Plante, L.A. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. Spring 2009;2(1):140-147.
Lauren A. Plante, MD, MPH, FACOG
Department of Obstetrics & Gynecology
Thomas Jefferson University
The cesarean rate in the US has been rising for decades, and in 2006 hit an all-time high of 31% (Hamilton, 2007.) This record is likely to stand for only a brief time, that is, until figures are released for 2007. Can it really be that one-third of women are unable to birth without high-level technological support? And is there an endpoint in sight? “In the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us.” (Gawande, 2006, 8) Against such an argument, who could hope to stand?
In a recent essay on the subject of childbirth, surgeon and author Atul Gawande muses on the Apgar score, obstetrical eponyms, and the rising cesarean rate. (Gawande, 2006) Although he lauds the success—often unheralded-- of obstetrics in saving mothers’ and infants’ lives, I hear within the paean a threnody for the vanishing art. Skilled obstetricians like those legends of the past, whose names lived on in the maneuvers they devised to usher babies into the world, are vanishing from current practice: goodbye, Lovset; hit the road, Rubin; Mauriceau, it’s been swell, but we’re through.
Gawande makes a case for the standardization of obstetrics. “You seek reliability. You begin to wonder whether forty-two thousand obstetricians…could really master all these techniques…obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.” (7) He suggests that techniques for effecting vaginal delivery—maneuvers to reduce a shoulder dystocia, deliver a breech baby, assist delivery with forceps—are so subject to variations in skill that they cannot be standardized for reliably good outcomes, while the cesarean operation is commonplace and consistent. It is, if you will, the least common denominator: every obstetrician knows how to perform one. While this is a fascinating perspective on the changing of obstetrical practice, for those of us who actually work on a busy obstetrical unit industrialized childbirth conjures up images of the factory floor.
The drive toward fewer delivery options appears at first glance to be supported by upper-middle-class women, who have the least number of social and economic obstacles to autonomy. In fact, cynical staff at hospitals delivering large numbers of well-insured upper-middle- class women often refer to their institutions as baby factories: these are the places in which cesarean rates are highest. It is, after all, a paradox: women with higher incomes, higher levels of education, and commercial insurance have higher rates of cesarean delivery. If cesarean is a response to any perceived risk, why would women at statistically lower risk of a poor outcome have higher cesarean delivery rates? New Jersey has the highest cesarean rate among states, (Denk 2006) but no lower levels of maternal or perinatal mortality. (MacDorman 2007, CDC 1999) What it does have, however, is the highest median household income. (Census Bureau 2007)
Does this paradox reflect a differential understanding of risk? I have seen, over years of practice in maternal-fetal medicine, an odd and somewhat unsettling pride among women who announce that they have a “high-risk pregnancy.” Although the inherent literal meaning of the term high-risk pregnancy is one that entails a greater risk of a poor outcome (for mother or baby,) the subtext seems to be that high risk equals high value. In some cases it is difficult to persuade a low-risk woman to continue her care with a general OBGYN practice instead. “But I’m high-risk,” she says. Does she really mean, “I’m high-status,” or “My baby is high-value,” specifically, more precious than someone else’s? Is it a statement of importance? Does it mean that she is special? Or is it a Disneyfication of a primal human endeavor, longing for the synthetic and dramatized experience in preference to the authentic? These questions are raised, but cannot possibly be answered, in this commentary.
Women who want to be high-risk (read: special) in their designation are nonetheless hugely risk-averse when it comes to the real thing. Obstetricians have tapped into that fear in daily practice. Vaginal birth after cesarean (VBAC), for example, is associated with a very low although measurable risk of uterine rupture. Presented with the figures and asked to sign a consent for VBAC which spells out that risk, most women now decline: the VBAC rate in 2005 was under 8%. (Martin, 2006) Whether this is driven by reluctance of doctors to offer or women to undergo VBAC is impossible to ascertain, but it is clear that fear is contagious. And the indications for the initial cesarean—without which the question of VBAC would never be raised—have broadened considerably: breeches, twins, large babies, small babies, slow labor, even no labor. We now see the phenomenon of perfectly healthy, low-risk pregnant women requesting cesarean delivery upfront, in an attempt to eliminate all potential labor-associated risk for the infant. Even in the absence of any medical or obstetric indication for abdominal delivery, many women now seem eager to go under the knife. Somehow a perspective is emerging that cesarean is the best bet for delivery.
National cesarean rates do correlate—inversely—with both neonatal mortality and maternal mortality rates at the extreme low end of the spectrum. For developing or low-income countries, where access to safe maternity care is an issue, a rise in national CS rates from 0% to 8-10% is accompanied by a drop in stillbirths, neonatal deaths, and maternal deaths. (Goldenberg 2007, McClure 2007.) But across the developed world, or across medium- and high-income countries, there is no additional benefit of further increase in cesarean rate (Althabe 2006.): Slovenia, with a 12% cesarean rate, has the same maternal mortality ratio as the US. Nordic maternal mortality ratios are only a fraction of the American, at a 50% lower cesarean rate. Neonatal mortality does not change in high-income countries across a range of CS rates from 10-40%. (Althabe) Infant mortality rates as low as 4 per 1000 are achieved at CS rates of 15% in a number of countries, contrasting favorably with the US infant mortality rate of 7 per 1000: the American system results in infant mortality nearly twice as high achieved at the cost of twice as many cesareans. It is hard to make the argument on a population basis that abdominal delivery is safer for mothers or babies, at least after a minimal necessary rate is achieved.
Nonetheless, seduced by the promise of pain-free, risk-free childbirth, women and their doctors are driving the cesarean rate ever higher. Rates approaching—or exceeding-- fifty percent are now seen in some hospitals (New Jersey Star-Ledger.) This is the normalization of deviance. This is the new normal.
It would be unfortunate enough if the push toward CS were limited to a few upper-middle-class women (“too posh to push.”) But, judging from the South American experience, everyone wants the lifestyle of the rich and famous. Cesarean rates as high as 80% among well-off women in the private sector in Brazil (Kilsztajn 2007) appear to have created prevalent expectations, either among physicians or among other groups of women, that cesarean is the preferred option. (Potter 2008; Behague 2002; Angeja 2006) In at least some cases, poor women have been known to put away their own funds to ensure they will be delivered abdominally rather than vaginally. This would suggest they are concerned about inequitable or unfair treatment unless they deliver by cesarean. In the US, we have heard arguments that women are entitled to autonomy in making their birth choices, and that therefore it is ethical to perform cesarean for no reason other than maternal request. Curiously, this vaunted autonomy stops at the door of the labor room. Women are implicitly allowed, or encouraged, to make only those choices which increase the power of the physician and which decrease their own.
Let us enumerate what a full spectrum of childbirth choices entails. Women can give birth at home unaided; at home with family or with trained assistance; in a birth center, either freestanding or hospital-based; in the hospital delivery room with trained assistance; or in the operating room where they are acted upon. But of all these choices, extending across the entire range of reliance upon the medical profession (from none to total), exercising the options at the end of the spectrum where the physician has the least sway will get women the least support. The American College of Obstetricians and Gynecologists calumniates not only women who want a home birth but anyone who advocates leaving that option open. (American College of Obstetricians and Gynecologists, 2008.) Once in the hospital, women who might like to exercise their right to self-determination by choosing vaginal birth after cesarean, or vaginal breech delivery, will have a hard time of it. (Leeman and Plante, 2006) Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?
Industrial obstetrics strips the locus of power definitively away from women. The history of childbirth in America reflects a persistent trend of increased control by physicians and increased medicalization. Childbirth moves, first, out of the home, and now out of the vagina. Stipulate that antibiotics and blood banks are good and necessary things, and that emergencies may, in fact, develop: still, the majority of births will be normal. Or they would be, without interference. The species that cannot birth its young becomes extinct. But fear has pushed nearly all American childbirth into the hospital, a campaign which continues even now that that battle looks to have been won. (American College of Obstetricians and Gynecologists, 2008) Still, despite the implied promise of safety if all the rules are followed—ID bracelets, intravenous lines, electronic fetal monitoring---labor may follow an unpredictable path. The definition of “normal” becomes ever narrower, and toleration of deviance ever lower. The final stage of this philosophy takes the process of birth away from the woman entirely and turns it into a surgical procedure performed by the doctor. Childbirth becomes a manufactured experience, shorn of any real risk or real power, one in which the woman is so far alienated from the capabilities of her body that she is only a package on an operating table for a professional to open.
We’ve seen industrial revolutions before. The classic example gave us cheap toys and manufactured goods. At first the consumer focuses on the price point and on the sheer reproducibility: every Thomas and Friends wooden railway toy is just like every other. When you reduce variation, you get “normal,” by anyone’s definition. The very notion of quality control is rooted in the factory. Economies of scale and industrial production give consumers cheaper product than the handcrafted item, so that just about anyone can afford to buy toys from China. (Unfortunately, cost is an issue for manufacturers too: lead paint is cheaper than the alternatives, so nearly 2 million of those Thomas and Friends wooden trains were recalled for safety concerns last year. Sometimes safety is trumped by other considerations when industry rules.) While industrialization reduces cost and reduces variation, it is not an unqualified good. Should we be so quick to cheer the industrialization of childbirth? (Gawande, 2006)
The industrialization of food production is, perhaps, a harbinger of the industrialization of childbirth. Food production was once local, varied and small-scale, but farms have been taken over by huge conglomerates, and monoculture of a small number of genetically uniform crops has replaced variety. The disappearance of cultivars—that is, the loss of deviants—means that random natural events could wipe out large swaths of the food supply. To draw an even more pointed parallel, meat in America is cheap and widely available because of industrialized animal production. These animals lead narrowly confined lives from conception to death. Reliance on a small number of breeds, confined animal feeding operations, and the production line essentially turn animals into factory products. Industrial animal production has exacted a price in ways that until recently were invisible to the average consumer: the pollution of air and groundwater, the increasing potential for foodborne illness, the escalation of antibiotic resistance which begins in industrial herds but moves into human populations, even the quality of those animals’ lives. Clearly, industrialization has a downside, although we may not notice the drawbacks until all competing models have vanished. While some would object to drawing an analogy between industrial food production and industrial childbirth, I submit that in both cases we see a conversion of a living creature to a commodity, with an emphasis on the end product and a marked disinterest in the natural process over time. Women can be processed through the childbirth machine and handed a baby at the other end, stripping them of their central role at the heart of things, and turning them instead into objects that someone else operates upon.
The paradox is this: women wish to be treated as individuals, and assert for themselves a wish to exert control, yet in the commodification and industrialization of childbirth they are so much more likely to be treated as units of production. I know of one large community hospital revamping their labor floor and planning for a 50% cesarean delivery rate: and just as we learned in the 1989 movie, Field of Dreams, if you build it, they will come. The staffing and scheduling patterns for a 50% cesarean rate, as well as administration plans for hospital length of stay, can’t be turned on a dime. Hospital administrations like predictability, in patient patterns, patient care pathways, and everything else. If we normalize this industrialized approach to childbirth, we are likely to be stuck in it for a very long time indeed—and we can’t look to the medical profession to correct it.
But maybe, just maybe, there’s a backlash coming. An entire generation of American women fed their infants artificial formula because they were told it was modern, convenient, and better for their babies. Decades of medical progress later, two-thirds of mothers at least attempt breastfeeding. (Wright 2001) The women’s movement has challenged the hegemony of the medical profession in the past. (Kaiser and Kaiser, 1974)
As a reaction to industrial agriculture and food marketing, the Slow Food and locavore movements have recently been born. If de-escalation of our food production practices is healthier or more humane, why is intensification of our child production practices better than sustainable childbirth? I’m waiting for the birth of the revolution, or at least, the revolution of birth. Will women who are interested in Slow Food or cage-free eggs find their way to a Slow Childbirth movement? Imagine: educated upper-middle-class women who buy songbird-certified organic coffee and worry about their carbon footprint, just saying no to the quick-fix cesarean culture. If they’re not part of the problem, maybe they can be part of the solution. But the impetus must come from women themselves. Do we really believe that industrial obstetrics is the best model for ourselves and our children? We must clearly understand that real autonomy does not mean cesarean on request, but instead a spectrum of birth options that honor women’s authentic choices. Real autonomy also means, to borrow a sentiment from Gandhi, that women should bring forth the change they wish to see in the world.
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