Several hundred years ago, a famous philosopher said, Cogito, ergo sum (I think, therefore I am). My motto is a bit different: I am mother, therefore I am guilty. My children are grown now, but I haven’t forgotten the pervasive guilt that parenting can engender. Unfortunately, I can’t help you with the guilt over school choice, screen time, or discipline — but there is one area in which I might be able to provide comfort. As an Ob/Gyn and a mother, I can tell you there is no reason to feel guilty about the choices you make during childbirth.
Sadly, thanks to the rising trend of “natural childbirth” ideology, these choices now are an area of our society where judgment, second-guessing, and guilt reign supreme. And there is no greater sin in this context than having had a Caesarean-section.
According to advocates of natural childbirth, an unmedicated vaginal delivery is the best way to ensure the health and happiness of your baby — anything else, and you’re a failure. For a telling example, we can look to award-winning actress Kate Winslet, who was actually so embarrassed about having a C-section for her first child that she led the world to believe that it never happened. Years later, she admitted she lied: “I just said that I had a natural birth because I was so completely traumatized by the fact that I hadn’t given birth. I felt like a complete failure.”
This feeling of failure associated with C-section is something I’ve never understood. Personally, I think C-section mothers should be extra proud of themselves. When offered the choice between risk to their unborn baby and risk to themselves, they chose taking on the risk in an effort to protect the baby. If that isn’t the essence of motherhood, I don’t know what is.
Sadly, the source of this guilt is largely misinformation. Below, I’ll take you through the facts.
The “Right” C-Section Rate
Everyone, medical professionals and natural birth advocates, can agree that the C-section rate in the United States is too high, and it may very well be that we can lower it without raising perinatal mortality rates. But by how much? Many natural childbirth advocates cite an old “optimal” C-section rate of 10 to 15%, which was issued by the World Health Organization (WHO) nearly 30 years ago. They usually don’t acknowledge, however, that the recommendation was quietly withdrawn in 2009, with WHO saying that there were never any data to support a rate that low. Indeed there was never any research that established an optimal rate at all. Marsden Wagner, MD, a pediatric epidemiologist and a WHO executive at the time the recommendation was issued, probably did more than anyone to promote the idea of a 15% C-section rate as ideal. Yet in a 2007 journal article that he co-authored, it is explicitly acknowledged that the 15% C-section rate recommendation of 1985 was made without any data to support it. That paper found that there are only two countries in the world that have C-section rates of less than 15% and low rates of maternal and neonatal mortality. Those countries are Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, every other country in the world with a C-section rate of less than 15% has unacceptably high levels of maternal and neonatal mortality. Virtually none of the countries with low rates of maternal and neonatal mortality have a C-section rate of 15% or below, and most have C-section rates that are far higher. The data actually show that a C-section rate of 15% is unacceptably low, and that for the best outcomes for both moms and babies the average should be at least 22%, with rates as high as 36% yielding low levels of maternal and neonatal mortality. The current U.S. rate of 32% is well within that range. Could the C-section rate be safely lowered to 22%? That is definitely a possibility. Could it be safely lowered to 10 to 15%? Absolutely not. On “Unnecessary” C-Sections
What makes C-sections difficult is that some of these procedures truly are unnecessary — but that is apparent only in retrospect. Now that C-sections are safe procedures (thanks to modern techniques), there are fewer risks to the baby that we are willing to tolerate. At the same time, we have developed a variety of technologies to determine if a baby faces increased risk. From electronic fetal monitoring to testing for gestational diabetes, we can recognize a possible cause for concern. Unfortunately, many of these technologies are imperfect. Although they have low false-negative rates (if they indicate that a baby is fine, the baby is almost certainly fine), they have high false-positive rates. That means that if a baby is identified as being at risk, it isn’t necessarily at risk. C-section then must be thought of as “a transfer of risk.” Vaginal delivery poses a much greater risk to the baby than to the mother (approximately 100 times higher). C-section, on the other hand, poses a marginally greater risk to the mother and dramatically reduces risk to the baby. What could be more natural than a loving mother opting to carry any increased risk rather than putting it on the baby? Consider C-section for breech birth. As doctors, we are obligated to tell women that a breech vaginal delivery greatly increases the risk of death or serious disability. Make no mistake, however, the absolute risk that the baby will not survive a vaginal breech birth is small, less than 1%. But to me that makes it all the more remarkable that most women carrying breech babies will choose C-section. Faced with the small, but real risk to their babies, most mothers will opt for abdominal surgery, with all the pain and the potentially harder recovery. The same thing goes for women who consent to C-section for fetal distress. In 2016, the diagnosis of fetal distress is imperfect at best. We know that almost all babies who experience lack of oxygen during labor will give evidence of that on electronic fetal monitoring. However, many babies who appear to be in distress may actually be fine. When a woman consents to a C-section for fetal distress, she is saying, in essence: I don’t know whether my baby is truly experiencing oxygen deprivation, but I don’t want to take any chances. Cut me, and help the baby. In other words, it’s a sign of devotion, not a sign of failure. Kate Winslet is not alone in her feelings of embarrassment and guilt, but in the end, there is absolutely no reason why she or any other mother should ever feel guilty about having a C-section. As a mother of four children, I say, “Bravo!” I never had to face the choice that many C-section mothers do, but I hope that I would have reacted as selflessly as they do.
Everyone, medical professionals and natural birth advocates, can agree that the C-section rate in the United States is too high, and it may very well be that we can lower it without raising perinatal mortality rates. But by how much? Many natural childbirth advocates cite an old “optimal” C-section rate of 10 to 15%, which was issued by the World Health Organization (WHO) nearly 30 years ago. They usually don’t acknowledge, however, that the recommendation was quietly withdrawn in 2009, with WHO saying that there were never any data to support a rate that low. Indeed there was never any research that established an optimal rate at all. Marsden Wagner, MD, a pediatric epidemiologist and a WHO executive at the time the recommendation was issued, probably did more than anyone to promote the idea of a 15% C-section rate as ideal. Yet in a 2007 journal article that he co-authored, it is explicitly acknowledged that the 15% C-section rate recommendation of 1985 was made without any data to support it. That paper found that there are only two countries in the world that have C-section rates of less than 15% and low rates of maternal and neonatal mortality. Those countries are Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, every other country in the world with a C-section rate of less than 15% has unacceptably high levels of maternal and neonatal mortality. Virtually none of the countries with low rates of maternal and neonatal mortality have a C-section rate of 15% or below, and most have C-section rates that are far higher. The data actually show that a C-section rate of 15% is unacceptably low, and that for the best outcomes for both moms and babies the average should be at least 22%, with rates as high as 36% yielding low levels of maternal and neonatal mortality. The current U.S. rate of 32% is well within that range. Could the C-section rate be safely lowered to 22%? That is definitely a possibility. Could it be safely lowered to 10 to 15%? Absolutely not. On “Unnecessary” C-Sections
What makes C-sections difficult is that some of these procedures truly are unnecessary — but that is apparent only in retrospect. Now that C-sections are safe procedures (thanks to modern techniques), there are fewer risks to the baby that we are willing to tolerate. At the same time, we have developed a variety of technologies to determine if a baby faces increased risk. From electronic fetal monitoring to testing for gestational diabetes, we can recognize a possible cause for concern. Unfortunately, many of these technologies are imperfect. Although they have low false-negative rates (if they indicate that a baby is fine, the baby is almost certainly fine), they have high false-positive rates. That means that if a baby is identified as being at risk, it isn’t necessarily at risk. C-section then must be thought of as “a transfer of risk.” Vaginal delivery poses a much greater risk to the baby than to the mother (approximately 100 times higher). C-section, on the other hand, poses a marginally greater risk to the mother and dramatically reduces risk to the baby. What could be more natural than a loving mother opting to carry any increased risk rather than putting it on the baby? Consider C-section for breech birth. As doctors, we are obligated to tell women that a breech vaginal delivery greatly increases the risk of death or serious disability. Make no mistake, however, the absolute risk that the baby will not survive a vaginal breech birth is small, less than 1%. But to me that makes it all the more remarkable that most women carrying breech babies will choose C-section. Faced with the small, but real risk to their babies, most mothers will opt for abdominal surgery, with all the pain and the potentially harder recovery. The same thing goes for women who consent to C-section for fetal distress. In 2016, the diagnosis of fetal distress is imperfect at best. We know that almost all babies who experience lack of oxygen during labor will give evidence of that on electronic fetal monitoring. However, many babies who appear to be in distress may actually be fine. When a woman consents to a C-section for fetal distress, she is saying, in essence: I don’t know whether my baby is truly experiencing oxygen deprivation, but I don’t want to take any chances. Cut me, and help the baby. In other words, it’s a sign of devotion, not a sign of failure. Kate Winslet is not alone in her feelings of embarrassment and guilt, but in the end, there is absolutely no reason why she or any other mother should ever feel guilty about having a C-section. As a mother of four children, I say, “Bravo!” I never had to face the choice that many C-section mothers do, but I hope that I would have reacted as selflessly as they do.
From PUSH BACK: Guilt in the Age of Natural Parenting by Amy Tuteur, MD. Copyright © 2016 by Amy Tuteur, MD. Reprinted by permission of Dey Street Books, an imprint of HarperCollins Publishers.
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