She sits before me in tears, a positive pregnancy test on the counter in front of us. It’s not that my patient doesn’t want a fourth child. But she is haunted by memories of her third cesarean section (C-section). Hours after her baby was delivered, she hemorrhaged and fell unconscious. Waking in the ICU, she learned she had been transfused several units of blood. Severe anemia and debilitating postoperative pain complicated her postpartum recovery.
Now, she is terrified of another C-section—the delivery of a child through an incision in the abdomen—and anxious about caring for four young children after major surgery. Or worse, leaving them motherless.
I want to reassure her, but as a member of Wisconsin’s state maternal mortality review team, I’m aware of cases like my patient’s that ended tragically. I’ve also seen them in the media and scientific literature. Even after controlling for risk factors that might have made C-section more likely, the risk of death after the procedure is 3.6 times higher than after vaginal birth.
Access to safe, timely surgical deliveries saves lives. But a review of my patient’s history shows that her first one was done for dubious reasons (an obstetrician deemed her pelvis too small for vaginal birth without even permitting her to attempt labor), and she was denied an attempt at a vaginal birth after cesarean (VBAC) for her second and third pregnancies by her physician. Rather than benefiting from the procedure, she has become its victim.
During my 17-year career, first as a labor and delivery nurse and then a certified nurse-midwife, I have grown frustrated watching patients like this one face the downstream consequences of an unnecessary surgery, and have become disheartened by the lack of will to hold health care systems accountable.
We need to name this problem for what it is: widespread, unchecked medical malpractice.
A study of 194 World Health Organization member states from 2005 through 2014 indicates that C-section rates beyond 19 percent do not improve maternal or infant outcomes. With the U.S. rate stuck at around 32 percent for the last 15 years, the difference amounts to about half a million unnecessary surgeries every year.
High C-section prevalence is often left out of the national conversation about rising maternal death rates, falling birth rates, and racial inequality in birth outcomes. Yet compared with vaginal births, people who deliver by the procedure are four to five times more likely to die. They have a harder time getting pregnant and have fewer children, whether by choice or necessity. Black and Hispanic pregnant people have higher rates than their white counterparts with similar risks, and they report more difficulty finding a provider willing to attend VBAC.
As a veteran of this field, I am struck, not by the intractability of high C-section rates but by how much low-hanging fruit exists. My community health center’s midwifery group, hospital-based and supported by wonderful obstetricians, has never had a cesarean rate exceeding 19 percent despite serving a population with numerous risk factors and socioeconomic challenges.
Too often, blame for the high C-section rate is diverted to pregnant people. They are deemed too old, too obese or too unhealthy to give birth vaginally. But data belie this argument. Rates vary 10-fold across U.S. hospitals, and there is extreme variation even when comparing similar-risk people. In reality, the biggest risk factor for the procedure is the hospital you walk into.
The impunity with which some doctors perform this surgery, despite having no real medical justification, is alarming. I have seen patients’ medical records stating one was done for “failure to progress” after a mere two-hour attempt at labor induction, and because a baby was expected to be too large (he weighed seven pounds). Another patient’s procedure was done when she presented with uncomplicated labor at eight centimeters dilation because her hospital didn’t allow VBACs.
As a nurse, I remember surgeries done because the doctor “had a flight to catch” or “didn’t want to be up all night.” My experiences must not be unique; the timing of unplanned C-section shows that the surgery is performed at times of day that are convenient for medical staff, even in the case of fetal intolerance of labor, a reason for the surgery that is supposed to protect the baby from imminent harm consequent to not getting enough oxygenated blood from the placenta or umbilical cord. Yet this diagnosis is inconsistently made based on continuous electronic fetal monitoring technology that has poor ability to predict newborn outcomes.
Compounding the problem, many providers and hospitals ban or discourage VBACs, on the basis of increased risk to the fetus if the prior cesarean scar breaks open during labor, so the vast majority of people with a prior C-section who have another baby will also have another cesarean. These policies downplay the serious risks that each additional surgery poses to the mother.
We need substantial changes to fix the badly misaligned incentives surrounding birth. Perversely, doctors who perform C-sections, a surgery that takes about 45 minutes, usually get paid more than those who patiently await vaginal birth, a process that can take hours or days. Hospitals, which also bill more for the surgeries, lack motivation to demand accountability from doctors on staff, which likely incentivizes the procedure.
To correct this, insurance companies and Medicaid should raise the reimbursement rate for vaginal birth to parity with C-section. That has already been shown to result in lower C-section rates in Minnesota, and it appropriately compensates providers who invest time and energy in care that promotes vaginal birth. Payers could also decrease rates by shunting patients away from hospitals and providers with unjustifiably high procedure numbers, or refusing to reimburse health care systems that consistently ignore the American College of Obstetricians and Gynecologists’ established guidelines for when the surgery is necessary.
A longer-term solution is to integrate more midwives into the U.S. health care system, a trend that has already been associated with falling C-section rates.
Despite the growing popularity of midwifery, some hospital boards and medical staffs refuse to let midwives deliver at their hospitals, and discriminatory state laws restrict their practice. Health care systems from Michigan to Massachusetts have shut down midwifery practices despite opposition from patients. To correct this, insurance companies and Medicaid should require the inclusion of midwives in the networks they cover and steer their patients toward settings where midwives are allowed to practice.
Aware of the trend toward unnecessary C-section, some pregnant people go to extraordinary lengths to protect themselves. They write birth plans, travel long distances to obtain a VBAC, and even pay out-of-pocket for doulas and home-birth midwives. Self-advocacy is important, but pregnant people shouldn’t have to rely on it to avoid unnecessary surgery. The onus of assuring safe, evidence-based care belongs to the health care system.
This system continues to fail thousands of people like my patient, exposing them to life-threatening harm. We owe it her to demand better.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.
The opinions reflected in this article are the author’s own, and not those of Sixteenth Street Community Health Centers or the Wisconsin Maternal Mortality Review Team.
