A cesarean birth is technically defined by medical scientists as "one that involves an incision through the uterus to deliver an infant weighing more than 5OOg -- about one pound" (Kolata, p.WH10). It is a major surgery; in fact, it is one of the bloodiest surgeries that doctors perform. The skin over the abdomen is cut and opened in layers until the uterus can be reached. The uterus is then cut open and the infant is removed head first.
Cesarean births were originally used as an emergency birthing alternative for complicated births and labors that endangered either the life of the child or the mother. The umibilical cord being wrapped around an infant's neck, a large infant in breech position or an absolute disproportion between the size of the infant's head and the mother's birth canal are several examples of an emergency situation requiring a cesarean.
The location and direction of the uterine incision distinguishes between the two main types of cesarean surgery. The "bikini cut" or cervical incision is a cut (horizontal or vertical) in the lower uterus. The classical cut, is a vertical incision into the main body of the uterus. This cut is less common because it increases the chances of a ruptured uterus during a VBAC (vaginal birth after cesarean). Women also opt for the bikini cut because the scar is less noticeable and easier to hide.
In 1970, the cesarean birth rate was 5.5% for the United States. By 1988, the rate had increased to 24.4% - an increase of almost 1% every year. The medical field has had a number of technological advances within the past twenty years. The cesarean rate, therefore, should have decreased as doctors have far more advanced techniques of monitoring the conditions of both the infant and the mother during labor and are able to predict and prevent complications at an earlier stage of labor. Instead, cesarean births have increased. Cesareans are still necessary in certain situations, but the one out of every five births is considered too much.
Convenience to the physician and patient compliance, has emerged as a key factor and controversial cause of the increase in the cesarean birth rate. It is easier for the doctor to schedule a two-hour operation and it is fearful for a woman to contemplate enduring a long and unpredictable labor. She is particularly fearful if she has not experienced parturition before. Finance is also a factor in the convenience issue. Cesareans cost twice as much natural childbirth and require a longer recovery period. This paper will discuss the cesarean controversy" in terms of the trends that have caused its sudden swift increase.
According to the National Center for Health Statistics, the rapid increase in cesareans is due to the convenient and routine scheduling of repeat cesareans, the increased rate of diagnosed fetal distress and the diagnosis of dystocia prolonged or abnormal labor. Repeat cesareans are the leading cause of the high-cesarean section rate because of the common belief "once a cesarean, always a cesarean." In 1987, 934,000 of the 3.7 million babies born in the US were born as cesareans. Vaginal Births After Cesareans (VBAC) were considered dangerous because most cesareans were perfomed using a classical cut. This was dangerous because it had the potential to cause scar tissue to separate. This separation could complicate birth and eventually lead to a rupture of the uterus. Women and doctors therefore thought a VBAC was extremely dangerous and almost impossible. The "bikini cut" alleviates most of the danger of a VBAC. Although there is evidence to suggest that VBACs are safe, only 2.6% of 3,452 women in a New York study chose to have a VBAC. The other 97.4% had cesareans.
The American College of Obstetricians and Gynecologists officially declared new guidelines on cesareans in 1987, "recommending that doctors try to decrease the cesarean rates by advising their patients not to have cesareans unless it is absolutely necessary." The major concern over repeat cesareans is over the health of the mother and infant. Cesareans carry the risks of major surgery like complications associated with infection, anesthesia and blood transfusion. Maternal mortality is also twice as high for women who undergo cesareans than those who experience natural childbirth.
Fetal monitoring is one of the most recent advances in medical technology. Fetal monitors record the infant's heartbeat during birth so that the physician can monitor both the child and the mother and diagnose any abnormalities in any or both of them. The monitors are either strapped around the woman's stomach or inserted directly into the fetus' scalp. Although the monitors are supposed to help the doctors, they often cause false alarm and lead to a number of unnecessary cesareans. According to Gena Corea, author of The Hidden Malpractice and The Mother Machine, "A lot of physicians say that the cesareans are necessary because of fetal distress, but a lot of the fetal distress is actually caused by the intervention in natural childbirth" (Ince, p.78). Doctors are also not always able to correctly interpret the fetal monitors: "When women who were at low risk were monitored electronically . . . doctors were three times more likely to diagnose abnormal fetal heart rates and fetal distress . . . women were twice as likely to have cesareans" (Kolata, p. 10).
Breech babies are also a cause for the high cesarean rates. Breech births occur when the infant's head is not turned towards the mother's birth canal before birth. The doctor must either perform a cesarean or turn the baby around. Most doctors prefer to perform a cesarean because the baby is more likely to be injured if the doctor tries to turn it around. A number of breech babies die soon after birth because of their long labor. Doctors, in these cases, tend to use cesareans as a prevention from malpractice suits (and dead babies).
Malpractice suits and insurance have definitely influenced the high rate of cesareans. Statistics show that almost all obstetricians have malpractice suits against them at least once every five years. In fact, in the past five years, malpractice insurance has risen 240% for obstetricians. In 1987, the average physician in a group paid $37,000 for malpractice insurance; in New York, the average was $95,000, and in Florida, $153,000 (Lutz, p. 66). Doctors, in attempts to avoid infant mortality and malpractice suits therefore opt for cesareans at the first signs of fetal distress. One doctor defends himself, saying that cesareans are done to bring a healthy baby into the world during a difficult birth: "If labor is not progressing or if there is any sign of fetal distress, we clearly move to do a cesarean" (Kolata, p 10). Studies, however, have proven that cesareans could in fact be more dangerous and are at times more painful than vaginal birth because of the potential of hemorrhaging or infection -- one in every 500 or one in every 10,000, depending on the hospital.
Convenience is a second unacknowledged factor in the increase in the rates of cesareans. Doctors do not have to spend endless hours in delivery rooms and families can schedule the birth (This, of course, doesn't apply to emergency or spontaneous cesareans). The convenience factor reflects the changes in society too. A woman was taught she should expect to suffer. she is nowadays not taught she must suffer, but she is also not taught much about the dangers of C-sections. Cesareans have twice the maternal mortality rate in comparison to vaginal births and have longer recovery periods. What happens then is the doctor decides in his own interests and the interests of the baby to perform a C-section, and ever after the woman's life is at higher risk from a childbirth. She is persuaded to go along as she is persuaded to believe the technology that suggested to her the baby could be or is in great danger.
Cesareans occur much more frequently in the cases of upper-class and middle-class Americans. The recovery is too long and the cesarean, like any other surgery, leaves the patient very fragile. The cesarean done on a low-income woman is more likely to be done in an emergency situation. The difference in pre-natal care is also a factor. A low-income mother will not be able to afford the special care required for both mother and infant after a cesarean. Studies have also found that middle-class and upper-class women who have private physicians are more likely to have cesareans because they develop closer relationships with their doctors. These physicians are quicker to diagnose fetal distress and opt for cesareans because they feel more responsible towards their patients and are more afraid of malpractice suits from patients in these income brackets. In addtion, one must not dismiss the reality that childbirth is still dangerous for mother and baby.
A recent study investigating the "physician factor" in a single community hospital in Detroit determined that "the substantial variation in the rate of cesarean section appears to be solely attributable to differences among clinicians" (Coyert, p. 707). In this study, the cesarean rate among doctors varied from 19.1% and 42.3% depending on the physician. This "physician factor" definitely has an impact on the rate of cesareans as some doctors feel cesareans are more necessary than other doctors. Again, the fear of malpractice suits would also be a major issue as some doctors use cesareans as a form of prevention: delayed labor has so much potential for complications for either the infant or mother.
Society's acceptance of the high rate of cesareans reflects changes in values. Research clearly indicates that cesareans are more common in affluent women. Research has also determined doctors' fear of malpractice suits as a major factor in their advising cesareans. The fear of the unknown and the pride of new technology have also contributed to these high rates because women and physicians are more likely to trust the fetal monitor and stop the labor than to suffer in dread, wondering if the infant will be healthy and normal. Recent surveys have indicated that cesarean rates are finally beginning to stabilize and VBAC rates are increasing -- though the evidence suggests that the old idea that any childbirth after the first cesarean is dangerous for the mother actually holds true. The vaginal birth is safer. But the statistics suggest people are only beginning to realize cesareans are serious surgeries that can be dangerous and costly, and are still likely to do what the physician wants during the crisis moments of childbirth.