Science and C-Sections: What Do We Know?

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I recently posted on the rise of maternal mortality rates over the past two decades in both Canada and the USA (and to a slight degree, the UK as well), countries known for their ever-increasing rates of interventions, and specifically, c-sections.  The problem is that the c-section has been seen as an equal alternative (or sometimes even better alternative) to vaginal birth for people with no medical reason to have a c-section.  But there are repercussions to this for both the mother and child and it’s my hope to explore those herein.  Notably, in order to avoid the confound of a previous c-section (in which there is a heightened risk of health problems for a vaginal birth), the outcomes described herein are based on first c-sections only.  A comparison of VBACs and second caesarean sections is a topic for another day with its own unique set of considerations and outcomes.

Most commonly, people discuss the morbidity and mortality factors (rightfully so).  Giving birth via caesarean section has been found to be associated with a two to seven times increase in risk of death for the mother[1][2] and morbidity is estimated at five to ten times that of a vaginal birth[3], even when the planned versus unplanned nature of the c-section is considered[4].  The mortality and morbidity rates for infants are similar to that for mothers, with a near three times increase in risk of mortality[5] and morbidity, most notably for respiratory problems[6].  The problem for most is that while the data shows an increased risk, the overall risk is very, very small and thus it gets masked.  But the risks are real and have been replicated time and again and yet the c-section rate in many countries continues to rise.

In a review of 79 studies on outcomes for c-sections and vaginal births (with or without other interventions), the authors found significant risks associated with rising c-section rates[7].  Specifically, c-sections were associated with greater risks of “maternal mortality, hysterectomy, ureteral tract and vesical injury, abdominal pain, neonatal respiratory morbidity, fetal death, placenta previa, and uterine rupture in future pregnancies” (p. 485).  While some of the 79 studies were observational—which means that some of these outcomes may be quite strong not because of the c-section, but because of a condition which led to the c-section—the authors did their best to control for that possibility.  Thus while their results may overestimate the risk, it is doubtful that the risk would completely disappear if one were to remove those cases in which an underlying cause was present.

So while we have ample evidence of the physical problems that can manifest from c-sections, especially when they are not undertaken for true medical reasons, that isn’t the only outcome we should be interested in.  In the concern for the medical (rightfully so to some degree), many people overlook the psychological and behavioural consequences of the caesarean section.  In an early meta-analysis on the topic[8], researchers found that mothers who birthed via c-section expressed less immediate and long-term satisfaction with the birth, were less likely ever to breast-feed (which was even greater for unplanned c-sections), experienced a much longer time to first interaction with their infants, had less positive reactions to them after birth, and interacted less with them at home.  This isn’t to say that all mothers will react this way, but that having a c-section heightens the risk of these psychosocial outcomes.  Interestingly, when the baby is breech, the psychosocial outcomes at 2 years post-partum are equivalent between those women who planned a caesarean section and those who planned a vaginal birth[9].

Given the previous meta-analysis findings on poor psychosocial outcomes after the birth, this raises the question of whether all c-sections are equal.  A planned c-section for a breech position (particularly historically when it was believed to be safest, despite that claim now being challenged) meant a woman was making a birth choice that arguably was safest for her and her child compared to a planned c-section for convenience in which a mother may not bond that well after more because of pre-existing ideas about motherhood.  And for women who end up with emergency c-sections, the terror and trauma that can lead up to that moment when labour isn’t progressing, or they run into problems that make them fear for their baby’s life, post-birth stress is something that must also be considered.  Thus, while the psychosocial outcomes of c-sections are real, it is worth exploring how the different types of c-sections affect maternal and infant outcomes and how the events leading to the c-section play a role in these outcomes as well.  The previous meta-analysis included this when possible, but sadly many early studies failed to make the distinction, making it impossible for the authors to determine many differences.

More recently, however, a detailed research review (focused only on methodologically sound studies) included such information in their review of the psychosocial effects of a c-section.[10]  These authors found that lower childbirth satisfaction (including feelings of powerlessness, lack of control, report a terrible or traumatic experience) was more prominent in women with c-sections, regardless of whether or not they were planned or unplanned.  With respect to depression, c-sections were related to an increased risk of depression for mothers with a history of depression only; however, unplanned caesarean sections were found to be associated with a large risk of symptoms and reactions in line with post-traumatic stress disorder.

(I think at this point it’s worth noting that not all unplanned c-sections need to be happening.  Yes, there are women with true complications that require medical interventions, but sadly, the cascade of interventions most women face in the hospital put them at increased risk for having to have an unplanned c-section.  Inductions, epidurals, pitocin, and having to give birth according to a schedule increase a woman’s risk for birthing via c-section and we’d be wise to remember these real emotional outcomes when we consider the “need” for these interventions.)

Returning to the research review[10], the relationship to parent-infant interactions was found to be somewhat mixed, with most studies on the topic (n=9) finding a reduction in interactions with their children – less play, less tactile stimulation, less favourable ratings more generally – as well as a reduction in breastfeeding rates and duration.  However, the authors note that there were two studies that were methodologically sound that failed to find these outcomes.  One positive outcome associated with c-sections was for women to plan around the birth, be it for employment, child care, or other responsibilities.  Some women also reported being relieved by the c-section as it ended labour when labour had been long and painful.  And finally, some women who are very much in favour of medicalized birth much prefer the c-section to vaginal birth and may not show any of the negative effects found in other research.  The psychosocial outcomes for these women are going to be very different because of the mindset going into it and we must be cognizant that this may be a preferable birthing method for some.

Another side effect of c-sections that rarely gets any discussion is food allergies.  Researchers have hypothesized that one pathway (of many) to food allergies is a delay in the colonization of a newborn and one study did find that children who were already at risk of developing allergies (due to family history) were four to seven times more likely to develop the allergy if born via caesarean section.  Importantly, there was no increase for children who were not at risk due to family history.[11]

Are there any medical benefits to the caesarean section (in general, obviously there are benefits when it’s medically necessary)?  The only health benefit I could find was a lower risk of urinary incontinence throughout the lifespan – both mild and more severe – compared to women who had vaginal births.[12]  This is probably not too surprising given the wear that the bladder can face during a vaginal delivery.  Interestingly, though, c-sections were also a risk factor for urinary incontinence relative to women who had never delivered, but the risk was greatest for women who had vaginal deliveries.

What can we do?

One of the considerations I spoke of in the recent piece on maternal mortality is obesity.  In the US, rates of obesity are higher than nearly any other Western nation and there is evidence that severely obese women require c-sections at relatively high rates.  One study found that 62% of morbidly obese women ended up with a c-section (compared to 24% of controls – still too a high number).[13]  A society that can place an emphasis on overall health is important.

A second factor that must be discussed is fear.  There are myriad reasons why women are far less versed with birth than our ancestors (and I mean going further back than grandparents or even great-great-grandparents) and women in other cultures, but regardless of the reasons, many women know virtually nothing about natural childbirth.  And it’s a problem.  Not just because women should know about their own biology and what to expect when giving birth (and not the typical stories nowadays where women just speak of how much it hurt), but because a fear of childbirth has been linked to an increased risk for c-sections[14].  In examining nearly 2,000 women during pregnancy, a severe fear of childbirth increased the risk of an emergency c-section in labour three-fold.  Given the risk of PTSD after c-sections, it would seem that women who already have strong negative feelings about birth may be at a particularly high risk of developing strong anxiety and stress post-birth.  This means we need to find ways to ensure women are truly educated about birth so that they can alleviate their fears and understand how their bodies work with the baby to birth.

But the final and most general thing we can do is offer SUPPORT.  Whether a c-section is a choice or not, some women may suffer effects that can have negative outcomes on their relationship with their child.  And for any woman who does end up down that path, she needs to be supported, cared for, and given the chance to get out of that frame of mind and be the best parent she can be without having to worry about depression, anxiety, or stress from a birth procedure.  (In fact, I would think all women should have access to this type of support as even vaginal births can end up going horribly wrong and women there need to be supported as well, but the addition of recuperating from surgery makes this potentially even more important for moms who had a c-section.)  This goes back to something I’ve written about before (see here) which is that as much as our society likes to put up the ideal that if your baby survives, you should be happy and ignore everything else, that is not the way we should proceed.  Birth – no matter what it looks like (natural, with pain relief, c-section, etc.) – can be empowering, lovely, and wonderful.  It can also be traumatic, scary, and painful.  And to parent, we need to ensure that all women have the tools to handle the negative aspects they may encounter to build a healthy and happy relationship with their child.

[1] Eckner JL.  Once a pregnancy, always a caesarean? Rationale and feasibility of a randomized control trial.  American Journal of Obstetrics & Gynecology 2004; 190: 314-8.

[2] Wagner M.  Choosing caesarean section.  The Lancet 2000; 356: 1677-80.

[3] Murphy DJ, Liebling RE, Verity L, Swingler R, Patel R.  Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study.  The Lancet 2001; 358: 1203-7.

[4] Hager RM, Daltveit AK, Hofoss D, Nilsen ST, Kolaas T, Oian P, et al.  Complications of caesarean deliveries: rates and risk factors.  American Journal of Obstetrics & Gynecology 2004; 190: 428-34.

[5] MacDorman MF, Declercq E, Menacker F, Malloy MH.  Infant and neonatal mortality for primary caesarean and vaginal births to women with no indicated risk, United States, 1998-2001 birth cohorts.  Birth 2006; 33: 175-82.

[6] Penna L, Arulkumaran S.  Caesarean section for non-medical reasons.  International Journal of Gynaecology and Obstetrics 2003; 82: 399-409.

[7] Belizan JM, Althabe F, Cafferata ML.  Health consequences of increasing caesarean section rates.  Epidemiology 2007; 18: 485-6.

[8] DiMatteo MR, Morton SC, Lepper HS, Damush TM, Carney MF, Pearson M, Kahn KL.  Caesarean childbirth and psychosocial outcomes: A meta-analysis.  Health Psychology 1996; 15: 303-314.

[9] The 2-year maternal follow-up Term Breech Trial Collaborative Group.  Maternal outcomes at 2 years after planned cesearean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial.  American Journal of Obstetrics & Gynecology 2004; 191: 917-27.

[10] Lobel M, DeLuca RS.  Psychosocial sequelae of caesarean delivery: review and analysis of their causes and implications.  Social Science & Medicine 2007; 2272-84.

[11] Eggesbo M, Botten G, Stiqum H, Nafstad P, Magnus P.  Is delivery by caesarean section a risk factor for food allergy?  The Journal of Allergy and Clinical Immunology 2003; 112: 420-6.

[12] Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S.  Urinary incontinence after vaginal delivery or caesarean section.  The New England Journal of Medicine 2003; 348: 900-7.

[13] Hood DD, Dewan DM.  Anesthetic and obstetric outcome in morbidly obese parturients.  Anesthesiology 1993; 79: 1210-8.

[14] Ryding EL, Wijma B, Wijma K, Rhydhstrom H.  Fear of childbirth during pregnancy may increase the risk of emergency caesarean section.  Acta Obstetrica et Gynecologica Scandinavica 1998; 77: 542-7.

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  1. Jespren says

    One of the biggest reasons I am so pro-homebirth is the relative c-section rates. Hospital? At least 30% (and perhaps much greater depending upon the hospital) c-section rate. Home birth? Most midwives have about a 3% c-section rate. So let’s see, just by giving birth in a hospital I am about 10 TIMES more likely to have a procedure which will increase my mortality rate by 2-7 times above the inherent risk of natural childbirth. Add in that outcomes aren’t much different for babes well…I can’t understand why anyone even passingly familiar with the data would elect a hospital birth without a serious medical reason to do so. Sure, with a real problem, like placenta previa or transverse lie, the risk is balanced in favor of hospital intervention (likely c-section), but simply ‘being pregnant’ isn’t a balanced risk/reward when considering how skewed your risk is via hospital/homebirth is.

  2. Ari says

    If women have the right to give birth at home, which I consider very foolish, then I want the right to request and receive a c-section. It’s my body.

    • says

      Why is it foolish? Research for low-risk pregnancies shows home birth is safer than a hospital birth. However, depending on where you live, you do have the right to request and receive a c-section. There just happen to be considerations you should consider before requesting that.

    • Allie says

      Why would you want to have surgery if it could be avoided. We are the ONLY country in the WORLD that medicalizes pregnancy . Every other country uses midwifes unless you are high-risk and the norm is homebirths, and we have the some of the worst mortality rates in the world. Being pregnant is not an illness and shouldn’t be treated that way. We should have hospitals, there great when you need them. I think you should really do some research on what your saying. You sound really ignorant. Yeah just cut me open even if I don’t have to be. It is your body and you do what you wish, but why put yourself and your child at risk because you don’t know any better. It’s kind of sad.

      • Melanie says

        Well to be fair, Allie, many, many other countries have high C-section rates, even higher than the U.S. The current rate in Brazil, for example, is 70%.

  3. AmberM says

    This post is just what everyone needs to see. I am a c-section mother. It makes me sad, I feel cheated and defeated. Less of a woman. I honestly believe it could have been avoided.

    This just makes it even worse to know that this surgery made my mortality rate higher.

    I am pregnant again. Apparently no doctor in this County does VBACs this scares me. I am hoping my insurance coves a midwife, because if it does I am switching from an OB to a Midwife so that I can at least attempt to have this baby the way a woman should.

    It just makes things hard in the state of SC they are making it illegal for midwives to practice. :(

    • says

      Amber I’m so sorry. You shouldn’t feel less of a woman at all, but obviously we can’t control our feelings. I can see how you feel cheated though – I imagine I’d feel the same in your boots :( I do want to clarify that the mortality rate is DURING the birth, not after. Once it’s over and you survived, you survived.

      I wish you the best of luck on your VBAC. If you want, I did a piece with research on that if it helps you in any way, shape, or form.

      Good luck and please know that you are full woman and full mother :)

  4. Cgirls says

    I am all in favour of natural birth and home births etc, and birthed my own baby vaginally with no pain relief, but we mustn’t forget the stupidly high rate of maternal and infant death BEFORE birth was medicalised: birth posed the highest rate of death for both. So, just because we have medicalised birth, it doesn’t mean its always a terrible thing. You need only to look at the death rates for women and infants from birth/birth related complications in the countries that have NOT medicalised birth to see this. Things like obstetric fistulas are pretty much eradicated in countries where birth is highly monitored by medical professionals, yet women in other countries are being outcast from their tribes because they leak urine and faeces all day due to the birth processes. So it needs to be a mix of both,in my opinion. Perhaps a good model like in the Netherlands, where home birth is normal but things are still highly organised. You can’t really deny that modern medicine has given us huge leaps forward in the field really. I think sometimes it can be put forward as all too simple and in the past, it was not, and in many impoverished countries, it still isn’t. I hope I never have a C sect though.

    • Cgirls says

      So, by this, I mean that ideally well trained Midwives are present and OBs are not interfering. It’s much worse in some countries than others, ours is a mainly midwife run system.

    • says

      It’s hard to say the death rate was so horrible outside of the hygenic issues. Yes, it was absolutely higher, but the comparison rates of the times right before big medicalization were actually due to original medicalization. Doctors, not understanding the effects of hygiene and bacteria put many women at risk. Why there was a period where upper-class women, birthing with doctors, had a much higher rate of mortality and morbidity than did lower class women who birthed with midwives. So we must be clear that where medicalization has helped has been in the areas of things like pre-eclampsia and HELP and other diseases that influence birth and less on the normal course of birth.

      • Cgirls says

        Yes, I think that was probably my original point you just put it a whole lot more eloquently hah. As in, women still die of things that modern medicine can now prevent- pre-eclampsia or excess blood loss due to high grade placenta previa that would go unnoticed without modern medicine.

        Other things can happen during a “normal” pregnancy and birth that modern medicine has helped too: for eg, a baby can be born too fast, causing hemorrhage on the brain: hence trained professionals slowing down the pushing at certain times. Anyway, I think we’re probably on the same page (well…I wouldn’t love the page if I wasn’t in agreeance with what you write about!) but I always like to point out the other side of things that are not always black and white. :)

        • says

          And absolutely I never want to be seen as saying “Medicine is bad” – it’s not nearly as clear as that. But the idealization of medicalized birth and comparisons to times when disease was rampant and doctors were killing more patients than midwives isn’t a fair comparison either :) We need BOTH and right now I’d say we’ve swung too far in the medicalized direction :)

  5. CLF says

    I would not have my son if c-sections were not possible. I had no choice but to have a c-section after having undergone extensive uterine surgery for multiple fibroids in the past. I knew that if I ever became pregnant, a c-section would be my only delivery option due to high risk of uterine rupture. My son is now 7 and a half months old, was first breastfed at 1 hour old, and is still breastfeeding like a champ. He was nowhere other than in my arms during my entire hospital stay as a newborn, we had lots of skin to skin time, and I feel more bonded to him than anyone else in my life. The surgery didn’t interfere with any of that! He is healthy and so am I. I am proof that it is possible to have a wonderful birth and a successful breastfeeding relationship from day 1 after having a c-section. I know many more examples, so I just want to say that nobody should judge another woman for her birth “choice” because in many cases, it’s not a choice, but a necessity.

  6. mm says

    I have 2 boys – a nearly 5yo and a 10mo. During the 1s labour I didn’t sleep for 44hrs, pushed for 3,5hrs, at one stage my waters were broken as the labour started slowing down. Because of the prolonged time of pushing (due to my ‘weak’ contractions) I was put under a drip, and an episitomy was performed. My only pain relief was paracetamol during 1st stage of labour and then gas&air (+ local anesthetic for the episiotomy). I spent a good paart of he labour at home, but I wasn’t happy about it and i didn’t feel good over there – I felt I was left to myself. Eventually at 6cm I was allowed to come to hospital. As requested and planned I was at the Midwife Led Unit where I felt relieved – finally. I was lucky and managed to use birthing bath with spa lights etc, but due to problems with pushing, I was transferred to consultant unit where my son was born. I have never been that exhausted and drained :( With my 2nd baby I went for MS (membrane sweep) 7 days past my due date. I was lucky as my waters broke and my labour started with regular contractions within an hour from the MS. At 5cm I was advised my baby was breech and I had to make a choice – a vaginal breech delivery or cc. I have to add, that should the MS not worked then, I would have been offered induction at 14 days past my due date, which caused a lot of stress to me. All the risks have been explained to me. I wanted a nat. birth so much (I was only on gas&air), but I knew my baby would be rather big for me (4110g) and I could not stop thinking about something going wrong with the delivery (even though I know our hospital specializes in vaginal breech deliveries). At 6cm (and the labour was progressing very quickly) I decided on cc – purely because his was the safest for the baby or should i say – he risk was the smallest for the baby. The doctor told me that he didn’t want me to think that if the risk is small, it’s not there as this is not the case. He told me with cc risk for the baby is slightly smaller than with vaginal in our situation, but with cc the main risks are on me. I could not stop thinking and asking myself: ‘What if we are in the 3 in 1000 cases and something will happen to my boy?’ – and this was something I could not get rid of, so decided to make his birh as safe for him as possible and decided I waned cs (even though I have always wanted nat. birth). The cs itself wasn’t as bad as I had always imagined. In fact – I would have to say the opposite. The labour pain was gone very quickly, there were lots of ppl around me (i felt safe) including my dear mum. I knew my baby was born when i suddenly heard the cry – i did not expect it to be that quick! It wasn’t long and I was in the recovery room where my son and I had skin to skin contact and 1st breastfeeding. Comparing the two – well, the recovery..Nat. birth about 10 days after episiotomy, cs: 6-8 weeks tummy area (the internal cut) – so definitely 1:0 to nat. birth. Emotions wise – and I would never expect that – I felt great after cs! I was in very good mood, if i was teary it was tears of happiness (opposite to post my nat. birth :( ). There was no issue with milk coming even though ppl tend to say cc makes it impossible or milk is late – well I had the opposite experience wit nat. birh. Overall i cannot really complain at the cs I had. I would also like to say that I was misdiagnosed with my baby’s presentation and even days before i went into labor I was told baby’s head was down, where in fact this was incorrect – but scans aren’t performed towards the end of pregnancy even for the sake of establishing this. Had I gone gone home once my waters broke (as i was offered to do that if I wanted), I could have put my baby at risk with i.e potential cord prolapse :( and these are the situations when it’s good to be surrounded with ppl that can definitely help right there and then. And can I also stress that my pregnancy was straight forward, uncomplicated pregnancy, so I could potentially opt to give birth at home. I don’t think I was trusting my body enough to give birth to a breech baby vaginally…So, bearing all this in mind, I consider myself very, very lucky..I was gutted about the fact that I didn’t deliver naturally and had to come to terms that in this case. Although i was given the choice, I didn’t really have a choice – one of those things. But I was lucky that the waters broke, that the labour kicked off pretty much straight away, that i trusted my instinct and stayed at the hospital and that i have insisted on examination – as this is when everything’d changed.. I am happy though i had experienced contractions up until 6-7cm, as I had a bit of my nat. labour and I do think a vaginal delivery is something special, and when I think of a baby being born, I’m more likely to go back to my first birth experience even though it was so exhausting . It was magical and this was the reason I wanted to experience it again. If I am pregnant even again I will have huge dilema though deciding on delivery :( Vbac would be very tempted, but again – I know myself and I know the fear would be great, especially that the risk with vbac for the baby and for the mother is there (should the scar rupture) :( – it’s the risk factor for me again. With cc – risk higher for me, but again safer for the baby – the downside is again the longer recovery. I really don’t know what I would choose :(

  7. Natalie says

    The US does NOT have as high a rate of infant/maternal mortalities as everyone thinks. The numbers are skewed. We count mortality/morbidity rates differently than most other countries, so the numbers simply cannot be compared. In my opinion, medical interventions during pregnancy and delivery are necessary. There are very specific reasons why we don’t want women laboring for days. Think about what the baby goes through during a 36 hour labor. There are reasons why we monitor fetal heart rate and mom’s vitals. There are risks involved for c-sections and vaginal deliveries. The fact remains that doctors save lives and fewer moms and babies are dying than ever in human history. Fact.

    • says

      I’m unclear how you feel that external groups who do analyses include different numbers for different countries *without* mentioning that in their reports (as they often do include what goes into each report). How is it that you imagine the US rates differ compared to Canada or the UK or NZ?

      And of course doctors have saved lives – I didn’t argue that. But to say they are necessary carte blanche seems ridiculous. They are necessary sometimes. But all the time? Nope.

  8. Dina Clingman-Bell says

    Three C-sections (not by choice) but the follow up experience is what you make of it. I breastfed all three of my children – three years – four years and four years. They all were very attached to me mentally and physically. We always had a family bed until roughly ages four and five but they were and are still welcome to come snuggle when they want.

    Whilst, I would not have chosen to have any one of the surgeries; C-sections, although un-natural – save lives and I am grateful for the procedure.

    • says

      There’s what you make of it but not all women have the same support systems to make that a reality. That was something that this piece was speaking to: The need to make sure all women have access to any help needed.

  9. Julia says

    Just wanted to share that I had a TERRIBLE vaginal delivery, and was plagued by lingering issues and pain for months after. In my second pregnancy my baby was sideways (flipped after my water broke naturally) so I was told I’d need a C-sec. I was nervous, but honestly, it was SO MUCH BETTER than my vaginal delivery. I felt great by the time I left the hospital.

    For my 3rd, my doc said I was a candidate for vbac or repeat c-sec. There was no question in my mind. Repeat c-sec!!! It was another great delivery.

    Due to the emotional trauma from my vag delivery I didn’t feel like I bonded as well with first baby, as least right away. I was in so much pain for so long it really took a toll. 10 days after my C-sections I was out briskly walking with the baby, something I NEVER could have done after my vag birth.

    • says

      That’s wonderful you were able to have a wonderful second birth! I would argue that, as you experienced, the trauma is key to bonding post-birth. The problem is that more often than not, people don’t experience what you did (according to the research) and so women should be aware, but more importantly, SUPPORT should be in place for ALL births!

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