During the thirty minutes it took to drive herself to the hospital, all Amber Rosato remembers is feeling numb. She glanced in the rearview mirror of her dark blue Toyota Corolla at the empty infant car seats in the back. She knew two babies would be coming home with her — the twins she was carrying that she conceived after five heartbreaking years of infertility and pregnancy loss — but it just seemed so surreal.
Rosato, who is 36 years old now and lives in La Verne, California, wanted a vaginal birth. But Baby A was footling breech — the doctor showed her on the ultrasound monitor that the baby’s heel was kicking her cervix. So even though Kaiser Permanente Baldwin Park Medical Center was “pro vaginal delivery” (in Rosato’s words), her doctor said they would not allow it. Even though one study of over 600 twin births concluded that “there is no evidence that vaginal birth is unsafe… for breech first twins that weighed at least 1500 grams [3.3 pounds],” she was not given a choice.
Rosato’s husband, a pharmacy assistant, was forbidden to stay with her while the spinal anesthesia and catheter were placed. As the doctors prepped her for the operation they exchanged banter about the price of vacation rentals. “This is just another surgery for them,” Rosato remembers thinking, feeling dazed. “But this is the beginning of my family.” Rosato didn’t get to see, hold, or even touch her daughters after they were born (she gave Baby A a kiss on the cheek). She started shaking — a reaction to the anesthesia — and was so weak and groggy that she felt disconnected when she finally was allowed to cuddle them. “It was almost like they were a stranger’s babies,” she recalls sadly. “I didn’t really realize they were mine.”
Baby A could not suck. Baby B was not coordinated enough to suck, swallow, and breathe and kept turning gray. Both babies had overwhelming digestive issues. Born at 37 weeks, Rosato wishes the doctors had given the babies more time to mature in utero. Six years later, Rosato still has numb areas around the C-section scar, nerve damage on her skin from the operation.
Are America’s C-Section Rates Too High?
Stuart Fischbein, M.D., an obstetrician in private practice in Los Angeles who specializes in home birth, has been delivering babies for 34 years. He has attended over a hundred vaginal breech births and concurs that a twin pregnancy with a footling breech may be a valid reason for a cesarean birth. Fischbein explains that footling presentation carries a risk of the foot slipping through before the cervix is fully dilated, which could cause the baby’s body to only partly deliver, leaving the head to become dangerously entrapped above the cervix. There is also a slightly higher chance of the umbilical cord being born before the baby, which can sometimes cut off the baby’s oxygen supply, especially if the birth attendants do not respond correctly.
Two other experienced practitioners — an obstetrician in Wisconsin and a midwife in Oregon — tell me via email that if Baby A is breech but Baby B is head down there is a small but real risk of the babies’ heads interlocking in the vaginal canal, which can result in the death of one or both twins. Fischbein disagrees: “It’s a false argument used by people who don’t know what they’re doing when it comes to breech birth and want to rationalize limitation of options.”
There is no question that cesarean birth is sometimes an operation that can mean the difference between life and death, for both the mother and the baby. In Rosato’s case — though Baby B was not head down — the operation may have been warranted. But, Fischbein says, the majority of cesarean births are not medically necessary.
When first measured in 1965, the C-section rate in the United States was only 4.5 percent, and America had good overall birth outcomes, both for moms and their babies.
Today the C-section rate is 32.2 percent, according to the CDC, and we have the highest maternal mortality rate of any country in the industrialized world. Indeed, the United States has such a high infant mortality rate when compared to other developed countries that the Washington Post has described it as a “national embarrassment.”
“The C-section rate should be 10 or 15 percent in this country,” Fischbein says, referring to the World Health Organization’s statement on optimal cesarean rates. “But it’s over 30 percent, which means more than half of them are unnecessary… That’s over 600,000 unnecessary surgeries a year. If you were doing that many unnecessary knee or gall bladder surgeries, you would think someone would raise a stink about it.”
Barbara McFarlin, R.N., Ph.D., head of the Department of Women, Children and Family Health Science at the University of Illinois College of Nursing, agrees.
“Cesarean sections have increased steadily over the last 25 years, without a concomitant improvement in perinatal outcomes,” McFarlin explains. “The fetus has a lot to contribute, to determine when it’s ready to be born. Along with the high section rates in the United States, the number of medically induced inductions has skyrocketed. There is no longer a trust that our bodies have the ability to birth naturally.”
Even the American College of Obstetricians and Gynecologists (ACOG) is concerned. In March, 2014, recognizing that once a woman has had a C-section it is less likely she will later have vaginal births, the ACOG called for a safe reduction in primary C-sections.
A Life-Threatening Operation?
“Cesareans are one of the greatest innovations in modern medicine,” says Elliot Berlin, Executive Producer of the documentary film Heads Up: The Disappearing Art of Vaginal Breech Delivery. Berlin, a prenatal chiropractor, certified doula, and an expert in labor massage, has been working with pregnant women for 12 years.
“But just like any medical technique, if you use the right technique on the wrong person you can do more harm than good,” Berlin says. “If I perform CPR on someone who’s not breathing and has no pulse, I’m a hero. But if I do it on someone who has a pulse, I am going to go to jail for assault and battery.”
Cesarean birth has become so commonplace in America that expectant couples often don’t realize that, like any major surgery, it involves both short and long-term risks to both the mother and the baby. Instead, they are often wrongly told that it is the safest thing to do.
“Blood loss, hemorrhage, bowel problems, chronic pain, scarring, infection, bladder injury, problems with the placenta adhering to the scar tissue in subsequent pregnancies — these are all fairly common things,” Fischbein says. “And of course C-section for many women has a strong psychological backlash. There’s an emotional component for a woman who wanted a vaginal birth who may consider herself to be cheated from the birth she deserved, which can affect her for a lifetime.”
Well documented side effects of cesarean birth include injury to internal organs, emergency hysterectomy from uncontrolled bleeding, complications from anesthesia, severe infection, placenta accreta, chronic postpartum pain, and endometriosis.
A study of over 90,000 women in Latin America found that women who delivered via C-section had twice the risk of a prolonged hospital stay, four times the risk of hysterectomy, and were five times more likely to need postpartum antibiotic treatment compared with women delivering vaginally.
Another study published in Obstetrics & Gynecology of pregnancy-related deaths over a 7-year period in the United States revealed that nearly 36 women in every 100,000 died giving birth by cesarean, versus approximately nine women birthing vaginally, which suggests that a woman in America is as much as four times more likely to die if she gives birth via C-section.
Other research corroborates this: Data compiled from more than two million births in the United Kingdom in the 1990s showed that a woman was six times more likely to die from a C-section than a vaginal birth. A more recent study showed that a woman is three times more likely to die from complications resulting from cesarean.
Though the absolute risk of dying in childbirth is low in the United States, it is higher than in any other country in the industrialized world. While other countries are successfully lowering their maternal mortality rates, America is one of only eight countries in the world where childbirth-related deaths are on the rise.
Newspaper articles across the country put faces to these numbers:
There’s Casi Rott, a 36-year-old mother of two who was pregnant with triplets, who died on February 8, 2016 of a blood clot in her lungs. The clot developed in the hospital — Wesley Medical Center in Wichita, Kansas — after a cesarean birth. Her devastated husband has been left to raise five children on his own.
And 29-year-old Bethany Mellish who died on December 30, 2015 as she was giving birth via scheduled C-section to her second child, James, at the Hurley Medical Center in Michigan.
And also 26-year-old Liang Nie who bled to death at an Orange County hospital after her cesarean birth in March 2014. The family alleged the obstetrician abandoned the young mom before she was adequately stabilized. A jury agreed, awarding the grieving father $5 million.
And many, many more.
C-Sections Aren’t As Good As Vaginal Birth For Babies
There are many other reasons to avoid cesarean birth. It’s associated with lower breastfeeding success rates when compared to women who give birth vaginally, as well as with poorer health outcomes for infants. We are now understanding that C-section birth disrupts a baby’s immune system because the newborn misses out on being coated with the mother’s beneficial vaginal bacteria.
“If you’ve ever seen a birth, it’s messy,” says Andy Kuzmitz, M.D., who has been practicing family medicine in Ashland, Oregon, for over 25 years. He thinks we are greatly underestimating the importance of the microscopic zoo inside human beings.
“The baby’s head pushes on the bladder, releases urine, and makes stool come out. The baby is washed in these fecal organisms… The messy birth with a lot of fluids is all a good thing. That’s where the baby is going to be introduced to the microorganisms they will have for the rest of their life.”
Kuzmitz explains that the human body contains an intricate microbial ecosystem of trillions of microorganisms that inhabit our skin, genitals, mouth, nose, and intestines. These “good” bacteria not only aid in digestion, but they directly contribute to a healthy immune system by crowding out harmful bacteria, synthesizing compounds that are not present in our bodies at birth (like vitamin K, which is necessary for proper blood clotting), and playing a role in keeping our bodies from attacking themselves, thus diminishing the likelihood of autoimmune disorders.
The problem is that babies born via C-section have been found to be colonized by different bacteria than babies born vaginally. One 2015 study found that C-section babies were colonized by sometimes deadly hospital bacteria, including staphylococcus, corynebacterium, and propionibacterium. Another peer-reviewed discussion pointed out that the microbial make-up in the digestive tracts of infants born via C-section have been found to be disturbed for up to six months after birth.
“It’s not unusual for babies born by C-section to have trouble with their GI system for their first few months or even the first few years of life, because they don’t have those bacteria,” Kuzmitz says.
States With The Lowest C-Section Statistics
According to statistics from 2014 — the most recent year for which we have data — Utah has the lowest cesarean birth rate in the country: 22.2 percent; followed by Alaska: 23.7 percent; New Mexico: 24.3 percent; and Wisconsin: 26.1 percent.
Laurie Baksh, manager of the Utah Department of Public Health’s Maternal and Infant Health Program, who tracks the state’s birth statistics, believes there are two main reasons for Utah’s low C-section rates: Women in Utah tend to be healthy when they begin pregnancy (the state also has low rates of smoking, obesity, and alcoholism) and doctors in Utah tend to be more committed to, and less fearful of, vaginal birth than doctors in other states. A main factor in Utah’s good birth outcomes, Baksh says, is that the state has campaigned for no elective inductions before 39 weeks.
“We are not prematurely inducing women who may not be ready to deliver babies,” Baksh explains. “If you are inducing labor, and a woman’s body is not ready, it really contributes to the C-section rates.”
Taking It Slow
Dennis Hartung, an obstetrician who delivers babies in Wisconsin and Minnesota, takes off his shoes before he enters a room where a mom is in labor. He does not turn on the lights. He speaks calmly and quietly to the mom, encouraging her, and reminding her that she is doing a good job.
His peaceful, gentle attitude is contagious: in everything he does he conveys to the woman in labor that he believes in her body’s inherent ability to give birth.
Hartung has been practicing obstetrics for 22 years and has attended over 3,300 births. Though he describes himself as a “card-carrying member of ACOG,” he practices very differently from many of his colleagues.
“There are times when women can sit at 4 or 5 centimeters dilation before they progress,” he tells me. “We don’t rush them. We do tell them we can augment with Pitocin, if you want, or you can have more time — walk the halls, get in the tub. It’s your choice. But there’s nothing unusual about being four or five centimeters for a number of hours.”
Hartung’s cesarean section rate? Eleven percent.
Hartung’s willingness to let laboring women take their time is unusual among obstetricians. This is a model of birthing usually associated with midwives, especially midwives who attend women at freestanding birth centers and at home. But a 2015 study suggests that a collaborative model of care — where midwives and doctors work together — is a proven way to help reduce cesarean rates: When women at Marin General Hospital had around-the-clock access to midwives, as well as to hospital obstetricians focused solely on them, the primary C-section rate decreased from nearly 32 to 25 percent and the vaginal birth after cesarean (VBAC) success rate nearly doubled.
“For the majority of women, midwifery is the best choice,” argues Nancy Valentine, R.N., Ph.D., associate dean for Practice, Policy, and Partnerships at the University of Illinois College of Nursing in Chicago. “But we have become so medicalized in our thinking that the doctor is at the top of the heap and everybody should go to the best doctor to have the best baby, though that really doesn’t equate to the science.”
When Amber Rosato got pregnant again she resolved to do things differently. She told her doctors she was having a VBAC right from the beginning. At the end of her pregnancy, she refused to allow them to induce her labor early, insisting the doctors wait until the baby had gestated for a full 40 weeks.
“Holy cheeks!” The doctor exclaimed when the baby’s head appeared after nearly 24 hours of labor. Rosato instructed the doctor to give her the baby — who weighed nine pounds eight ounces — right away and to wait to clamp the cord.
“Being able to watch her coming out, looking at her, knowing she came out of my body, and was actually mine — from that moment we had such a bond. It was so different from her sisters,” Rosato remembers.
The hospital staff left the room. Rosato held her baby, skin-to-skin, on her chest, as she and her husband watched the sunrise out the hospital window. “It was a beautiful morning. It was very healing for me,” she says. “I felt I had come full circle in that moment.”
Jennifer Margulis, Ph.D., is an award-winning investigative journalist, Fulbright scholar, and author of Your Baby, Your Way: Taking Charge of Your Pregnancy, Childbirth, and Parenting Decisions for a Happier, Healthier Family. Find her on Facebook and follow her on Twitter.