The Escalator from Delivery Room to Operating Room

By Laura Liao, October 30, 2018

Mothers and medical professionals alike naturally evaluate the success of pregnancies by their end products: healthy babies and healthy moms. Fixation on these successful results, however, often leaves the actual process of childbirth by the wayside. Less consideration is given to whether the baby is delivered in a hospital bed or in an operating room by Caesarian section. The setting matters little to most, and I certainly never considered its importance until I took WGS.151, a class focused on the ways that gender and societal norms drive healthcare outcomes.

Studies show that babies delivered vaginally gain measurable immune benefits; they are less likely to develop obesity and autoimmune diseases later in life. Conversely, C‐sections increase risk of life‐threatening complications for the mother, like infections and internal bleeding. Beyond possible health benefits gained from vaginal birth, “natural” birth proponents also stress that quality birth experiences matter in and of themselves. In spite of these reasons to support natural births, almost one in every three births in the U.S. in 2016 were by C‐section. That marks a marginal decrease of 1 percent in C‐sections in the country since 2009, and C‐section rates continue to skyrocket worldwide. Leading health organizations like the World Health Organization recommend C‐section rates of 20 percent or lower, so why do rates fall short of these goals?

For one, a pregnant woman can elect a C‐section in advance for a number of medical reasons. The most prominent ones depend on her doctor's recommendation. In the event of a breech, in which the infant fails to rotate properly for vaginal birth, doctors default to a C‐section. For twins (or triplets, or wilder multiples), doctors also recommend C‐section. And if a woman has undergone a C‐section in the past, she will likely lean towards a C‐section again. Some women will also opt for a C‐section for comfort or convenience: the procedure protects against vaginal tears and against unpredictable maternity leave.

Apart from surface‐level medical decisions, however, lesser known historical and social reasons make women scheduled for vaginal birth more likely to undergo a C‐section. During the 20th century, industrialization of medicine and society at large migrated pregnant mothers from their homes into urban hospitals. They abandoned the traditional approach of inviting midwives into their own homes, opting for doctors with degrees in medical centers.

In modern times, the subconscious casual attitudes about C‐sections among mothers and medical professionals alike drive rates up. In a sense, a high C‐section rate is a positive‐feedback loop; the more mothers that undergo C‐sections, the more acceptable undergoing a C‐section becomes. C‐sections seem disparate from other surgeries; until recently, I certainly did not view C‐sections as major surgery with long‐term risks for both mother and child. Critics of current C‐section rates also point to the concerning conflict of interest that exists for doctors: C‐sections facilitate better work‐life balance and fewer lawsuits. As surgeon and public health researcher Atul Gawande explains in The New Yorker:

“Skeptics have noted that Cesarean delivery is suspiciously convenient for obstetricians' schedules and, hour for hour, is paid more handsomely than vaginal birth. Obstetricians say that fear of malpractice suits pushes them to do C‐sections more frequently than even they consider necessary.”

While it is impossible to deny the lower mortality rates allowed by rapid improvement of medical practices and tools during the last century, more work remains to prioritize the health of expectant mothers. Hospitals, by nature, are large administrative organizations that may not put patients first. While an individual doctor in any given hospital may genuinely prioritize the mother and her newborn, current procedures for childbirth set up a snowball effect that tumbles downhill to C‐section too often.

For example, the National Partnership for Women and Families states that epidurals, commonly applied to decrease the pain of childbirth, often include a synthetic oxytocin hormone meant to offset the decrease in contraction rates that painkillers can cause. As a result, some women may react strongly and rapidly accelerate their labor, while others struggle to push at the critical point of delivery due to loss of sensation. Epidurals also risk significant drops in maternal blood pressure that can harm the child. Hospitals additionally worsen childbirth by leaving mothers in bed without mobility, which disregards the woman's comfort and removes gravity's assistance (two commonly cited advantages to home births).

Home birth advocates claim that childbirth at home in the presence of experienced midwives can solve this problem, especially for low‐risk pregnancies. They argue that women's bodies are evolutionarily designed to optimize childbirth, and that the comfort and freedom of the home precipitates success. But the solution to the C‐section problem doesn't seem so black‐and‐white. A study titled “Team Birth Project” led by Dr. Neel Shah at the Harvard School of Public Health seeks to target what Shah calls the “huge gray zone” of decision‐making during the hectic process of childbirth. By increasing communication between the childbirth team and the mother, the project seeks to prioritize patient preferences, verbalize decision‐making, and actively prevent C‐sections. In a particularly interesting case involving expectant mother Melisa McDougall, high‐risk OB‐GYN Dr. Terri Marino halted a seemingly inevitable C‐section by suggesting a final attempt at extraction after Melisa had already been wheeled into the operating room. Not only did the team successfully avoid a C‐section, but they also fulfilled Melisa's wish to have a natural birth. The project is already seeing marked decreases in C‐section rates and is being implemented at various hospitals across the country.

Modern medicine undoubtedly decreases maternal and newborn mortality rates with its ready access to emergency resources and well‐trained doctors. For some, the debate ends there. However, for more families and medical professionals alike, the C‐section is no longer a simple means to an end. Mothers might lose things, biological and psychological, when they experience C‐section, and today's initiatives to lower C‐section rates foreshadow a more thoughtful and deliberate future.