Choose & Lose: Promoting Cesareans and Other Invasive Interventions
by Marsden Wagner

[Editor’s note: This article first appeared in Midwifery Today Issue 85, Spring 2008.]

After more than a decade of trying to bring down the number of c-sections, some obstetricians are now reversing themselves and promoting more of them. In fact, a growing number of American obstetricians now urge women to “choose” a cesarean even when there is no medical indication that they need one.

The following statement is from a popular book titled The Girlfriends’ Guide to Pregnancy:

With a scheduled cesarean section, you and your doctor have agreed to a time at which you will enter the hospital in a fairly calm and leisurely fashion, and he or she will extract your baby through a small slit at the top of your pubic hair. There are a lot of reasons to schedule a cesarean section.… Other women elect to have a cesarean because they want to maintain the vaginal tone of a teenager, and their doctors find a medical explanation that will suit the insurance company.(1)

This illustrates the degree to which our society at large condones the concept of women choosing c-section, as well as doctors committing insurance fraud. A recent president of the American College of Obstetricians and Gynecologists (ACOG) went a step further in a paper titled “Patient Choice Cesarean,” in which he calls this major abdominal surgery “a life-enhancing operation.”(2)

C-section is an essential surgical procedure that, when properly applied, can save the lives of women and babies. But giving pregnant women the option of choosing to have a birth by c-section when not medically necessary is another matter entirely. Put simply, c-section, even when “elective” (done by choice and not the result of a risky situation or an emergency), increases the chance that the woman and/or the baby will die. Contrast this last sentence, which is based on scientific evidence, with the glowing statement, quoted in the previous paragraph, on the advantages of choosing c-section.

Today many, if not most, obstetricians do not attend births:
They perform fetal extractions through the vagina or through an abdominal cut.

— Faith Gibson, midwife and author

Obstetricians have a number of reasons for encouraging women to have c-sections. First, though, we must recognize that saying they are doing it because it is a woman’s right to choose any kind of birth she wants is blatant spin-doctoring. It is ridiculous to suppose that obstetricians have suddenly discovered women’s rights. For proof we need only remember the ACOG recommendation that doctors and hospitals be strongly urged to refuse when a family requests permission to make a birth video.(3) This is clear evidence that we can count on organized obstetrics to put fear of litigation ahead of family values and women’s rights. [Editor’s note: Remember also that most women in the US cannot choose a VBAC either; the majority of doctors and hospitals refuse to allow it.]

Why would obstetricians use the rhetoric of women’s rights to get what they themselves want—a surgical birth? There are three compelling reasons. First, scheduling c-sections allows obstetricians to maintain their present overextended style of practice and bring the most time-consuming piece of it under control. They can split their time among seeing patients in the office, doing gynecological surgical procedures in the hospital and attending births, on a timetable of their choosing, and reduce the chance that they will be required to attend births at inconvenient times. For some, it is perhaps their only chance to have a decent personal life. Vaginal birth takes twelve hours on average and happens twenty-four hours a day, seven days a week. C-section takes twenty minutes, and most of the time it can be conveniently scheduled. Doctors may deny that they promote elective c-section for convenience, but their position is not believable.

I appeared on the television program Good Morning America to debate the president of ACOG. When I suggested that obstetricians sometimes do things for their own convenience, the ACOG president indignantly replied that obstetricians never do things for their own convenience. However, we have proof to the contrary. Federal studies that analyze birth certificates tell us that the percentage of US births that happen Monday to Friday, nine to five, is rapidly increasing. Even “emergency” c-sections are more common Monday to Friday, nine to five.(4)

The second reason obstetricians want more woman to have c-sections is to avoid litigation. Obstetricians are desperate to stay out of courtrooms where, unlike in hospitals, they are vulnerable and are not “top gun.”

And let the angel whom thou still hast served
Tell thee,
Macduff was from his mother’s womb
Untimely ripp’d.

— Shakespeare, Macbeth, V, vii, 43

The third reason for promoting more c-sections relates to the present crisis in American obstetrics. Politicians, HMOs and the US public are rapidly realizing that having highly trained surgical specialists caring for healthy pregnant women and catching perfectly normal babies at low-risk births is wrong. Midwives cost much less. When obstetricians promote c-sections, they are protecting their territory by encouraging women to choose the one type of birth that only they can provide.

So when obstetricians succeed in talking women into choosing c-sections, in one fell swoop they make their schedules more convenient, may reduce their risk of litigation and win a point over the competition.

These are the big reasons obstetricians want to perform more c-sections. Several subtle but pervasive factors also underlie this trend. For one, because obstetricians have been trained to manage the small percentage of cases of high-risk birth where things can and do go wrong, they are afraid of birth. They are like the auto mechanic who sees only the Fords that have broken down and have been brought to his shop and ends up thinking that all Fords are in imminent danger of breaking down. He forgets that he never sees all the Fords on the road that are running just fine.

This fear of imminent trouble leads obstetricians to intervene too early with procedures that create complications—necessitating more procedures. One intervention leads to another, in a cascade of interventions that all lead to c-section. In the past decade, the classic example of such a cascade is an induction of labor with powerful drugs, which leads to increased labor pain, which leads to an epidural block to relieve the pain, which leads to a slowing of labor, which becomes “failure to progress”: the number one diagnosis used to justify pulling the baby out with forceps or a vacuum extractor or performing a c-section.

Another factor in the wave of high-tech, high-interventionist births is that medicalized birth is all obstetricians know, and fish can’t see the water they swim in.(5) Most obstetricians have experienced only hospital-based birth, managed within a medical model. They have never seen natural birth. As a result, they cannot see the profound effect their interventions have on the entire process. This is put well in a World Health Organization (WHO) publication:

By medicalizing birth, that is, by separating the woman from her own environment and surrounding her with strange people using strange machines to do strange things to her, the woman’s state of mind and body are so altered that her way of carrying through this intimate act must also be altered. It is not possible for obstetricians to know what births would have been like before these manipulations—they have no idea what non-medicalized birth is. The entire modern published literature in obstetrics is based on observations of medicalized birth.(6)

Another subtle factor driving some obstetricians to promote invasive interventions such as c-sections is their fundamental belief in machines and technology and lack of belief in women and their bodies. Obstetricians tend to have blind faith in technology and the mantra: technology = progress = modern. Here examples abound. Most obstetricians routinely use an electronic fetal heart monitor to observe the baby’s heartbeat during labor, in spite of clear scientific evidence that a good old-fashioned stethoscope is just as reliable.(7) When estimating the length of a pregnancy by measuring the fetus as seen in an ultrasound picture became popular in the 1980s, obstetricians dropped the tried-and-true method of asking the woman about her last menstrual cycle. Yet scientific evidence shows that when predicting the expected date of birth, ultrasound scanning is no more accurate than using the date of the woman’s last period.(8)

Women’s bodies work best to give birth when they are standing, sitting or squatting. Yet when the obstetrics establishment began to realize that putting a woman on her back inhibited the birth process, instead of encouraging women to simply take a more natural vertical position, they set about designing a variety of high-tech adjustable birthing beds or chairs. These furnishings are typically made of metal, are mechanically complex and allow for a number of positions. Each one costs thousands of dollars. A beanbag chair works better than any of them, however, because the woman can mold the chair to fit her own body. Of course with a beanbag chair or with the woman in a vertical position, the obstetrician would have to be situated below the woman.

I once visited a public maternity hospital where large numbers of women were in labor. When I suggested to the chief nurse who was showing me around the ward that they consider using vertical birth positions, she replied, “But that would require the doctors to get down on the floor. They would never consider doing that.”

Here is one last example of the lengths to which the medical-industrial complex will go to mechanize normal human functions. As we’ve seen, using powerful drugs to induce labor or stimulate uterine contractions has serious risks. Another method for stimulating contractions involves no risk whatsoever, but is rarely, if ever, used in hospital obstetrics, perhaps because it is “too natural.” For centuries, midwives have relied on the woman’s partner, the midwife or the woman herself to stimulate the woman’s nipples to promote uterine contractions. In 1990, an obstetrician working with a commercial firm sought FDA approval for a nipple stimulation device that includes an electric pump and a “suction hood” that fits over the nipple.(9) In machines we trust.

Throughout the twentieth century, this arrogant belief that obstetricians know better than nature has led to a series of failed attempts to improve on biological and social evolution. Doctors replaced midwives in the US for low-risk births, and then later science proved that midwives were safer. Hospitals replaced home as the setting for low-risk births, and then later science proved that planned out-of-hospital births are as safe as hospital births and involve far less unnecessary intervention. Hospital staff replaced the family as the primary support providers for a woman in labor, and later science proved that a birth is safer when the family is present. The practice of taking newborns away from mothers in the first twenty minutes after birth replaced the practice of leaving babies with their mothers, and later science proved the importance of mother-baby bonding during this time. Putting normal newborns in a central nursery replaced rooming babies with their mothers, and later science proved that rooming-in is superior. Man-made milk replaced woman-made breast milk, and later science proved that breast milk is far superior to infant formula. If more obstetricians experienced an earthquake, a volcano or a tsunami, perhaps they would realize that their ideas of controlling nature are ineffective, pathetic, and—most important—dangerous.

Marsden Wagner, MD, is a perinatologist and perinatal epidemiologist from California and an outspoken supporter of midwifery. He was director of Women’s and Children’s Health in the World Health Organization for 15 years. From his current home in Takoma Park, Maryland, Marsden travels the world to talk about improving maternity care, including the appropriate use of technology in birth and utilizing midwives for the best outcomes. He raised four children as a single father. His books, Born in the USA, Creating Your Birth Plan, and Pursuing the Birth Machine, are invaluable for anyone involved in birth.

References:

  1. Iovine, V. 1995. The Girlfriends’ Guide to Pregnancy. New York: Pocket Books. p. 217–18.
  2. Harer, W.B. 2000. “Patient Choice Cesarean.” American College of Obstetricians and Gynecologists Clinical Review 5(2): 12–16.
  3. ACOG Committee Opinion number 207. 1998. “Liability Implications of Recording Procedures or Treatments.”
  4. For detailed data on childbirth in the US collected by the federal government, including birth by the day of the week, see www.cdc.gov/nchs/births.htm. Cesarean for convenience is discussed in M. Hurst and P. Summey. 1984. “Childbirth and Social Class: The Case of Cesarean Delivery,” Social Science and Medicine. 18(8): 621–31. For a more complete discussion of the issue of c-section and doctors’ convenience, see M. Wagner, 1994. Pursuing the Birth Machine: The Search for Appropriate Birth Technology (London: ACE Graphics), pp. 186–88. Also see M. Wagner. 2000. “Choosing Caesarean Section,” Lancet 356: 1677–80.
  5. For a more thorough discussion of the consequences of obstetricians having experienced only one type of birth, see M. Wagner. 2001. “Fish Can’t See Water: The Need to Humanize Birth.” Int J Gynaecol Obstet 75 Suppl 1 : s25–37.
  6. World Health Organization. 1985. “Having a Baby in Europe.” Public Health in Europe 26: 85.
  7. M. Enkin, M., et al. 2000. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. New York: Oxford University Press. p. 271, reports the results of twelve randomized, controlled trials comparing electronic fetal monitoring (EFM) with intermittent auscultation of the fetal heart rate, involving more than fifty-eight thousand women in 10 centers. C-section rates were higher in the EFM group but there were no differences in outcome for the babies in the EFM and auscultation groups. For an excellent discussion of the limitations of EFM, see Goer, H. 1999. The Thinking Woman’s Guide to a Better Birth. New York: Penguin Putnam., pp. 85–98.
  8. Backie, B., and J. Nackling. 1994. “Term Prediction in Routine Ultrasound Practice,” Acta Obstet Gynecol Scand 73(2): 113–18.
  9. For information on the mechanical nipple stimulation device, see U.S. Food and Drug Administration Advisory Panel on Obstetrics and Gynecology, minutes, 4 Apr 1990.

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