Here’s one of those headlines that can get everyone going: C-Section Rates Around the Globe at ‘Epidemic’ Proportions. According to the British medical journal The Lancet, a World Health Organization study on cesarean rates in Asia found “China’s 46 percent C-section rate was followed by Vietnam and Thailand with 36 percent and 34 percent, respectively. The lowest rates were in Cambodia, with 15 percent, and India, with 18 percent.” In the United States, the rate’s around 30 percent. Latin America may be as high as 35 percent.
There are at least three significant issues that require teasing apart: what are the health implications of such elevated c-section rates? What’s motivating this steep rise? And how—if, as research suggests, the answer to that first question is elective and not medically necessary c-sections represent a dangerous medical practice and the answer to the second question is the central motivation appears to be that c-sections are expensive and hospitals profit from them—to best address the third issue: how best support individual women in their choices while advocating such that the majority make the smartest choices for the population’s health?
For one thing, consumers—women—will need to be re-educated. The MSNBC article about the study includes this quote by a Vietnamese woman, Trang Thanh Van, 25, days before the birth of her first child: “I think it’s safer for the mother and child to have C-sections, and the relatives feel more secure because it’s very simple and very common now. People worry that using tools to pull the baby out (in a vaginal birth) may affect their brains.”
Co-author of the Asia report, Dr. A. Metin Gulmezoglu said, “The relative safety of the operation leads people to think it’s as safe as vaginal birth. That’s unlikely to be the case.”
Herein lies the difficulty of making large-scale shifts once technology steamrolls in: no individual wants to have a choice taken away. For that matter, if the individual wants that choice—or feels it worked—then the desire is justification for it being the best one (quite possibly, on an individual level, it may be). Reproductive health issues are so darn personal, making these global to individual conversations—inevitably, always, these are issues both global and intimate at once—so difficult.
The individual wants to convince him/herself the choice—even if the numbers show otherwise—about a c-section is best/safest/right, and it’d be more comfortable if that best/safest/right choice was true beyond him or herself (in the case of birth, herself), right? That’s how we work; we like company in our decisions, we like support for them.
Anyone who believes in this sacred tenet of reproductive justice and women’s equality—that women must maintain agency over their bodies—does not want to deem interventions that women may want or need wrong. Currently, a ban on abortion in Nicaragua means a woman in need of chemotherapy and radiation therapy for breast cancer is being denied those treatments, because she’s pregnant, and pregnant women cannot undergo chemo or radiation. That’s an extreme case. You probably have a much less dire example that springs immediately to mind: that third round of IVF that gave your friend her twins or the elective c-section you wouldn’t have chosen but your friend swears by or the hysterectomy selected by someone with high risk for ovarian cancer.
Lisa Gould Rubin, co-author of The Birth That's Right for You: A Doctor and a Doula Help You Choose and Customize the Best Birth Option to Fit Your Needs, said in a 2008 interview, “I really challenge the notion that there's a single ‘best’ birth; that's why I wanted to write a book urging each woman to find the option that is best for her. I believe there's not nearly enough support out there right now for women to find their most comfortable choice and settle with that, as opposed to someone else's idea of what she should do.”
If there weren’t some strong belief in this right to “choice,” birth centers and doulas and elective c-sections would all go by the wayside.
But don’t neglect economics. What’s more, remember that economics work in strange ways. Katie Allison Granju wrote on her Mama Pundit blog this weekend about her person c-section dilemma: “When C was born in 2007, our total medical bills for several days of labor, numerous checks of my progress at both the birth center and later, at the hospital, a manual version (flipping the baby), two epidurals, two hospital admissions (admitted then sent home when labor slowed then admitted again when things picked back up), followed by a c-section was probably double what it would have been if we had just had the damn c-section the first time anyone suggested it… the out of pocket expense to us was in more than 4k. We were paying that baby off for more than a year! My insurance this time is still good by general standards, but it actually covers less than the insurance I had when C was born. So whether it’s right or wrong, we have to do whatever we can to keep our out of pocket costs down. If a scheduled c-section without trial of labor would minimize costs, that’s a factor I have to consider because it impacts our whole family, as well as my general stress level.” Granju continues: “I don’t really care about missing out on a ‘regular’ birth; been there, done that. My main concerns about a repeat c-section are the fact that it’s major surgery, and something can ALWAYS go very wrong in major surgery, and my dread of getting the epidural.”
For a mother having her fifth child, the whole picture remains in clear view—and the pragmatic issue of money is pressing. All starry-eyed choices, though, unless you have endless means, may end up including one’s household budget, as must be true on a larger scale about health care—ahem to the insurers and Senators for not caring about our citizens’ needs better—budget.
Because I can’t step into anyone else’s shoes (or in the case of these reproductive questions, stirrups), I can’t and won’t comment on anyone’s personal decision re: childbirth. As a major fan of the birth process (I thought long and hard about becoming a midwife and indeed, having provided labor support for a bunch of friends, you can count me amongst the birth junkies), I have seen a huge range of births—homebirth to c-sections—and am awed by all; I’m awed by that singular welcome that’s as powerful in a bedroom as in a surgery suite, and I’m awed, awed by women. That whole pregnancy thing is not for sissies let’s face it.
So, the real question is this: how can we do the hard, careful, at times painful work of separating out the personal and the political in order to move toward creating the reproductive and social justice, not simply choices for some? How can we strive to make something as universal as childbirth the safest experience for the most women? Can we think strategically and compassionately? Can we be disciplined and find ways to advocate for “best practices” without inducing guilt and without taking away choices that may be critical for some women? Can we think of ourselves and for one another? These are tall orders, especially when so many health care “systems” are driven by profit and politics. Yet, headlines with epidemic in the title and women as the subject, well, we’d probably like to make those kinds of stories history.
