Recent studies on women’s health have highlighted the continuing trend of excessive C-sections during childbirth, revealing concerning and deadly complications caused by this procedure.
When performed as needed, cesarean section surgeries are an essential procedure in obstetric care. But new data is showing that an overuse of the procedure, rampant in U.S. hospitals, can be deadly. Like any other abdominal surgery, C-sections come with inherent risks that have to be weighed by the woman and her physician team. The overuse of C-sections has opened up women to unnecessary complications. These risks include a very dangerous condition called placenta accreta.
Placenta accreta occurs when the placenta fuses with scar tissue left on the uterus, usually from a previous surgery. Two-thirds of mothers with placenta accreta will hemorrhage during childbirth, in which case they can die from blood loss in just ten minutes. Even if a hospital’s team is trained to treat this particular condition (which many are not, because research into placenta accreta did not begin until 2015), saving the mother’s life may require more blood than a small or rural hospital might have available at the time. (New York Times)
Maternal-fetal medicine specialist Dr. Robert M. Silver began researching placenta accreta in the early 2000s, and published a study showing how a woman’s chance of developing it jumps dramatically after each C-section. Placenta accreta affected approximately 1 in 4,000 pregnancies in the 1970s compared with 1 in 272 pregnancies today. In the United States, despite the preferences of many mothers, the vast majority of pregnant people who have already undergone C-sections will be recommended another. (NYT)
Why has the cesarean section rate skyrocketed?
Since the 1970s, the C-section rate in the United States has increased by more than five times. In 1970, 5.5 percent of all deliveries were C-sections (Pubmed). By 1978, this number was 15.2 percent. In 2023, the rate was 32.3 percent (AMA), which far exceeds public health recommendations (NYT). What happened?
There is a confluence of factors at play.
One is the general decline of midwifery in the United States. Midwifery was a standard global practice until the 20th century.Midwives would travel to the homes of women and babies to offer holistic care surrounding their pregnancies and births (A Brief History of Midwifery). Anti-midwife advocates, including many doctors who looked down upon the practice, campaigned for laws and educational restrictions that effectively dismantled the profession in America within the past century.
This was a massive blow to women’s ability to receive a form of personalized maternity care that many understaffed hospitals cannot provide due to the sheer volume of patients coming in for other ailments. Still, doctors have opposed the practice of midwifery on the grounds that a more Western, “scientific” approach is preferable. In practice this means relying on hospitals for birth and prioritizing quick pain relief over holistic care. It is also a profit-driven practice that is intended to save money for hospitals by shortening mothers’ stays and relying on medication instead of care staff.
As a result of this agenda, today 98 percent of births in America take place in hospitals with doctors. In contrast, 75% of births in other developed nations like France and Japan include midwives who are often providing care at homes or birthing centers.
Electronic fetal monitoring and AI stand in for care staff
Another factor is rise of electronic fetal monitoring. The top justification for emergency cesarean sections is “fetal distress,” a condition that electronic fetal monitoring has proven to be incapable of accurately predicting, but that hospitals across the U.S. still rely upon as a cost-saving measure (NYT).
Electronic fetal monitoring involves round-the-clock monitoring of the baby’s heartbeat. The technology allows for nurses — and with growing frequency, unproven artificial intelligence algorithms — to monitor many babies at once rather than stop at each mother’s bedside with a stethoscope. Studies show that electronic fetal monitoring is no more effective than periodic stethoscope checks. (NYT) The monitor, once placed on a woman in labor, limits her ability to move, trapping her in what is arguably one of the least advantageous positions: prone on her back.
Experts say that the prevalence of electronic fetal monitoring can cause doctors to overreact to normal or ambiguous heartbeat fluctuations and call for unnecessary C-sections (NYT). In reviews dating as far back as 1996, it was found to increase the odds of a doctor ordering a C-section by 63 percent (NYT). But in the U.S., doctors still embrace this technology. Archived advertisements at the National Library of Medicine show that monitor manufacturers have boasted to hospital executives that this technology intends to stand in for medical and care staff. (NYT)
The profit-driven healthcare in the United States also encourages hospitals to cut costs by adding artificial intelligence into the mix of technology overreliance. For example, the University of Maryland has introduced AI into its remote fetal monitoring hubs (NYT). PeriGen, the creator of the software, recently retracted its claim that 50 studies have backed up the effectiveness of its AI monitoring after a New York Times journalist requested information about the sources on its website (NYT).
A lawyer from OhioHealth hospital said to a group of hospital executives last August that doubling up on monitoring technology “just looks good” from the standpoint of preventing lawsuits against hospitals, no matter how ineffective the technology actually is (NYT).
Improving outcomes takes time and effort
The New York Times recently reported on the hard work of Dr. Elizabeth Bostock, who sought to address the alarming rate of C-sections occurring at Rochester General Hospital in New York. While many healthcare professionals view rising C-section rates as inevitable for various reasons, Bostock worked to show that addressing the problem at the point of care could reverse the trend. (NYT)
Since 2019, Rochester General saw the steepest drop in C-sections across the country. A few of the successful tactics include:
- Low-risk patients were rerouted to care by midwives
- Care teams needed to complete a new checklist that would promote vaginal delivery before surgery
- Increased nurse education around delivery and to change individual attitudes towards vaginal birth
- Difficult 1:1 conversations with doctors about their surgery rates
All of these solutions required hospital administrators to devote special time and attention for each patient– something that profit-driven hospitals tend not to prioritize.
Data published by Dr. Rebecca Clark also illuminated the factors influencing C-section rates across the country (NYT). She found that while the hospitals’ individual, objective characteristics do not have an impact on the rate, the pay for the physicians does.
C-sections require less time and bring in an average of 54.5% more money from insurance payments than vaginal births.(NYT) When insurers make the payments equal for each procedure, studies have shown the surgery rate declines. Another obstetrician working under Bostock noted that physicians are financially incentivized to hasten births via C-section at the end of their shifts rather than wait for natural delivery, in which case another physician may get the payout if the birth occurs after the first clocks out (NYT).
Addressing women’s healthcare in the U.S.
In the United States, there is much work to be done around women’s healthcare. The maternal mortality rate in the United States (23.8 per 100,000) is already nearly three times higher than that of France (8.7), the country with the next highest rate, and it has consistently increased since updated reporting requirements were issued in 2018 (TCF).
The work needs to happen both on the hospital floor as well as in public policy. The solutions put forth by Bostock are a great example of how to address the crisis on the local level. But this cannot fully make up for decades of disinvestment in women’s healthcare.
Lisa David, President of New York’s largest nonprofit health agency Public Health Solutions, wrote that women’s healthcare “used to be a common sense, bipartisan cause” (Health Solutions). But on top of national funding cuts to hospitals, health centers, and programs like Medicaid, the far-right conflation of “women’s health” with “abortion” has also led to attacks on all women’s healthcare, including breast cancer, cervical cancer, ovarian cancer, mental health, sexually transmitted infections, bone health, menopause and more.
The data is clear: this crisis is reversible. But it will take intentional time and effort from physicians to change attitudes around birth, increased education for care staff, investment into women’s healthcare by politicians, and the total unraveling of profit from the healthcare system. Women and their babies deserve personal care that is not dependent on cost-cutting technology or a hospital’s bottom line.
Feature image by Nowforever, 2013. CCSA 4.0
