Childbirth is often an experience of both pain and hard-won pride. But for Patrisse Cullors, a performance artist and co-founder of Black Lives Matter, her first childbirth experience left her feeling “embarrassed.” She had wanted a natural birth, but after complications emerged, she says, the doctor did a cesarean section without consulting her or explaining why. “I went into having a major surgery without knowing the impact or the implications — both short-term and long-term impacts on my body,” she recalls. For a long time afterward, she felt alienated and unnerved about how little control she had had in the process. “I felt like it was unnecessarily negligent,” she says.
Her experience was also unnecessarily common.
A new health care study published as a Lancet series maps out the global prevalence of cesarean sections, particularly those without underlying medical causes. Globally, the C-section rate has risen — in parallel with other trends such as women giving birth in hospitals rather than at home with midwives. At the same time, the data reveals a troubling contradiction: In rich countries, surgical delivery is overused, while women in poor countries cannot get C-sections that they need when vaginal birth is unsafe and surgery is medically necessary. As of 2015, about 20 percent of live births are done by C-section, ranging from less than 5 percent in East Africa, to a staggering 44 percent in Latin America and the Caribbean. In the US and North America as a whole, the C-section rate hovers around 30 percent. But the WHO recommends about 10 percent to 15 percent as a safe overall level.
Meanwhile, the US stands out by another measure: Despite having a world-class medical system, it’s a dangerous place to bring a life into the world. About 700 American women die in childbirth every year — massively lagging other affluent countries and roughly in the range of Turkey. It also ranks far higher in the infant mortality rate than comparable countries. About 50,000 women are estimated to suffer severe, costly complications each year. Faced with the intersection of unparalleled wealth, excessive C-sections, and a disturbing maternal health record, researchers see a possible intersection between surgical intervention, the maternal health crisis, and the systemic inequalities in health care that shape people’s birth experiences in the US.
The safety of a C-section varies widely depending on a person’s socioeconomic and medical context. In countries with advanced health care systems, C-sections can be, in many cases, an appropriate choice to preserve maternal or newborn health. But they are often not medically necessary. US hospitals vary widely in C-section rates, due in large part to physicians’ preferences, which may or may not be based on actual health risk. Yet each surgical intervention introduces uncertainties to the childbirth process, including risk of maternal and postpartum infections, hysterectomy and newborns dying or being placed in intensive care.
Sometimes women opt for C-sections on their own — for example, due to a painful or traumatic past childbirth experience, or simply a perception that a C-section would be safer. But usually, during the birth, the decision is driven by the doctor. With more women getting C-sections around the world, researchers are questioning whether medical staff always make the wisest choice.
According to a long-term survey study by Childbirth Connection, many women feel that they are not in control of their own birthing process. Among women giving birth via C-section for the first time, nearly one in eight reported that their medical provider had “pressured” them, and about one in five felt the decision was not their own. Just 2 percent overall had voluntarily scheduled the procedure without an underlying medical reason. (A 2010 analysis by the National Institutes of Health found that nationally, only about 10 percent of C-sections are “truly elective,” rather than medically driven.) Most respondents also indicated they were generally “uninformed about potential harms of cesarean section.” And for the women who had previously had C-sections, many wanted to have a vaginal birth for their current pregnancy, but were not able to, often because the medical provider was “unwilling.”
“From the women’s perspective, they’re not asking for this,” says Eugene DeClercq, a maternal health scholar at Boston University School of Public Health. While facilities with higher C-section rates often justify the pattern by pointing to how many high-risk pregnancies they handle, he tells Truthout, a closer analysis of risk data shows that choice, not health risk, is the main influence when deciding on C-sections. Doctors might simply err on the side of what seems efficient (since a C-section can be scheduled), or financially beneficial, because surgery is a costlier procedure overall. Researchers also speculate that fear of litigation, in case something goes wrong with a vaginal birth, leads doctors to see C-sections as legally “protective.”
In many cases, women experience a “cascade” of interventions, with C-sections accompanying other interventions such as the use of epidurals or induced labor.
DeClercq adds that the rate of C-sections is “tied much more to the culture of the place, and how they vary on [the question] of, what do you do in the gray areas?”
The gray areas pose deep costs for the health care system as a whole. Spending on “unnecessary interventions in maternity care” is estimated at about $18 billion annually. One study estimates that adjusting the C-section rate to about 15 percent worldwide would save health care systems roughly $2.3 billion.
The emphasis on C-sections in both obstetric practice and training could be exacting professional costs as well, by diminishing health care providers’ capacity for handling vaginal births. According to Gerard Visser, co-author of the Lancet series and chair of the Committee for Safe Motherhood and Newborn Health at the maternal health organization FIGO, “there might be a vicious circle: more C-sections, less experience with (difficult) vaginal deliveries, more C-sections.”
Yet the highest price of excessive intervention falls on those giving birth, exposing them to avoidable risk and exacerbating underlying social inequities. The power dynamics driving decision-making in childbirth hinge on the color line. C-sections are more commonly used among Black women compared to other racial groups — a rate of about 36 percent, or 5 percent higher than the national rate. The trend folds into a constellation of disproportionate risks that burden Black mothers in childbirth, along with higher maternal and infant mortality, lack of or inadequate prenatal care, obesity or low birth weight. Post-childbirth surveys of women suggest that the C-section gap — particularly for low-risk pregnancies — parallels other disparities tied both to socioeconomic status and direct racial bias: Black and Latina women were more likely than white peers to be assigned a prenatal care provider (rather than make their own choice), and more likely to have a birth attendant they had never met before. Meanwhile, in the everyday culture of the delivery room, Black and Latina women reported higher rates of experiencing poor treatment from hospital staff. Amid an atmosphere of alienation and mistrust during pregnancy and labor, Black women also express greater preference, compared to other racial groups, for low-intervention childbirth, including both vaginal birth and home-based birth.
Maternal health advocates say the disproportionality reveals overarching bias across the health system: “Black women are supposed to be going somewhere to get care — and instead they’re ignored, and they’re neglected, and eventually, the impact is really grave,” says Cullors, who is also a senior fellow for Maternal Mortality at the political advocacy network MomsRising. As a community organizer, she adds, “I’ve heard so many stories where women are like, ‘I don’t think I needed to have this, but I wouldn’t know because I was in such a hyped state.’” Recent debates on the ethics of childbirth intervention, she tells Truthout, should point to the need for “people who are pregnant [to] know their rights and what they’re allowed to ask for and what they’re allowed to challenge. Especially when it comes to so many people being threatened by doctors to have a C-section.”
From a global perspective, aside from excessive C-section rates overall, a parallel trend has emerged of women in poorer countries not being able to access C-sections due to lack of health care resources. Holly Kennedy, a US-based researcher with the Yale School of Nursing who co-authored a Lancet article on C-section trends, points to a “paradox of ‘too much; not enough,’ in that we intervene too much in countries with high resources and not enough in countries without.”
To better align C-section levels with public health needs, medical providers can start simply by putting those giving birth at the center of the process. One potential way to do this is through a practice that defies the trend of over-medicalizing childbirth: midwifery. Although midwife childbirth is culturally associated with societies lacking modern health care facilities, another Lancet study on midwifery concluded that, in both wealthier and poorer countries, a systemic shift toward “Care led by midwives — educated, licensed, regulated, integrated in the health system and working in interdisciplinary teams” would lead to improved maternal health and healthier childbirths overall, along with lower costs. Comprehensive midwife care — whether in a home birth or in collaboration with hospital staff — has recently gained prominence in the US as an alternative framework offering greater privacy and less unneeded intervention. But even in mainstream medical institutions, DeClercq argues, the whole health care infrastructure would be safer if all women were given “a choice of birth setting that was supported,” including home birth when they wanted it, with access to a hospital when they needed it.
The differences in birth experiences today embody both the commonality of the experience, and the social fissures that divide it. Though the climbing rates of C-sections mark just one snapshot of the broader dynamics of global health, they also reflect a fundamental disconnect between the medical status quo and the needs and feelings of women during one of the most vulnerable moments of their lives. Now may be the time to renew our understanding of childbirth, centering the experience not so much on the doctor’s orders, but on the individual’s informed choice.