouldn't have today. Last week my hospital -- St. Luke's in San Francisco -- made local news when it announced that it would no longer be scheduling VBACs, inciting a protest march demanding an end to the VBAC ban.

The debate over the safety (and, by extension, the moral righteousness) of C-sections on demand is one that typically pits midwives against doctors, and granola-eating home-birthers against Posh Spice wannabes. Medically, the evidence is mixed. On the one hand, last year an National Institutes of Health conference (covered by Broadsheet at the time) concluded that it couldn't determine whether the risks of C-section outweighed the benefits. On the other hand, some studies have shown that C-sections triple the risk of complications and maternal death.

But as someone who ended up getting two lovely little girls from my two loathsome birthing experiences, I still have little idea if the doctors saved my life and my daughters' lives or I capitulated to their medical birthing model. But I question the idea that women are driving this trend by themselves, without influence from the doctors who educate them.

Would women really choose C-sections if they knew what they entailed? One city in China will have a rare research pool to study this question: This past weekend, as a Mother's Day tribute, the city of Changsha -- the capital of central China's Hunan Province -- broadcast video footage of a woman giving birth by cesarean in the town square.

By Carol Lloyd

Carol Lloyd is currently at work on a book about the gentrification wars in San Francisco's Mission District.

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