tag:theconversation.com,2011:/id/topics/cesarean-section-17520/articlescesarean section – The Conversation2021-06-24T15:21:38Ztag:theconversation.com,2011:article/1623102021-06-24T15:21:38Z2021-06-24T15:21:38ZRequests for caesarean birth brushed aside, despite guidelines to respect maternal choices<figure><img src="https://images.theconversation.com/files/407726/original/file-20210622-21-xdvaco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>When first-time mother Melanie approached her obstetrician-gynecologist in Ontario to request a caesarean birth plan, she found his response unsettling. </p>
<blockquote>
<p>“I was told I didn’t have a right to choose how I could bring my daughter into this world, that no OB-GYN would honour my request. I would have to get over it and give birth vaginally. He also told me he did not agree with doctors that do honour them.” </p>
</blockquote>
<p>Feeling anxious and stressed, Melanie turned to a <a href="https://www.facebook.com/groups/403330643071622/permalink/5376118625792774/?comment_id=5388968111174492&notif_id=1620111335542948&notif_t=group_comment&ref=notif">social media group</a> for help. </p>
<p>Meanwhile, 50 kilometres away in the same province, Jessica made the same request to her doctor. She explains that the idea of someone else deciding what would happen to her body was upsetting.</p>
<p>“Thankfully, I totally lucked out and got an extremely supportive OB-GYN,” said Jessica. “I calmly explained my reasons for wanting a caesarean, and she heard me and agreed right away.”</p>
<h2>Variability in maternity care</h2>
<p>In 2018, the <a href="https://doi.org/10.1016/j.jogc.2017.12.009">Society of Obstetricians and Gynaecologists of Canada (SOGC) published guidance</a> on maternal requests for caesarean birth. It advises doctors to explore the reasons for the request and discuss potential risks and benefits. Doctors who disagree with a caesarean birth request have a responsibility to refer the woman for a second opinion or transfer her care. Yet in reality, many women are simply told no. </p>
<p>This prompted a graduate student in my health sciences team, together with a faculty of nursing graduate student, to explore why maternity care experiences can be so different. <a href="https://doi.org/10.1016/j.jogc.2021.02.103">The initial findings</a> highlight the need for clear, consistent procedures for doctors to follow when presented with caesarean birth requests.</p>
<p>A review of research studies and patient information showed that <a href="https://www.medicinenet.com/patient_autonomy/definition.htm">patient autonomy</a> is supported in principle. However, in clinical practice, requesting a caesarean birth in Canada is similar to the <a href="https://www.birthrights.org.uk/2018/08/21/maternal-request-caesarean-research-highlights-postcode-lottery/">postcode lottery found in the United Kingdom</a>, where hospitals differ in how they interpret and implement <a href="https://www.nice.org.uk/guidance/ng192/chapter/Recommendations">caesarean birth guidance</a>. </p>
<p>Information on patient websites such as <a href="https://www.healthlinkbc.ca/health-topics/tn8162">HealthLink BC</a> and <a href="https://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=tn8162">MyHealth Alberta</a>, stating “experts feel that C-section should only be done for medical reasons,” contradicts <a href="https://doi.org/10.1016/j.jogc.2017.12.009">the SOGC</a>, and also contradicts the evidence. </p>
<h2>Research on caesarean birth safety</h2>
<p>A <a href="https://doi.org/10.1503/cmaj.202262">recent study</a> from researchers at the University of Ottawa suggests planned caesarean births are safe and may have fewer short-term complications compared to planned vaginal births, which include forceps deliveries and emergency surgery. The team reviewed more than 400,000 low-risk pregnancies in Ontario (2012–2018) where “maternal request” was included in hospital data; a total 0.4 per cent of all births and 3.9 per cent of all caesareans. </p>
<p>They also learned about the women who had requested a caesarean birth — or at least, the women whose requests were agreed to. These women were more likely to be white, older (35+), first-time mothers and more likely to have had anxiety, to gain excess weight during pregnancy, to have more education and to have conceived by IVF. </p>
<h2>Doctors often choose caesarean birth</h2>
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<img alt="Caesarean birth choice" src="https://images.theconversation.com/files/405005/original/file-20210608-28272-12vhv3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/405005/original/file-20210608-28272-12vhv3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1542&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405005/original/file-20210608-28272-12vhv3h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1542&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405005/original/file-20210608-28272-12vhv3h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1542&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405005/original/file-20210608-28272-12vhv3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1938&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405005/original/file-20210608-28272-12vhv3h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1938&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405005/original/file-20210608-28272-12vhv3h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1938&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Lydia’s caesarean birth: ‘an amazing experience.’</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<p>Many doctors choose a caesarean birth for their own children too. A <a href="https://doi.org/10.1007/s00192-005-1324-3">survey of 162 Canadian health-care professionals</a> in 2005 found they were more likely to choose a caesarean for themselves or their partners than they were to offer it to their patients, and this was true for both first-time (at least six per cent) and subsequent births. Yet health professionals can still be refused.</p>
<p>Lydia, a nurse in British Columbia, said: “My request was brushed aside. I broke down in tears saying I didn’t want prolapse, tears or nerve damage, but my doctor said a caesarean wouldn’t be a good choice for me or my baby.” </p>
<p>Lydia “didn’t want to be a pushy patient,” but says that during the birth, “all of my feared concerns, in addition to my son having <a href="https://www.aboutkidshealth.ca/Article?contentid=409&language=English">shoulder dystocia, a compressed cord</a> and being <a href="https://www.aboutkidshealth.ca/Article?contentid=466&language=English">flat at birth</a>” (difficulty breathing, with loss of muscle tone) became a reality. With her second baby, Lydia’s caesarean request was agreed to before she even conceived, and she had what she calls “an amazing experience.” </p>
<p>So why couldn’t this happen the first time too?</p>
<h2>Barriers to choice</h2>
<p>In line with the <a href="https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf?sequence=1">World Health Organization’s position</a> — which cites a lack of evidence of benefits for caesareans that aren’t medically necessary, as well as the risks associated with surgery — many doctors disagree with caesarean birth choice. They want to <a href="https://doi.org/10.1016/S1701-2163(16)34029-4">reduce medical interventions</a>, and especially caesarean surgeries.</p>
<p>Even the <a href="https://media.uottawa.ca/news/planned-caesarean-births-safe-low-risk-pregnancies">media statement accompanying the new University of Ottawa research</a> emphasized “reassurance to those concerned about… rising caesarean delivery rates,” with <a href="https://www.physiciansweekly.com/rate-of-planned-c-section-on-maternal-request-stable-in-canada/">Physician’s Weekly reporting</a>: “Rate of planned C-section on maternal request stable in Canada.” </p>
<p>But at what cost?</p>
<p>Dr. Fiona Mattatall, an obstetrician in Calgary, told us that “denying a patient’s choice in mode of delivery for their pregnancy is an antiquated paternalistic approach to care.” And the inconsistencies described by some Canadian women raise serious inequity concerns. </p>
<h2>Knowledge, persistence and luck</h2>
<p>Julie describes how her family doctor in Ontario “laughed at my concerns, and said she doubted I’d find someone, but I was too determined to let her throw me off.” </p>
<p>Similarly, Heather in British Columbia says she questioned her first doctor’s advice after checking the medical research database <a href="https://pubmed.ncbi.nlm.nih.gov/">PubMed</a>, and asked for a new doctor, who agreed to her caesarean request. Mary’s doctor in Québec agreed immediately, but Mary was so worried beforehand, “I was even considering abortion should my request for a C-section be denied.” </p>
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<a href="https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Caesarean birth research" src="https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=362&fit=crop&dpr=1 600w, https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=362&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=362&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=454&fit=crop&dpr=1 754w, https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=454&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/407774/original/file-20210622-27-1l9xanw.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=454&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Research poster presented at 2021 Science Writers & Communicators of Canada Conference.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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<p>Women also experience delays. When staff at Lisa’s local hospital in British Columbia told her “they don’t refer patients for elective caesarean,” she had months of “being questioned about it, lectured or brushed off” before being sent to a mental health professional who said, “I don’t even know why you’re here.” </p>
<p>Lisa was 33 weeks pregnant before finally being referred to a doctor who agreed to her request, and was only then able to relax in her pregnancy. She says: </p>
<blockquote>
<p>“The only thing that helped was my own persistence and not letting myself be talked out of a choice I was sure I had the right to make.”</p>
</blockquote>
<h2>Inequities must not continue</h2>
<p>Eventually, Melanie in Ontario was also able to find a doctor who agreed to her request, albeit in a different city, and a 40-minute drive each way for all her appointments. “I will definitely be opting for another elective caesarean, and will let no one tell me how to bring my baby into this world, as it’s no one else’s body, and no one else’s experience,” she said.</p>
<p>Importantly, the <a href="https://doi.org/10.1016/j.jogc.2017.12.009">SOGC’s caesarean guidance</a> followed a British <a href="https://www.supremecourt.uk/cases/uksc-2013-0136.html">landmark Supreme Court judgment</a> in 2015 that ruled while a woman “cannot force her doctor to offer treatment which he or she considers futile or inappropriate,” the “medical profession must respect her choice.” </p>
<p>Our research concludes that Canada’s maternity care system needs to meet this challenge in ways that afford all women the right to informed choice, without health equity barriers. As Jessica says:</p>
<blockquote>
<p>“Quality medical care that is respectful and affirming, that allows you choice and control over your own body, should never be a matter of luck.”</p>
</blockquote><img src="https://counter.theconversation.com/content/162310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pauline McDonagh Hull is affiliated with the voluntary organisation Caesarean Birth (caesareanbirth.org).</span></em></p><p class="fine-print"><em><span>Bonnie Lashewicz does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many pregnant women who request planned caesarean deliveries are simply told no, despite guidelines advising doctors who disagree to offer referral or transfer care.Pauline McDonagh Hull, Graduate student, Department of Community Health Sciences, Cumming School of Medicine, University of CalgaryBonnie Lashewicz, Associate Professor, Department of Community Health Sciences, Cumming School of Medicine, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1326502020-03-11T12:22:58Z2020-03-11T12:22:58ZNewborn babies weigh less today – possibly due to the increased popularity of cesarean sections and induced labor<figure><img src="https://images.theconversation.com/files/319455/original/file-20200309-118913-1b33ag4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cesarean sections have become more common in the U.S. </span> <span class="attribution"><span class="source">Tomsickova Tatyana/Shutterstock.com</span></span></figcaption></figure><p><em>The Research Brief is a short take on interesting academic work.</em></p>
<h2>The big idea</h2>
<p>The decline in U.S. birth weight has been somewhat of a puzzle for public health researchers. Between 1990 and 2017, average <a href="https://www.cdc.gov/nchs/nvss/births.htm">birth weight declined</a> from 7.36 pounds to 7.19 pounds.</p>
<p>There was some speculation about what might explain the decline in birth weight. Some thought it might be the <a href="https://doi.org/10.1097/AOG.0b013e3181cbd5f5">fact that the average U.S. mother is now older</a>. Other research suggested that the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3977951/">decline in average length of pregnancies</a> might play a role. </p>
<p>Sociologist and demographer <a href="https://www.colorado.edu/sociology/ryan-masters">Ryan K. Masters</a> <a href="https://www.andreatilstra.com">and I</a> wanted to contribute to the conversation by examining how cesarean deliveries and induction of labor might be involved. </p>
<p>We used the Centers for Disease Control and Prevention’s <a href="https://www.cdc.gov/nchs/nvss/births.htm">National Vital Statistics Systems data</a> to examine single U.S. births between 1990 and 2013. We discovered, <a href="https://doi.org/10.1007/s13524-019-00843-w">in a study published Jan. 29</a>, that the rate of cesarean deliveries increased from 25% to 31% and that labor induction increased from 12% to 29%. </p>
<p>The data show that physicians are intervening more in births than they did in years past, most frequently between weeks 37 and 39 of pregnancy. Weeks 37 to 38 are <a href="https://www.acog.org/About-ACOG/ACOG-Departments/Deliveries-Before-39-Weeks?IsMobileSet=false">typically considered “early full term,”</a> while weeks 39 and 40 are considered full term. </p>
<p>Research shows that there are <a href="https://doi.org/10.1542/peds.2009-0913">substantive differences in the weight of infants</a> born between 37 and 41 weeks. So interventions are increasingly occurring at a key time in gestation, when a substantial amount of fetal growth occurs. </p>
<p>We then simulated what might have happened to average U.S. birth weights if rates of cesarean deliveries and labor induction had not increased. We found that if rates of obstetric interventions had not increased, then U.S. birth weight would have increased. </p>
<p><iframe id="4NyjG" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/4NyjG/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Why it matters</h2>
<p>These technologies are certainly beneficial in many circumstances, <a href="https://doi.org/10.1016/j.ajog.2011.01.062">including high-risk pregnancies</a>, which are often delivered early. But the vast majority of the interventions are not occurring among preterm births. </p>
<p>Obstetric interventions are more expensive for patients and hospitals than births that proceed without intervention.</p>
<p>Inductions and c-sections are also associated with <a href="https://doi.org/10.1016/S0140-6736(18)31930-5">potential maternal and infant health risks</a>. For example, cesarean deliveries are associated with increased risk of uterine rupture for mothers and altered immune development for infants. </p>
<p>Despite recommendations from the American College of Obstetricians and Gynecologists <a href="https://journals.lww.com/greenjournal/Fulltext/2019/02000/ACOG_Committee_Opinion_No__765__Avoidance_of.43.aspx">to not intervene before week 39</a>, the most dramatic increases in interventions are occurring just before that time. </p>
<h2>What still isn’t known</h2>
<p>Medical professionals and public health scholars alike are interested in decreasing the rates of these interventions, especially those that are not medically necessary.</p>
<p>But researchers don’t know much about why rates of cesarean deliveries and labor induction increased. </p>
<p>Some research suggests that the rise is happening because <a href="https://nyupress.org/9780814764114/cut-it-out/">health care organizations are under pressure</a> to make money and to avoid potential legal consequences. This can result in encouraging physicians to turn to profit-generators like cesarean deliveries.</p>
<p>This question is the topic of my dissertation research. I hope to shed more light on changes in how society talks about the risk of obstetric interventions. Studies show that <a href="https://doi.org/10.1053/j.semperi.2012.04.025">physicians</a> are more afraid of situations that they perceive as risky and as such might act in ways to protect themselves. The medical field is encouraging physicians to engage in more defensive medicine, as indicated by <a href="http://doi.org/10.1097/MLR.0b013e31818475de">higher medical malpractice premiums</a>. </p>
<p>Our team also doesn’t know much about how the patterns we observed vary by demographic characteristics. We’re now investigating this further, by examining patterns across mothers’ race and ethnicity and the state where the birth occurred. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/132650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Tilstra receives funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). </span></em></p>The decline in US birth weight is somewhat of a puzzle for public health researchers.Andrea Tilstra, Ph.D. Candidate in Sociology, University of Colorado BoulderLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/684272016-12-20T19:06:54Z2016-12-20T19:06:54ZWhy we should be concerned with the rise and rise of early planned births<figure><img src="https://images.theconversation.com/files/147511/original/image-20161125-15356-1eujyzj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women and their care givers need to be aware of the long-term risks of an early planned delivery.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/44829895?src=n_FhX35wokHTFgyveEIkqg-1-31&id=44829895&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Over the past two decades there has been a major change in birth practices that has resulted in a silent but <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0056238">steady shift</a> towards women giving birth before 40 weeks.</p>
<p><a href="http://www.ajog.org/article/S0002-9378(12)00736-3/abstract">Planned early births</a>, either by inducing labour or by planned caesarean, have fuelled this shift.</p>
<p>Until recently, researchers had thought there were no long-term risks to babies born a little early. However, a growing body of evidence points to long-term developmental delay by the time these children reach school.</p>
<p>It’s time to rethink our attitude to early planned births and to advise women and their care givers that giving birth early carries long-term as well as short-term risks.</p>
<h2>A shifting pattern</h2>
<p>In New South Wales, in the mid 90s, a woman was most likely to deliver at 40 weeks. Now, between 38 and 39 weeks is the most common. During that time there has also been a year-on-year increase in the number of births between 34 to 39 weeks. <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0056238">Currently</a> nearly one in five of all single babies born is at 38 weeks, one in 15 at 37 weeks and one in 40 at 36 weeks.</p>
<p>The rise in early planned birth is a result of both planned interventions because of concerns over the mother’s and/or baby’s welfare or, less commonly, for convenience.</p>
<p>Factors that have contributed to planned early births on health grounds have included increased ultrasound surveillance in pregnancy, which has increased the detection of babies who are small for their gestational age. The lack of sufficiently accurate tests to distinguish a healthy small baby from a small one that is compromised means these babies can be delivered early in the belief this is a safer option. </p>
<p>Another factor is that diabetes in pregnancy is more common, which can lead to problems at birth, such as the baby being very large or suffering from respiratory distress, or for the mother, such as high blood pressure and <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-pre-eclampsia">preeclampsia</a>. So 37 weeks, or term, has become an accepted time for planned birth for these babies.</p>
<p>Planning to give birth early occurs in the belief that early delivery carries no significant risk to the baby or is safer for the mother and/or baby compared with continuing the pregnancy. <a href="http://journals.lww.com/greenjournal/Fulltext/2009/12000/Women_s_Perceptions_Regarding_the_Safety_of_Births.15.aspx">Widely held views</a> that it is safe for the baby to be born a few weeks early may lead to a decision for elective early birth for no medical reasons.</p>
<p>While much attention and research has focused on the short and long-term consequences of <em>very early</em> birth, there has been far less attention to the risks to babies born <em>just a little early</em>.</p>
<p>For many years, we have assumed babies born after 37 weeks gestation have no risk of problems. After all, the official definition of “term” has been classified as the period between 37 and 42 weeks of pregnancy.</p>
<p>However, there is no scientific basis for 37 weeks being recognised as the time when a baby is mature.</p>
<h2>Short and long-term consequences</h2>
<p>An early planned birth has consequences for babies, both in the short-term and, as researchers are discovering, in the long term.</p>
<p><a href="http://www.ajog.org/article/S0002-9378(12)00736-3/abstract">We have described</a> that every week a baby is born prior to 39 weeks increases the likelihood of the need for breathing support and admission to newborn intensive care. This is important as these babies occupy scarce resources that could be avoided if birth could be safely delayed by a week.</p>
<p>However, until recently, researchers thought there were no longer term effects of birth at 37 weeks or even from 34 weeks. That belief is changing.</p>
<p>In <a href="https://pediatrics.aappublications.org/content/pediatrics/early/2016/11/03/peds.2016-2002.full.pdf">our study</a>, we used routinely collected birth data for more than 150,000 children to determine how their development was associated with their gestational age and circumstances of birth.</p>
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<a href="https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150834/original/image-20161219-24271-ef7mmw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">An early planned birth was associated with developmental delay by the time the children reached kindergarten.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/366916757?src=EjWG_pHMGqPKzGPFgpJcmg-1-55&id=366916757&size=medium_jpg">from www.shutterstock.com</a></span>
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</figure>
<p>We then looked at how these children performed when they started school using data from the <a href="https://www.aedc.gov.au">Australian Early Development Census</a>. This census, which kindergarten teachers take every three years, assesses children’s physical health and well-being, social competence, emotional maturity, language and cognitive skills, communication skills and general knowledge. These are associated with longer term health, education and social outcomes.</p>
<p>We found for every week a child was born earlier than 39 weeks there was a small but significant increase in the likelihood of them being developmentally vulnerable; they scored poorly on two or more of these categories.</p>
<p>The risk was higher for babies born after a planned birth compared with spontaneous birth. Our results are very similar to <a href="http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13324/abstract">other data</a> from South Australia.</p>
<p>These results tell us the final weeks of pregnancy are crucial for optimal brain development. Indeed the brain weighs two-thirds at 34 weeks of what it will weigh at 40 weeks. It is in the final weeks of development that many finer brain networks linked to developmental outcome are formed.</p>
<h2>What we’d like to see</h2>
<p>A healthy start to life is the greatest gift we can give to a child. Changes in birth practices need urgent reappraisal in light of population changes to early birth that have longer term developmental implications; the threshold at which we resort to planned birth needs careful rethinking.</p>
<p>Women and their care providers should aim for birth as close to 39-40 weeks as possible when considering early birth.</p>
<p>Elective planned birth in the absence of any risk factors should not occur before 39 weeks.</p>
<p>If there are special considerations in pregnancy such as a mother’s high blood pressure or diabetes, or the baby is found to be small, the aim should be to prolong the pregnancy for as long as it is deemed safe to do so.</p>
<p>This approach will not only reduce the likelihood of short-term problems but also improve children’s long-term development.</p><img src="https://counter.theconversation.com/content/68427/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Morris is an obstetrician who leads a large population health research group interested in optimising maternity services and outcomes. His work is supported by NHMRC and NSW Ministry of Health.</span></em></p>Planning to give birth just a little early carries long-term risks for babies, as researchers are discovering. This is why we should be concerned.Jonathan Morris, Professor of Obstetrics and Gynaecology and Director, Kolling Institute of Medical Research Obstetrics, Gynaecology and Neonatology, Northern Clinical School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/656602016-09-26T06:47:44Z2016-09-26T06:47:44ZErdoğan banned caesarean sections, so why does Turkey have the highest rates in the OECD?<p>Turkey has the <a href="http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2015/caesarean-sections_health_glance-2015-37-en">highest caesarean section rate</a> of any OECD country – one in every two women gives birth by caesarean. This rate has risen from 26% in 1998, far surpassing the <a href="http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf">optimal rate</a> of 15% recommended by the World Health Organisation. </p>
<p>There is no doubt that the caesarean section can be a lifesaving operation for both infants and mothers. But the global increase in caesarean rates in recent decades has sparked debate about the benefits and <a href="http://www.webmd.com/baby/tc/caesarean-section-risks-and-complications">risks</a>, especially for surgeries performed without medical reason. </p>
<p>A <a href="http://apps.who.int/iris/bitstream/10665/70494/1/WHO_RHR_HRP_10.20_eng.pdf">global survey</a> from the WHO in 2010 found that instances of maternal death, admission to intensive care units, blood transfusions and hysterectomies were three times more common for women who had on-demand caesarean sections than for those who had a vaginal delivery. </p>
<h2>Erdoğan’s nation-building campaign</h2>
<p>In 2012, Recep Tayyip Erdoğan, then prime minister of Turkey, put high caesarean section rates on the public agenda, condemning the procedure as a “step taken to prevent this country’s population from growing further”, adding that he also saw abortion as murder. </p>
<p>Following this <a href="http://www.hurriyetdailynews.com/abortion-sparks-raging-debate-in-turkey.aspx?pageID=238&nID=21740&NewsCatID=339">speech</a>, caesarean births continued to be widely criticised in the public arena, often along with abortion, as part of “<a href="http://www.independent.co.uk/life-style/health-and-families/health-news/abortions-are-like-air-strikes-on-civilians-turkish-pm-recep-tayyip-erdogans-rant-sparks-womens-rage-7800939.html">a sneaky plan</a>” to reduce Turkey’s standing on the world stage. </p>
<p>Thanks to resistance from women and human rights movements, a debated ban on abortion has not been enacted. </p>
<p>Yet, in July 2012, a “<a href="http://www.loc.gov/law/foreign-news/article/turkey-law-restricting-caesarean-births/">caesarean law</a>” was adopted, making Turkey the first country to punish elective caesarean sections. This law allows doctors with high caesarean rates to be investigated or fined.</p>
<p>The attempt to reduce caesarean section rates is related to the pro-birth agenda of now-President Erdoğan’s Justice and Development Party, which has been in power since 2002. </p>
<p>The government has become obsessed with population. With a <a href="http://www.hurriyetdailynews.com/turkey-faces-aging-population-as-fertility-rate-declines--.aspx?PageID=238&NID=99203&NewsCatID=341">fertility rate around 2.1%</a>, Turkey can no longer be classified as a young country. Erdoğan has <a href="http://www.al-monitor.com/pulse/originals/2013/08/erdogan-asks-turks-to-have-three-children.html#ixzz4KkDXPF3F">called</a> “on those sisters who are devoted to our cause. Come, please donate to this nation at least three children.” </p>
<p>The financial burden of caesarean surgeries on the public budget is another factor in the campaign. Due to longer hospital stays, additional medication and the need for more health-care services, caesarean births are more <a href="http://hjog.org/issues/current-issue/71-articles-in-press/295-comparison-of-healthcare-costs-associated-with-vaginal-births-versus-caesarean-sections.html">costly</a> than vaginal births.</p>
<h2>Ineffective laws</h2>
<p>Despite the controversial law, high caesarean section rates in Turkey have not been reduced by a considerable level. Indeed, the decrease in ceasareans in public hospitals due to punitive measures have been off-set by the increase in private hospitals. The average rate <a href="http://www.hthayat.com/yasam/guncel/haber/1035698-turkiyede-sezaryen-oranlari-2016">in private hospitals</a> has reached more than 65%.</p>
<p>These figures can only be brought down by understanding the many factors that lead to elevated caesarean rates. The issue needs to be perceived within an overall critique of medicalised childbirth and commercialised health-care systems. </p>
<p>Commercialisation of health systems has resulted in increased caesarean surgeries in <a href="https://www.researchgate.net/publication/284185383_Rethinking_health_care_commercialization_Evidence_from_Malaysia">Malaysia</a>, <a href="http://heapol.oxfordjournals.org/content/17/1/90.short">India</a>, <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.557.8917&rep=rep1&type=pdf">Greece</a> and <a href="https://www.researchgate.net/publication/45720373_Health_reform_and_caesarean_sections_in_the_private_sector_The_experience_of_Peru">Peru</a>. </p>
<p>In 2003, <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1410433#t=article">reform of Turkey’s health-care system</a> led to the commercialisation and commodification of services in line with the demands of global markets. <a href="http://marmassistance.com/private-hospital-sector-in-turkey-continues-to-flourish/">Since then, there has been a significant increase</a> in the number of private hospitals. It’s no coincidence that the number of caesarean sections has almost doubled in this period.</p>
<p>Another factor in the structural rise of caesarean rates is malpractice laws. obstetrician/gynecologists (OB/GYN) are the specialists <a href="http://www.ncbi.nlm.nih.gov/pubmed/15489176">who are sued the most</a> in Turkey; <a href="http://www.milliyet.com.tr/sezaryen-oranlarinda-dunyada-ilk-ucteyiz-pembenar-detay-aile-1547062/">45% of Turkish doctors</a> prefer caesarean sections because of malpractice lawsuits concerns, 41% because it is less risky and 27% because it is shorter, easier and safer. Easy scheduling may play a role in doctors’ potential preference for caesarean sections, as they struggle under the stress of long working hours. </p>
<p><a href="http://www.midwife.org/acnm/files/cclibraryfiles/filename/000000002128/midwifery%20evidence-based%20practice%20issue%20brief%20finalmay%202012.pdf">Care from a midwife</a> results in fewer caesarean births than physician care. For instance, the Netherlands, where obstetric care is provided by midwives, had one of the lowest caesarean rates: <a href="http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015/caesarean-section-rates-2013-or-nearest-year_health_glance-2015-graph90-en#.V-SSNZOLSRs">15.6%</a> in 2013. In Turkey, where around <a href="http://www.hips.hacettepe.edu.tr/tnsa2013/rapor/TNSA_2013_ana_rapor.pdf">19%</a> of births were performed by midwives in 2013, the caesarean rate was 50.4%. Active involvement of midwives would also help reduce the workload of OB/GYNs.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/138947/original/image-20160923-2591-pdf2lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/138947/original/image-20160923-2591-pdf2lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/138947/original/image-20160923-2591-pdf2lt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/138947/original/image-20160923-2591-pdf2lt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/138947/original/image-20160923-2591-pdf2lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=462&fit=crop&dpr=1 754w, https://images.theconversation.com/files/138947/original/image-20160923-2591-pdf2lt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=462&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/138947/original/image-20160923-2591-pdf2lt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=462&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Turkish doula assists a woman to cope with labour contractions.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>While some women choose a caesarean section on demand due to easy planning, others may prefer it due to the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4320721/">fear of pain</a>. Especially for first-time mothers, the fear about the unknown birth experience is potentially heightened by media images of childbirth and traumatic birth stories. </p>
<h2>Putting women first</h2>
<p>The way to overcome this fear factor is not to humiliate and disempower women as <a href="http://www.hurriyetdailynews.com/mothers-afraid-of-pain-cannot-raise-brave-children-turkish-health-minister-says.aspx?pageID=238&nID=51818&NewsCatID=341">the Turkish government has done</a>, but rather to provide better mental and physical birth preparation, which empowers women through informed consent. </p>
<p>Qualified midwives and <a href="http://www.pqcnc.org/documents/sivbIIIdoc/PQCNCSIVBNewsletter20121126.pdf">doulas</a> (professional birth companions) can help support women before, during and after birth. A <a href="http://apps.who.int/rhl/pregnancy_childbirth/childbirth/routine_care/cd0003766_amorimm_com/en/">WHO review</a> of 21 trials involving 15,061 women reveals that continuous support during labour increases the likelihood of vaginal birth and lowers the incidence of caesarean sections.</p>
<p>The debate over high caesarean rates has been dominated by the patriarchal Turkish state in recent years. Yet, as a complex issue involving women and health professionals, it cannot be tackled by top-down restraining measures.</p>
<p>A genuine and more comprehensive approach needs to be developed; one that respects the rights and autonomy of women to make decisions about their own bodies. Unless necessary conditions to encourage natural vaginal birth are provided, any punitive and restrictive measures are certain to fail. </p>
<hr>
<p><em>This is the first instalment of our ongoing series about birth trends worldwide.</em></p><img src="https://counter.theconversation.com/content/65660/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Selen Göbelez Dumas is a practising doula.</span></em></p>Turkey’s high cesarean rates cannot be tackled by top-down restrictive laws.Selen Göbelez Dumas, PhD Candidate, Department of Sociology, Mimar Sinan Fine Arts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/462992015-09-09T05:02:37Z2015-09-09T05:02:37ZAre we overscheduling our kids from the moment they’re born? The real ‘labor’ economics<figure><img src="https://images.theconversation.com/files/93342/original/image-20150828-19918-s99d7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hurry up! We're on the clock. </span> <span class="attribution"><span class="source">Baby birth via www.shutterstock.com</span></span></figcaption></figure><p>Are we overscheduling our children even from the moment of their birth? </p>
<p>We live in an on-demand world. Movies are shown on request, food is delivered on call and drivers arrive when beckoned. As an economist, not a medical doctor, I was surprised to find new data that suggest more babies are showing up when scheduled rather than on their own time frame.</p>
<p>Numerous writers have suggested that <a href="http://parenting.blogs.nytimes.com/2013/10/11/10-signs-your-parent-is-overscheduled/">parents</a>, <a href="http://www.washingtonpost.com/wp-dyn/content/discussion/2008/07/09/DI2008070901910.html">teenagers</a> and <a href="http://www.nytimes.com/2013/10/13/fashion/over-scheduled-children-how-big-a-problem.html">children</a> are all <a href="http://www.cnn.com/2013/03/08/living/overscheduled-busy-children/">overscheduled</a>. Should birth be scheduled too?</p>
<h2>The baby boom</h2>
<p>In the early 1970s, an influential <a href="http://www.karger.com/Article/PDF/155472">review</a> of when women gave birth found that “[m]ore human births occur between 1:00 and 6:00 am than at other times of day.” Today, this no longer happens, since most babies in the US are born midafternoon in the middle of the week.</p>
<p>Not only does this issue set the tone from the very beginning of our lives, but it also is occurring on an enormous scale. Currently, the US has about four million births each year. To put that number in context, <a href="http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo02a-eng.htm">Canada</a>, our northern neighbor, has a population that is almost 36 million people. This means every decade more babies are born in the US than all the people living in Canada! </p>
<p>Not only are large numbers born, but childbirth is a big business since the “<a href="http://www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.html">cumulative costs</a> of approximately four million annual births is well over US$50 billion.”</p>
<h2>When are babies born?</h2>
<p>Starting in 2003, states across the US began switching to a new standardized birth certificate that gathers much more information than the old birth certificate. Part of the extra information is the exact time of day when each child was born. The below table shows the time and day when babies were born, taken from the five most recent years of publicly released information.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=126&fit=crop&dpr=1 600w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=126&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=126&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=158&fit=crop&dpr=1 754w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=158&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=158&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This table shows the time and day when babies in the US are born, from 2009 to 2013.</span>
<span class="attribution"><span class="source">Author's calculations</span></span>
</figcaption>
</figure>
<p>There is no reason to expect that babies prefer leaving the womb on any particular day of the week. This means that births should be roughly evenly spaced out throughout the week. However, the table’s shaded gray bottom row shows this even spacing doesn’t happen. Instead, only 20% of all babies are born on Saturday or Sunday. If births were evenly distributed, about 29% (two days out of seven) of all births should occur on the weekend.</p>
<p>Babies are also not born randomly throughout a particular day in the US. If babies were born evenly spaced during the day, each of the table’s four time slots should have about 25% of all births. However, the shaded gray far right column shows far more babies than expected are born between noon and 6:00 pm. Interestingly, the midnight to 6:00 am time frame is now the least likely period for a baby to be born, capturing only 16.4% of all births. This is a far cry from the <a href="http://www.karger.com/Article/PDF/155472">1972 review</a> quoted above that found the early morning hours were the most likely time for women to give birth.</p>
<p>The yellow numbers in the center of the table show the most likely time for a baby to be born is Tuesday afternoon, closely followed by Wednesday and Thursday afternoons. The least likely time for a baby to be born, shaded in green, is very early Sunday or Monday morning.</p>
<h2>Why the change?</h2>
<p>There are primarily three ways to give birth: vaginal delivery, induced delivery and Cesarean section. Looking at the time of day when births occur using each method shows very different patterns (see graph <a href="http://www.cdc.gov/nchs/data/databriefs/db200.pdf#fig2">here</a>).</p>
<p>Vaginal births happen more or less evenly spaced out during the day, with a slight bump in the early morning hours. C-section births typically happen either around 8:00 am or noon. Induced deliveries typically happen around 3:00 pm.</p>
<p>Why are so many babies now born on Tuesday afternoons instead of early in the morning, like the data from the 1970s showed? Births today are more likely by <a href="http://www.ncbi.nlm.nih.gov/pubmed/17011400">C-section</a> or induction. </p>
<p>The percentage of women who give birth by C-section has dramatically increased over time (see graph <a href="http://www.cdc.gov/nchs/data/databriefs/db35.pdf#fig01">here</a>). In 1991, about 23% of all women giving birth had a C-section, but by 2010 this was almost <a href="http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf#tab21">33%</a>. Since only about one-quarter of all women who undergo a C-section did a trial of labor, this indicates many C-sections are scheduled (see table 14 <a href="ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdf">here</a>). C-sections may be scheduled by the doctor, or by the mother, or as emergency procedures. Unfortunately, birth records don’t indicate why a C-section was performed.</p>
<p>The same trend occurred for births that were induced (see graph <a href="http://www.cdc.gov/nchs/data/databriefs/db155.pdf#fig01">here</a>). In 1990, about 10% of all women giving birth were induced, but by 2010 the share had more than doubled to almost 24%. </p>
<p>There are many potential <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751192/">reasons</a> for the increases in C-sections and inductions. Examples range from improved medical imaging that lets doctors determine with more accuracy uterine and fetal conditions during the last few weeks of pregnancy to a desire by doctors to avoid any type of problem to either mother or unborn child. </p>
<h2>Is scheduling a reason?</h2>
<p>Scheduling to meet the convenience of doctors and other medical staff is likely one factor driving this shift in birth times. <a href="http://www.bls.gov/opub/ils/pdf/opbils68.pdf">Data on when</a> doctors and other medical professionals work show the vast majority are currently on the <a href="http://businessmacroeconomics.com/">job</a> from 8:00 am to 4:00 pm. Relatively few work during the wee hours of the night and early morning.</p>
<p>The shift from vaginal childbirth to C-section or induction has moved more babies from being born in the middle of the night to times more closely aligned with health care workers’ daily <a href="https://www.jstage.jst.go.jp/article/bst/5/4/5_2011.v5.4.139/_pdf">schedules</a>. Research suggests that when doctors and patients have an opportunity to decide when to schedule a birth, the <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=907406">doctor’s preferences win</a> out about three-quarters of the time, possibly because doctor’s value their <a href="http://www.sciencedirect.com/science/article/pii/0167629695000399">leisure</a>.</p>
<p>Scheduling by mothers might be a contributing factor in a small number of cases. Research has found that some Chinese mothers appear to be <a href="http://www.sciencedirect.com/science/article/pii/S1570677X15000404">scheduling their sons’</a> births to avoid unlucky days and ensure a lucky birthday. <a href="https://www.aeaweb.org/articles.php?doi=10.1257/pol.20130243">Tax implications</a> also have a small impact on births around New Year’s Eve. </p>
<p>The <a href="http://www.marchofdimes.org/mission.aspx">March of Dimes</a>, a non-profit devoted to preventing birth defects, is concerned about scheduling; it runs a <a href="http://www.marchofdimes.org/pregnancy/why-at-least-39-weeks-is-best-for-your-baby.aspx">campaign</a> asking mothers to wait until 39 weeks before giving birth. The National Institutes of Health convened an expert panel that estimated <a href="http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-Maternal-Request#2">2.5%</a> of all births in the United States are cesarean deliveries done on maternal request, but cautioned that it has “<a href="https://consensus.nih.gov/2006/cesareanstatement.pdf">little confidence in the validity of these estimates</a>.”</p>
<h2>Does it matter?</h2>
<p>So what does this trend mean for the health of the baby and the mother? </p>
<p>There is research that suggests it is more <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1986.tb07863.x/abstract;jsessionid=E648C1C7FE957E4C63597282E3788CE6.f03t01">dangerous</a> to have a baby in the <a href="http://link.springer.com/article/10.1186%2F1471-2393-12-92">middle of the night</a>, when less medical staff is available. But the <a href="http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery">actual riskiness</a> of vaginal childbirth, C-section or induced delivery is affected by a whole host of factors depending on the mother’s, child’s and hospital’s characteristics.</p>
<p>This shift from unscheduled births to setting birth times is unparalleled in history. There is a clear benefit to scheduling a birth when there is a medical need. However, when there are no medical concerns, there are <a href="http://www.sciencedirect.com/science/article/pii/S0167629613001458">advantages</a> to being flexible and spontaneous.</p>
<p>As a middle-aged male, I will never give birth. However, I think our lives are diminished when every event is scheduled, starting from the moment of birth. What do you think?</p><img src="https://counter.theconversation.com/content/46299/count.gif" alt="The Conversation" width="1" height="1" />
Are we overscheduling our children even from the moment of their birth? We live in an on-demand world. Movies are shown on request, food is delivered on call and drivers arrive when beckoned. As an economist…Jay L. Zagorsky, Economist and Research Scientist, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/430332015-06-11T11:07:13Z2015-06-11T11:07:13ZDo kids born by C-section have a higher risk of chronic disease? A new study looks at the evidence<figure><img src="https://images.theconversation.com/files/84605/original/image-20150610-6787-xc885g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">With c-sections becoming so common, it's time that we started to investigate what that means for child health. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-50320798/stock-photo-baby-being-born-via-caesarean-section-coming-out.html?src=kGVNkZx7HRGkqOZmBxTWFg-1-5">Baby via www.shutterstock.com. </a></span></figcaption></figure><p>In many parts of the world, rates of cesarean delivery are too high, and growing. In the UK, for instance, about one-quarter of babies are born by cesarean. In the US, the rate is one-third, and in Brazil, it is one-half. The World Health Organization recommends that no more than <a href="http://www.who.int/bulletin/volumes/85/10/06-039289/en/">15% of deliveries</a> be by cesarean. </p>
<p>The reasons behind these variations and growing numbers are complex, and beyond my scope here. Whatever the reason, more and more babies are entering the world surgically. We need to understand the potential consequences. </p>
<h2>The high C-section rate is an emerging global health issue</h2>
<p>Cesarean can be a medical necessity, or even an emergency. Decision-making can be fraught, with doctors and soon-to-be parents discussing risks and benefits during labor. Let’s put that aside.</p>
<p>Instead, let’s talk about the kind of information that clinicians and parents want to weigh in cooler moments, when cesarean is neither a medical necessity nor an emergency. </p>
<p>There has been much media attention of late to cesarean delivery on maternal request. It appears that this is rare in the US. One source estimates that <a href="http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-Maternal-Request">2.5%</a> of births are cesareans requested by mothers. But it appears much more common in other parts of the world. For example, in southeast China, <a href="http://dx.doi.org/10.1097/AOG.0b013e31816e349e">20% of births</a> were recorded as cesareans on maternal request in 2006. In some middle-income countries, skyrocketing elective cesareans have become a pressing public health matter. </p>
<p>In the US, there’s another setting that is more relevant. Many women who have had previous cesareans are able to go on to have vaginal births, from a medical perspective. But fewer than <a href="http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_01.pdf">10% of births</a> to women who have had prior cesareans are vaginal deliveries. Repeat cesareans are a health concern worldwide, as more women receive a cesarean with their first birth. </p>
<p>The bottom line is that both of these settings – maternal request in low-risk pregnancy, and prior cesarean – offer a clear opportunity for a cool, deliberative weighing of risks.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84606/original/image-20150610-6817-1gmev0e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">What do we know about the long-term effects of C-sections?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-151050818/stock-photo-new-born-infant-asleep-in-the-blanket-in-delivery-room.html?src=lOXbZs-mhEm3MeXtdXp4kA-1-53">Baby via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Weighing risks and benefits for the child</h2>
<p>In the short term – the hours and days surrounding birth – different modes of delivery bring different risks. For instance, parents might want to know that babies born by cesarean are more likely to need a brief stay in the newborn intensive care unit, while children born by vaginal delivery are more likely to have serious bruises under the scalp, requiring a short course of light therapy.</p>
<p>But when it comes to potential long-term health risks from C-section delivery, there is less information available. To date, discussions about delivery risks have tended to focus on long-term health problems with vaginal delivery. These include the very small risk of brain damage, injury to the the nerves of the arm (from shoulder dystocia), and other conditions.</p>
<p>This is changing, with growing evidence that delivery by cesarean may come with an increased chance of obesity, asthma and diabetes during childhood. In a piece that appears this week in the British Medical Journal, I <a href="http://dx.doi.org/10.1136/bmj.h2410">discuss and evaluate</a> this evidence, along with my colleague Jianmeng Liu of Peking University.</p>
<h2>Evidence of long-term child health risks</h2>
<p>The gold standard for evidence in medical science is the study where two treatments are compared in groups of volunteer patients whose treatment is determined by a coin flip. This is called a randomized study. Reviewing the published literature, we found six randomized studies comparing cesarean and vaginal delivery. All were conducted in scenarios where the optimal delivery choice was unclear (for example, delivery of twins and babies coming feet first, or “breech”). </p>
<p>These randomized studies mostly focused on the benefits and risks for mothers’ health. Only one of the studies followed children beyond the newborn period. The <a href="http://www.sciencedirect.com/science/article/pii/S0002937804006568">Term Breech Trial</a> found that children in the cesarean group were in worse general health than those in the vaginal delivery group at two years of age. While the researchers didn’t go into great detail about the kinds of health problems that the children had, this finding was striking. Unfortunately, the children were not followed up later in life.</p>
<p>We also reviewed the summary evidence from over 50 nonrandomized studies that compared the health of groups of children delivered by the two methods. Those generally find a correlation between cesarean delivery and increased likelihood of childhood <a href="http://www.nature.com/ijo/journal/v37/n7/abs/ijo2012195a.html">obesity</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2007.02780.x/abstract">asthma</a> and <a href="http://link.springer.com/article/10.1007/s00125-008-0941-z#page-1">diabetes</a>. </p>
<p>Using the summary data and extrapolating the findings to the US population, my coauthor and I estimated a childhood obesity rate of 15.8% for children delivered vaginally versus a 19.4% rate for children delivered by cesarean, a childhood asthma rate among children delivered vaginally of 7.9% versus a 9.5% rate for children delivered by cesarean, and a childhood type 1 diabetes rate of 1.79 cases per 1,000 children versus a rate of 2.13 per 1,000 for children delivered by cesarean. Again, these are just estimates, helping to translate the statistics into accessible numbers.</p>
<p>But importantly, correlation isn’t causation: women who have cesareans may be less healthy, and so their children might also be less healthy, regardless of how they are delivered. As it turns out, some correlational studies suffer from this limitation more than others. I believe that we can still get useful information about risks by focusing on the strongest of these correlational, nonrandomized studies. </p>
<p>As always, better data and further research are needed. I’ll have more to say about that later.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84608/original/image-20150610-6790-2mdsb7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We need more research to better understand potential long-term consequences.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-144900949/stock-photo-group-of-multiethnic-babies-isolated-on-white-background.html?src=pp-same_model-144900946-iCa_O-Xncev06iw0hlGHRw-1&ws=1">Babies via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Why might cesarean be linked to long term health risks?</h2>
<p>Stepping back, why might delivery matter? <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110651/">One theory</a> says that it has to do with intestinal bacteria, which are important in food uptake and fighting infections. During vaginal birth, babies swallow maternal vaginal bacteria, and those bacteria are early colonizers of the babies’ intestines. Cesarean-born babies miss this exposure. It is possible that the resulting early differences in resident gut bacteria result in differences in health, later on.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/23414680?dopt=Abstract">Another theory</a> focuses on the healthy, positive stress of labor and delivery, and the ways that stress “programs” a baby’s genes. According to this theory, the key programmers are levels of hormones such as oxytocin, cortisol and adrenalin. These give rise to so-called epigenetic changes that in turn determine the risk of disease later in life. </p>
<h2>What do the experts say?</h2>
<p>In medicine, expert advice is often delivered in the form of written clinical guidelines that summarize the evidence for clinicians and make recommendations for treatment. Recently, two influential groups – one in the <a href="http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-Maternal-Request">US</a>, and the other in the <a href="http://www.nice.org.uk/guidance/cg132/evidence/cg132-caesarean-section-full-guideline-3">UK</a> – issued guidelines for Cesarean Delivery on Maternal Request (CDMR). These guidance documents were pieces of advice to inform decisions in this very specific nonemergency situation.</p>
<p>After reviewing evidence, both groups concluded that vaginal delivery should be recommended for healthy women with low-risk pregnancies. In that group, requests for cesarean should be honored, after a women receives counseling about resources that are available, including pain control. Women requesting cesarean should also understand the risks and benefits of their choice. Strikingly, neither of the two documents mentioned the relatively new evidence on long-term risks to child health, such as obesity, asthma and diabetes. </p>
<h2>Time to talk it over</h2>
<p>It’s time for that evidence to enter the wider conversation. A good way to start would be to review and critically assess the evidence in updated guidelines. This would educate doctors and midwives, allowing them to present fuller information to their patients.</p>
<p>Make no mistake: the evidence linking cesarean to worse child health outcomes is far from airtight. We look forward to getting better evidence in future clinical trials, or cleaner correlational studies.</p>
<p>Again: cesarean is sometimes medically indicated, and is sometimes even an emergency. But in the US, and in many nations around the world, the high cesarean rate isn’t just a question of medical need. Patients, midwives and doctors are making choices, and those choices should be as informed as possible. </p>
<p>The evidence isn’t perfect. But then, it rarely is.</p><img src="https://counter.theconversation.com/content/43033/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jan Blustein received funding from NYU CTSA grant UL1TR000038 from the National Center for the Advancement of Translational Science (NCATS), NIH.</span></em></p>As more and more babies are delivered by cesarean section, we need to start investigating what that means for their long-term health.Jan Blustein, Professor of Health Policy and Population Health, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/426542015-06-03T21:04:31Z2015-06-03T21:04:31ZAre hospitals the safest place for healthy women to have babies? An obstetrician thinks twice<figure><img src="https://images.theconversation.com/files/83738/original/image-20150602-19262-6iuk9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For childbirth, how much intervention is too much?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-101285830/stock-photo-pregnant-woman-feels-hard-contraction-in-a-hospital-labor-delivery-room-concept-photo-of.html?src=ZQXTKVCyhZ7PhTly4Q7FgA-1-8">Image of pregnant woman via www.shutterstock.com.</a></span></figcaption></figure><p>There is a good chance that your grandparents were born at home. I am going to go ahead and assume they turned out fine, or at least fine enough, since you were eventually born too and are now reading this.</p>
<p>But since the late 1960s, very few babies in the United Kingdom or the United States have been born outside of hospitals. As a result, you may find the <a href="http://www.nice.org.uk/guidance/cg190">new guidelines</a> from the UK’s National Institutes for Health and Care Excellence (NICE) just as surprising as I did. For many healthy women, the NICE guidelines authors believe, there may be significant benefits to going back to the way things were.</p>
<p>Shortly after the NICE guidelines were issued, the New England Journal of Medicine invited me to <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1501461">write a response</a>. The idea that any pregnant patient might be safer giving birth outside the hospital seemed heretical, at least to an American obstetrician like me. Knowing that no study or guideline is foolproof, I began my task by looking for holes to form a rebuttal.</p>
<p>I soon realized that this rebuttal largely hinged on flaws in the American system, not the British one. While we take excellent care of sick patients, we do less well for healthy patients with routine pregnancies – largely in the form of turning to medical interventions more than strictly necessary.</p>
<p>As the guidelines suggest, some women in the UK with low-risk pregnancies may be better off staying out of the hospital. Why? Because the significant risks of over-intervention in hospitals, such as unnecessary C-sections, may be far more likely (and therefore more dangerous) for patients than the risks of under-intervention at home or in birth centers. But women in the UK have access to greater range of settings where they can give birth. For women in much of the US, the choice is often the hospital or nothing.</p>
<h2>Are hospitals always the best option? The view from the UK</h2>
<p>The British <a href="http://www.bmj.com/content/343/bmj.d7400">Birthplace Study</a>, upon which the NICE guidelines are based, reviewed 64,000 low-risk births to compare the relative safety of giving birth in one of four settings: a hospital obstetric unit led by physicians, an “alongside” midwifery-led birth center (on the same site as a hospital obstetric unit), a freestanding midwifery-led birth center, and at home. The study included only women with low-risk pregnancies. Women with obesity, diabetes, hypertension or other medical conditions were excluded from the study.</p>
<p>For low-risk women who had never given birth before, home birth led to bad outcomes (such as <a href="http://www.ninds.nih.gov/disorders/encephalopathy/encephalopathy.htm">encephalopathy</a> or stillbirth) slightly less than 1% of the time. That’s rare, but still twice as risky as the other options. Birth centers were no riskier than hospitals for first-time moms, and all options (including home) appeared equally safe for women who had given birth before.</p>
<p>By contrast, this same group of low-risk women was between four and eight times more likely to get a C-section if they started off getting their care in the hospital compared to other settings. Rather than being driven by patient risk or preference, this tendency toward C-sections appeared to be driven by proximity to the operating room. </p>
<p>While the NICE guidelines make it clear that women should be free to choose the birth setting they are most comfortable with, they point out that the risks of over-intervention in the hospital may outweigh the risks of under-intervention at a birth center or at home for the majority of expecting mothers.</p>
<p>The situation is different for women in the US. Last year 90% of births were attended by physicians, while just <a href="http://www.nytimes.com/2014/12/15/opinion/are-midwives-safer-than-doctors.html?_r=1">9% were attended by midwives</a>. Fewer than 1% of US women have their babies at <a href="http://healthland.time.com/2013/01/31/midwives-say-birthing-centers-could-cut-c-section-rates-and-save-billions/">birth centers</a>. While access to care is guaranteed in the UK, nearly <a href="http://www.midwife.org/ACOG-and-ACNM-Press-Release">half of US counties</a> have no midwife, obstetrician or other maternity care professional. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83726/original/image-20150602-19238-prorh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A baby born in the US has a one-in-three chance of being delivered via C-section.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-283045757/stock-photo-instrument-for-cesarean.html?src=r5WdI7g244v4K3XBYUnIUQ-3-26">C-section via www.shutterstock.com.</a></span>
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<h2>C-sections are routine, but not without complications</h2>
<p>Today, newborn babies in the US have a <a href="http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf">one-in-three</a> chance of entering the world through an abdominal incision. In the UK, the odds are lower – more like <a href="http://dx.doi.org/10.1111/1471-0528.13284">one in four</a>, but everyone on both sides of the Atlantic agrees this still represents too much help. </p>
<p>Part of the challenge may be a feature of the species. <em>Homo sapiens</em> have always required some form of extra help being born. Narrow pelvises are required for walking upright, and large frontal lobes are required for nuanced thought. Neither works in our favor when it comes to navigating the birth canal. The unresolved question is how much help is truly necessary – and how much help is too much. </p>
<p>Cesareans are designed to be a lifesaving surgery, but they are now so routine that C-sections have become the most common major surgery performed on human beings, period. It hasn’t been until recently that we started to fully consider the downsides of cesarean deliveries.</p>
<p>For starters, caring for a newborn while dealing with a 12-centimeter skin incision in your own abdomen is the pits, especially when compared to caring for a newborn without having a 12-centimeter skin incision.</p>
<p>Though common, let’s not forget that C-sections are a major abdominal surgery that can lead to <a href="http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery">threefold higher rates of serious complications</a> for mothers compared to vaginal delivery (2.7% vs 0.9%). These complications can include severe infection, organ injury and hemorrhage.</p>
<p>I should also point out that the first C-section a woman has is an easy surgery – I can train an intern to do one safely in just a few weeks. But most women have more than one child, and most women who have a C-section the first time will have a C-section the next time. Obstetricians are among a small group of surgeons who regularly operate on the same part of the same patient over and over again, dissecting thicker layers of old scar tissue with each surgery. </p>
<p>By the second, third, or fourth C-section on the same patient, the anatomy becomes distorted and the surgery becomes increasingly technical. I recently did a cesarean where the woman’s abdominal muscles, bladder and uterus were fused together like a melted box of crayons.</p>
<p>In the most dreaded cases, a woman’s placenta (a large bag of blood vessels that nourishes the fetus) can get stuck in this mess of tissue and fail to detach normally. In these cases, pints of blood may be lost within minutes, and the only way to stop the bleeding is often to do a hysterectomy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83732/original/image-20150602-19235-1wt34sj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">C-sections are 500% more common in the US today than in the 1970s.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-127442744/stock-photo-classic-cesarean-section-in-the-operating-theater.html?src=pp-photo-283045757-r5WdI7g244v4K3XBYUnIUQ-6&ws=1">Baby via www.shutterstock.com.</a></span>
</figcaption>
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<h2>Why do hospitals mean more interventions? It comes down to risk perception</h2>
<p>Since 1970, the number of C-sections performed in the US has gone up by <a href="http://www.consumerreports.org/cro/2014/05/what-hospitals-do-not-want-you-to-know-about-c-sections/index.htm">500%</a>. Some of this increase is because mothers have become older and less healthy, conferring greater risks in pregnancy. But having a baby in this decade is not 500% riskier than having a baby in the 1970s. We know this because C-sections rates in just the women who are young and perfectly healthy have gone up just as quickly. And contrary to popular belief, this has little to do with maternal preferences. First-time mothers who request C-sections with no medical reason make up <a href="http://www.childbirthconnection.org/article.asp?ck=10372">fewer than 1% of the total</a>.</p>
<p>What’s driving the increase in C-sections in the US is unclear, but much of the drive to do more comes from our perception of risk. Although my professional contribution to childbirth is often just to catch, my responsibility as a scalpel-trained, general obstetrician in the United States is to mitigate risk. </p>
<p>I am acutely aware that even women with healthy pregnancies can develop life-threatening hemorrhage, fetal distress or other unanticipated emergencies during labor that require surgical intervention.</p>
<p>My job is to get the baby delivered before it is too late, and often I’m working with ambiguous information. I know how long labor should take on average, but don’t have a precise estimate of how long labor should take for the patient in front of me. What if the baby is too big or the pelvis is too narrow? C-sections often come down to a game-time decision.</p>
<p>Fortunately, I can make sure this decision is never wrong. If the baby looks a little blue and lackluster right after I do a C-section, I’m convinced I did it just in time. But if the baby is pink and vigorous after I do a C-section, I’m still convinced I did it just in time. Without evidence to the contrary, it is easy for me and many of my colleagues to believe that operating is always the right course of action.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83740/original/image-20150602-19232-14b9kbk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">When it comes to safety, it’s better to overshoot.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-101285830/stock-photo-pregnant-woman-feels-hard-contraction-in-a-hospital-labor-delivery-room-concept-photo-of.html?src=ZQXTKVCyhZ7PhTly4Q7FgA-1-8">Baby via www.shutterstock.com.</a></span>
</figcaption>
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<p>When it comes to the safety of mothers and newborns, most would agree that it is better to overshoot than undershoot. The problem is that we are overshooting by a lot, in ways that lead to more insidious harm. Nearly half of the cesareans we do in the US currently appear to be unnecessary, and come at a cost of 20,000 avoidable surgical complications and <a href="http://transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-of-Having-a-Baby1.pdf">US$5 billion of budget-busting spending in the US annually</a>.</p>
<p>C-sections may have consequences for babies as well, in ways that we are just beginning to understand. Exposure to normal bacteria in the birth canal may play a role in the development of a baby’s immune system. A Danish study of two million children born at full term found that those born by cesarean were <a href="http://dx.doi.org/10.1542/peds.2014-0596">significantly more likely to develop chronic immune disorders</a>. Others have suggested that going from the womb to an artificial warmer can have an impact on immediate bonding, and even success with breastfeeding.</p>
<p>In parts of the world where women do not have access to skilled birth attendants, large numbers of mothers and babies die from preventable causes. Even for the healthiest among us, <a href="http://www.mylifetime.com/shows/born-in-the-wild">walking into the woods to have your baby</a> would be unwise. Still, much of the developed world offers only one pragmatic alternative: the hospital. For more than a half-century, we have believed that spending many hours, if not days, in a hospital bed with a smattering of ultrasound gel, clips, wires, heart tones, random beeps and routine alarms is the safest way to have a baby.</p>
<p>Many of the patients I care for benefit from my surgical training. I get to save lives while also sharing in one of the most profoundly joyous moments that families experience. But obstetricians like me may be hardwired to operate, and too many operations are harmful to patients. One strategy to fix this might be to change our wiring. Another may be the British way: for patients to stay away from obstetricians altogether – at least until you need one.</p><img src="https://counter.theconversation.com/content/42654/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neel Shah receives funding from the Rx Foundation, the CRICO/Harvard Risk Management Foundation, and the ABIM Foundation. He is affiliated with the nonprofit organization Costs of Care, Inc. as the Founder and Executive Director.</span></em></p>Humans have always required some form of extra help being born. But how much help is truly necessary – and how much is too much.Neel Shah, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.