
Doctors warn of alarming C-section 'epidemic' - walterbell
https://www.dw.com/en/doctors-warn-of-alarming-c-section-epidemic/a-45856378?maca=en-RSS_en_Flipboard-9487-xml-media
======
danw1979
Women feel enormous pressure (at least here in the UK) to give birth
naturally, from both their peers and health professionals.

How a baby is delivered is none of anyone's business but the mother herself.

My wife (an epidemiologist) deliberated for months over having our second by
VBAC (vaginal birth after csection) and opted to go for it, due to the
overwhelming expectation from everyone around her that she should do it
naturally, and despite having read an Australian study indicating higher rates
of stillbirth during VBAC [citation needed]. Sadly, our daughter didn't make
it through the labor.

Needless to say, the csections that safely delivered my first, and recently
(yay) third children seem like a miracle of modern medicine to us both.

Even before this personal tragedy, I was astounded by the sheer force of
opinion surrounding the cesarean section and childbirth in general. This is
creating an environment where women are not able to make their own choices and
I fear that the doctors in this article, however well meaning, by warning of
an "epidemic" are only adding fuel to this fire.

~~~
Angostura
> How a baby is delivered is none of anyone's business but the mother herself.
> I'm sorry for your loss.

Caesarian's costs the NHS around £1,700 a time compared with £750, for a
normal childbirth and women also stay in hospital for twice as long on
average. There is a general presumption in the UK that avoiding what is an
invasive operation is preferable for both baby and mother alike, in the
absence of other factors.

I would argue that clearly How a baby is delivered _is_ other people's
business since other people are involved. However the ultimate choice should
be the mother's.

~~~
monocularvision
> I would argue that clearly How a baby is delivered is other people's
> business since other people are involved.

This is one major reason to oppose publicly funded health care. _Every_
decision becomes a public one.

~~~
rsanders
The situation isn't terribly different for private health insurance. You're
still spending out of a shared pool of dollars, and you don't have complete
freedom in how you choose to do so.

~~~
monocularvision
And I would never choose a health care system mostly funded out of private
insurance either.

------
SigmundA
This really seems like one obvious way in which we are effecting our own
evolution and would not be surprised if in a short time (on an evolutionary
scale) that humans will require c-sections for successful birth.

This may not be a bad thing, the reason child birth is so difficult for humans
vs most other animals is our head size vs the female pelvis. C-sections bypass
the evolutionary constraint allowing more large headed babies to smaller
pelvis women which could allow greater head size and perhaps even more
intelligence.

[https://en.wikipedia.org/wiki/Obstetrical_dilemma](https://en.wikipedia.org/wiki/Obstetrical_dilemma)

~~~
aklemm
Do babies with too-big heads regularly die at birth if C-section isn't
available?

~~~
stordoff
As far as I know, no, because emergency Caesareans are available (I was an
emergency Caesarean - my mother was told I was 'small', and I ended up being
close to 13lbs[1]), but it can cause other complications - my sister still has
a small scar from a forceps birth, and the recovery time was longer for my
mother.

[1] The entire pre-birth care was flawed - at one point they couldn't find a
pulse for over 24 hours and they were telling my mother to induce labour
(because I was dead...).

Edit: spelling fix

------
jaclaz
In 2015 the WHO has issued this [0] [1]:

>Conclusions

Based on the available data, and using internationally accepted methods to
assess the evidence with the most appropriate analytical techniques, WHO
concludes:

1\. Caesarean sections are effective in saving maternal and infant lives, but
only when they are required for medically indicated reasons.

2\. At population level, caesarean section rates higher than 10% are not
associated with reductions in maternal and newborn mortality rates.

3\. Caesarean sections can cause significant and sometimes permanent
complications, disability or death particularly in settings that lack the
facilities and/or capacity to properly conduct safe surgery and treat surgical
complications. Caesarean sections should ideally only be undertaken when
medically necessary.

4\. Every effort should be made to provide caesarean sections to women in
need, rather than striving to achieve a specific rate.

5\. The effects of caesarean section rates on other outcomes, such as maternal
and perinatal morbidity, paediatric outcomes, and psychological or social
well-being are still unclear. More research is needed to understand the health
effects of caesarean section on immediate and future outcomes.

[0]
[https://www.who.int/reproductivehealth/publications/maternal...](https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-
statement/en/)

[1] (PDF)
[http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15...](http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf)

~~~
nickwalton00
Well said, I think where all things indicate it will be healthy normal births
should be the default, but when medical risks indicate otherwise than c
sections can provide life saving help.

~~~
jaclaz
Yep, if you think about it, the above advice is nothing but "common sense" and
good medicine practice.

The point is that the decision between a normal birth and a C-section is to be
taken on a case by case basis by a (hopefully) competent doctor and not
"planned" (one way or the other) in advance or decided because of other
reasons.

Anecdata, my uncle was a surgeon and he always repeated us that "if it is
really-really, and I mean _really_ needed, than go for it, but otherwise never
let anyone cut through your body".

------
rayiner
Relevant counterpoint: [http://www.skepticalob.com/2018/03/what-if-c-sections-
are-be...](http://www.skepticalob.com/2018/03/what-if-c-sections-are-better-
and-safer-than-vaginal-birth.html).

The article doesn’t actually say why C sections are bad, it presupposes that
fact, and assumes that rising C section rates must indicate some sort of
“epidemic.”

~~~
tptacek
Caesarians are way more dangerous than vaginal births. A C-section patient can
die of pulmonary embolism from the blood clots from the procedure, directly
from bleeding (the surgeon can nick an artery or the incision can lacerate
during the actual birth), the wound can get infected (it's quite a large
wound), and, of course, it's major surgery, so the anaesthesia can kill you
(even if you're not all the way under; my wife had a near miss when our first
was born). The risks get worse in subsequent Caesarians.

~~~
ineedasername
You would think this is true, but the mortality rate for c-sections tends to
be higher because they are often performed in the presence of other extreme
complications that contribute to the higher mortality rate. The mortality rate
for non-complication (elective) ceasarian is actually lower.

 _The Birth Trauma Association found that mortality rates are lowest for women
who have elective caesareans._ [0]

[https://amp.theguardian.com/lifeandstyle/2017/jan/21/how-
ris...](https://amp.theguardian.com/lifeandstyle/2017/jan/21/how-risky-are-
caesarean-births)

~~~
tptacek
All the link you're providing says is that uncomplicated C-sections are less
risky than complicated ones. Sure, that sounds right.

~~~
eridius
Direct quote from the very first paragraph of the article:

> _The Birth Trauma Association found that mortality rates are lowest for
> women who have elective caesareans._

The context is comparing maternal death rate for vaginal delivery vs
caesarean.

Here's a Telegraph article that goes into more detail, including giving actual
numbers: [https://www.telegraph.co.uk/news/uknews/1584671/Women-
choosi...](https://www.telegraph.co.uk/news/uknews/1584671/Women-choosing-
caesarean-have-low-death-rate.html)

From the Telegraph article, the maternal death rate for pre-planned caesareans
is 3.1 per 100,000 women, whereas the maternal death rate for everyone else
(natural birth plus emergency caesarean) is 3.9 per 100,000 women (and the
original article gave the maternal death rate for vaginal birth at 4 per
100,000 women).

~~~
tptacek
I read the Guardian article differently than you did but concede the Telegraph
article makes the comparison plainer.

------
grecy
My sister-in-law just had her first baby, and got very into all of these
statistics and the "medical industrial complex take on childbirth"

I believe the WHO recommends around 10-15% of births should be C-Section in a
healthy population, but the figures in first world countries are at least 3-5
times that.

There are about 3 million stories of ladies "booking in" their birth a month
or three in advance. I.e. I want my baby on the 3rd of May, lets schedule a
C-Section now. It's more convenient that way. Also tons of stories of doctors
wanting to go home for the weekend or to play golf, so they do a C-Section
after only an hour of labor so they can hurry it up.

It's horrifying that hospitals will market a "natural birth" as anything that
is vaginal. i.e. it doesn't matter how many drugs they give you, it doesn't
matter what drugs they give you to speed up the afterbirth, etc. etc. It's
still "natural".

~~~
harry8
"natural" like half of women dead in childbirth natural?

~~~
Synaesthesia
When there are problems, you operate. Otherwise it’s preferable for natural
birth for mother and baby, for reasons mentioned above.

~~~
KaiserPro
no.

There are a whole host of reasons for having a c-section. The risk of having a
massive tear (ie vag to arse(4c tear), or literally tearing a new arsehole) is
1 in 4. This has long term life altering consequences.

An "elective" c-section is not the same as "booking in". The less "identity
politics" that are wrapped up in this, the better.

~~~
iforgotpassword
No.

> The risk of having a massive tear (ie vag to arse(4c tear), or literally
> tearing a new arsehole) is 1 in 4.

Yes and it usually heals very well. The tissue there is made to deal with
that. My sister had that happen 5 years ago, it even continued into her gut
for a few cm. So that was a very bad case, but it still healed perfectly,
although it took about 3 month.

~~~
KaiserPro
... 3 months. Unless she had corrective surgery then she's almost certainly
got some level of incontinence.

There will(or should) have been physiotherapy to get some semblance control
back.

Look, there is nothing wrong with a c-section or a vaginal delivery. To make
women feel that they are somehow inferior for having one is totally
unacceptable. Something like 10-20% of births endup in caesarian, otherwise
there is a massive chance of a bad outcome for both child and mother.

Source: wife who is a paediatrician and attends lots of births where the child
is in distress.

------
jsoc815
Find it interesting that the article seems to place the blame on the women,
when it's long been said that the docs and hospitals, ever in search of time
compression and profits, were encouraging c-sections versus vaginal birth.
That, to my knowledge, is the likely cause of the procedure appearing
"fashionable" and "modern."

~~~
DoreenMichele
I actually think it is probably more insidious than that. We have a lot fewer
full-time homemakers. Women are much more likely to have paid jobs.

The only way to schedule the birth is by scheduling a C-section. Waiting for
the baby to show up when it decides to do so is a very organic, let nature
take its course, humble thing to do and it is pretty alien to how most people
live these days in developed countries.

Historically, we farmed. We had to figure out how to respect nature and work
with it. Most jobs today don't really do that. We think we are in control.

~~~
cellis
Actually historically, we foraged and hunted. After reading _Sapiens_ I’m
convinced that _farming_ actually set humans on the path towards this very
suffering. Large scale war, famine and pretty much every post agrarian
revolution ill, is a direct consequence of having food surpluses.

~~~
laythea
I haven't had my first coffee in the morning yet, so it may be me, but I'm
struggling to see the link between food surplus & farming and war?

~~~
jessaustin
Hunting/gathering/swiddening tribes may have wars but they're just tribal
wars, which are more like random murders. Lots of regret but those left alive
can move on. In order to get awful generation-destroying authoritarian _war_
wars, you have to have a sovereign. A sovereign requires what James C. Scott
has called "legible" surplus. This is a surplus the sovereign can expect at
regular intervals in the same locations. That is, fixed agriculture,
preferably of grains or similar crops that don't spoil easily but require lots
of related industry in order to support life.

------
epmaybe
Interesting article. I also thought that encouraging cesarean sections was
something obstetricians did often to avoid the time spent waiting for
delivery. However, in my training I witnessed quite the opposite. My resident
and attending physicians were very cautious with going forward with cesarean
sections, and would do whatever they could to continue with vaginal delivery
when the mother wanted that, and also encouraged patients that wanted cesarean
to consider vaginal delivery.

Obviously this is one hospital, but it did help me not be as cynical of the
profession, and will probably help serve as a reminder to do what's best for
my future patients.

~~~
lellotope
With the birth of our daughter, we had a different, and more complicated
experience.

Pre-delivery there was no pressure to do a c-section. None at all. My wife
definitely did not want one.

At the time of delivery, though, there was very much pressure to do a
c-section. Although the admitting resident didn't seem to pressure my wife,
care was quickly transferred (because of shift reasons) to other physicians
(resident and attending) who did.

The way this manifested, though, was sort of subtle. For example, my wife had
a procedure done to speed up the delivery; however, as we found out later, we
were definitely not sufficiently informed of the consequences of the
procedure, one of which was increased likelihood of a c-section. They tried to
talk my wife into a c-section, and then when she declined, they tried to talk
her into other procedures that would speed up the delivery, and would omit
mention of the fact that they were associated with increased likelihood of
c-section. Overall, even if c-sections weren't being explicitly mentioned,
they were kind of relied on or assumed, for time and convenience reasons. The
discussion was sort of like "Oh you don't want a c-section? Ok, then how about
X to speed things up? Oh--I forgot to mention that now we probably have to do
a c-section? Oops!" It came across as manipulative to me.

My wife did not have a c-section, but this was probably only because the
nurses there (who were phenomenal) were actively arguing with the physicians
to not do one, and to wait. We weren't really in the hospital that long
either.

~~~
wizzard
This is a well-known phenomenon called the cascade of intervention:
[http://www.childbirthconnection.org/maternity-
care/cascade-o...](http://www.childbirthconnection.org/maternity-care/cascade-
of-intervention/)

------
snapit
My opinion based on living with a midwife for most of my life. Not fair to
blame the women for this The reason is more to do with the doctors or medical
staff being cautious about complications from a normal birth than caused by
the preference of a women for chosing a c section.

------
giardini
C-section babies are prone to certain ailments later in life:

"Giant study links C-sections with chronic disorders" -

[http://sciencenordic.com/giant-study-links-c-sections-
chroni...](http://sciencenordic.com/giant-study-links-c-sections-chronic-
disorders)

My guess is that this is tied to the reduced exposure to the mothers' vaginal
and anal microbiome that occurs during vaginal delivery but which is absent in
C-section.

Much as childhood exposure to animals reduces autoimmune disorders in later
life, natural birth also likely does the same.

"Study: Children who grow up on family farms and drink raw milk have fewer
allergies, autoimmune disorders"

[https://www.naturalnews.com/035802_raw_milk_farms_allergies....](https://www.naturalnews.com/035802_raw_milk_farms_allergies.html#)

~~~
nemonemo
As the article says, the cause is not certain. From some study, higher
c-section rate correlates with higher income, so my guess is that it could
just be an outcome of better hygiene according to the hygiene theory.

------
ertand
I wonder what its correlation with induction is. Artificially inducing labor
does not tend to give the body enough time to adjust and progress.

~~~
dabbledash
Elective induction of labor at 39 weeks results in a _lower_ c-section rate
than expectant management (waiting to see if labor will start naturally).

[https://www.nih.gov/news-events/news-releases/induced-
labor-...](https://www.nih.gov/news-events/news-releases/induced-
labor-39-weeks-may-reduce-likelihood-c-section-nih-study-suggests)

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049989/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049989/)

Normally though, induction happens because there is some problem or because
the pregnancy has gone past the due date, and in these cases your risk of a
c-section is already elevated.

~~~
ertand
Makes sense. As mentioned in the comments, there are different ways of
inducing labor. I was referring to usage of pitocin or similar too early in
the process, instead of gradually inducing the labor with other medications.
We had success with just misoprostol during our labor, but the process was
quite long.

~~~
dabbledash
These inductions would have been primarily pitocin and / or cervical ripening
agents like cirvidil.

~~~
ertand
Misoprostol is also a cervical ripening agent comparable to cervidil.

------
sambe
Several papers were released as part of a series, and are available currently
in full text form:

[https://www.thelancet.com/series/caesarean-
section](https://www.thelancet.com/series/caesarean-section)

The more sensational language being reported appears to come from the FIGO
position paper rather than the research. I’m not sure about the relationship
between the two but they look to have been published together.

------
StreamBright
C section saved the life of my child. I do not care if there is an "epidemic"
(what a heck does it mean in a context of a surgical procedure at all???).

~~~
gdubs
It means that in some cases the procedure is life saving, and in other cases
unnecessary and potentially riskier than vaginal delivery. (Happy for you and
your family that your child made it out OK — don’t know if it was recent, but
congrats nonetheless!)

~~~
StreamBright
Well I was kind of interested how can somebody use epidemic as a noun for a
surgical procedure. There are many factors to this but c-section is often
safer for the child than normal birth. I am not sure if there is any problem
with c-sections, in my country it is widely used even as an elective option
without issues. It is hard to see the downside.

~~~
techsin101
Again, study is pointing out that c section is being performed more than
necessary, in fact so much more that it's epidemic. From data WHO calculated
that about 20% deliveries should require c section. But numbers are reaching
to 45%. Bad Effects in children born with c section are un clear and major
surgery has risks for mother as well. Doing a surgery when not necessary is
always a bad idea. So if you had a good out come, good for you. But understand
you're one data point and can not be reflective of what should be.

------
amalag
My mother was in labor for over 36 hours (maybe more, she told me but I
forgot) in 1976. You know that would be a C-section nowadays. She had two more
children after that. I don't know how long her labor was for those but I
assume it wasn't as bad.

~~~
zrail
My wife was in labor for 40ish hours in 2016. There was never any pressure for
a c-section.

------
kdowining
Every article I read on c-sections misses some really important facts:

1\. c-section mortality and complication rates are often not separated between
the women who get c-sections pre-scheduled and women who get them after hours
of damaging labor and something already going horribly wrong. In fact, when I
looked at the data for my own c-section, it seemed to indicate that scheduled
c-sections were as safe if not safer than vaginal birth.

2\. Vaginal birth leads to lifelong incontinence and sexual dysfunction in
many women. Would I take a miniscule chance of death in exchange for not
peeing my pants for the next 50 years? Yes. In exchange for having a way
higher chance of a pain-free sex life again? Yes. Quality of life matters.
Your relationship with your partner and with your own body matters. So many of
these studies basically end in the hospital - i.e. did mom and baby survive,
but then do not look at long-term outcomes of the MOM at all. I know many
women with these issues. Women with horrific tearing and scarring, too.
They're still dealing with it years later. It's not trivial even though these
studies make it sound like the only thing is whether you live, not how you
live.

3\. c-sections do not carry the risk of baby being deprived of oxygen during
birth. No risk of cord getting stuck around the head, etc. The people trying
to convince me that I shouldn't have a c-section because of very ambiguous
studies dealing with asthma or allergies are totally missing the forest for
the trees on this one.

Lastly, and this is an experiential point from someone who has actually had a
c-section: the whole thing was completely painless. I was on my feet the same
day. I only had a bit of trouble going from laying to standing in the first
couple of days, but I otherwise was in pain and could walk, sit, take care of
the baby, everything else. By the time I was out of the hospital on day 5 I
felt completely back to normal and could do anything and everything. Is it
major surgery? Sure. But I can tell you that women who had vaginal deliveries
were still in pain weeks after the delivery and for months if they had
extensive tearing or episiotomies. Most of my friends on the "natural" train,
now having done that and seen my experience in comparison, wish they hadn't
gone that route because they're still dealing with the damage it caused them.

~~~
kdowining
Otherwise _not_ in pain.

------
basicplus2
Thats nothing.. perth western australia has been the csection capital of the
planet

Heres 2012 figures

[https://www.birthsavvy.com.au/caesarean-section-rates-
perth-...](https://www.birthsavvy.com.au/caesarean-section-rates-perth-2015/)

~~~
lathiat
Hello from Perth. Just recently had our daughter at SJOG Murdoch but was not a
Caesar. However we went with our obstetrician partially because he was less
likely to push towards Caesar and that ended up being our experience. He was
happy to wait and deliver late.

We had some non trivial complications though from going natural.

There was however clearly a high rate of those around us but I think basically
it’s one of the more well known private hospitals for people to visit where
you get the choice so plenty of people are just choosing to go that way for
various reasons. also we are 30 but most of the people in our prenatal class
were older except one.

------
hypertexthero
Interesting perspectives from cesarean born people:

[https://cesareanvoices.com/](https://cesareanvoices.com/)

See in particular this presentation by Jane English:

[https://cesareanvoices.com/SHOW-small.pdf](https://cesareanvoices.com/SHOW-
small.pdf)

------
acd
Babies ingest vital microbes during natural birth helping kick start their
immune system when exciting from the mothers vagina. It also helps to get the
babys breathing started. The microbes that babies get in contact with during
natural birth help form their gut microbes. Gut microbes are essential to
human health. If we eat food from animals that have been given antibiotics or
we take antibiotics, we mess with the gut microbe system that prevents us from
getting sick.

To clean environment is not good for humans. Ie with a little dirt our immune
system is better. That is why for example people growing up on the country
side has less allergy.

[https://www.wired.com/2014/04/missing-microbes-antibiotic-
re...](https://www.wired.com/2014/04/missing-microbes-antibiotic-resistance-
birth/)

The Normal Gut Microbiota: An Essential Factor in Health. Article
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983973/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983973/)

------
kuwze
I know most people on HN are guys, but I've heard a lot of women talk about
the peer pressure. In fact some women look down on those that have children
via a C-section. It's despicable.

~~~
watwut
C-section all in all hurts more and you heal longer after that and you need
more help afterwards. Plus it limits how many kids you can have safely.

The dominance of guys shows up mostly by completely ignoring practical
considerations.

------
lanius
I'm surprised C-section rates are higher among wealthier, education women. I
would assume educated women are more likely to understand the risks associated
with C-sections.

~~~
v_lisivka
Heads of their babies are larger, while vagina is same, so higher risk to rip
vagina and die, so higher C-section rate.

~~~
chongli
It's not the size of the vagina that's the issue, it's the size of the pelvis.
The vagina is extremely flexible. Bones much less so.

------
JustSomeNobody
Years ago c-section rise was due to medical malpractice lawsuits from people
like John Edwards, now it’s a fashion trend by the well to dos. Wow.

------
harry8
Ok so no mention of the health implications of so called "natural" childbirth,
which aren't trivial and have an increasing risk as your age. No mention of
the rising age of mothers in wealthy countries. No mention of different trade
offs for fit 19 year olds and less active 35 year olds. A lot of 30+ women
decide they don't want to piss their pants and have painful intercourse for
the rest of their lives. Word gets around and it undermines trust in doctors
advice when they don't even mention the issues. A higher proportion of doctors
make the c-section choice. They're kind of educated, doctors, less likely to
be bullshitted into higher, unnecessary fees too.

But you're not an idiot so you want the actual numbers. So did I. Not
available, no research done and/or no doctors know of it and can hand you
print outs of the papers.

So much for evidence based medicine... There's an epidemic of women not just
doing what they're told! FFS Lancet. How's their credibility nowadays? Taking
hits?

~~~
paavoova
Women have been giving birth since creation with minimal enough problems for
humans to survive and succeed as a species - it absolutely is natural, no idea
why you put that in quotations. Why stop at C-sections? Raise them in test
tubes a la Brave New World, skip the biological process entirely. After all,
it's much safer, quite possibly even zero risks on the woman's part.

The thing with C-sections is that until fairly recently, children weren't
inoculated with the mother's vaginal canal microbes. Now they know better and
do a smear, but that means many children failed to receive a proper immune
boost when they needed it most. There's an growing body of evidence that
suggests early microbial exposure is required for proper immune development
and function, and that the lack of this exposure is linked to allergies and
other self-inflicted immune diseases. I can't speak of any data off the top of
my head, but perhaps the doctors recommending against C-sections are aware of
decades of data on C-sections and childrens health?

~~~
isostatic
At a species level yes, childbirth works fine.

Before the modern era deaths of both child and mother were very high (10%+)
when giving birth.

That said, the U.S. approach to childbirth is clearly not working, with
childbirth deaths at 3 times that of Canada, and higher than the rest of the
developed world.

~~~
jessaustin
Like lots of things in USA this is tied to racism. Whites in USA have risks
similar to those of other developed nations. Analysis has found that nonwhite
immigrants have largely the same results as USA whites. However, their
daughters have the same elevated risks as other minorities in USA. Public
health experts don't have any idea why this is, so they're no closer to
solving this problem than e.g. the public education system is to fixing its
own racist outcomes.

