It has come to my attention that Dr. Amy has recently had a post in which she blasts home-birth and natural-birth advocates for talking about a 15% C-section rate as being ideal. She also talks about the fact that countries with high C-section rates have low maternal mortality and vice versa. In connecting these topics, she seems to be advocating for a high C-section rate as being a good thing and possibly even necessary for low maternal mortality. But when pinned down, she doesn’t carry it that far — yet she implies it as much as possible.
It seems to me that she was just trying to find something to sneer at home-birth and natural-birth advocates for, and getting on her high horse of being so much smarter than them because she found a study which shows that countries that have lower than 15% C-section rates have high maternal mortality and vice versa is one way of doing it. The fact that just looking at C-section rates and a country’s maternal and neonatal mortatity is so incredibly shallow never seemed to enter her mind. Nor did she seem to remember that just two short years ago, she said that a 30% C-section rate was “at least twice what it ought to be.” So, two years ago, she was in accord with the natural-birth advocates she’s now demeaning for saying that a 15% C-section rate is what it ought to be. While I understand that people’s understanding can change over time, she never explained how she came up with “an ideal C-section rate,” nor what changed her mind from a near-30% C-section rate being “outrageous” to being acceptable or even laudable.
Delving a little deeper into this question, we see that on the face of it, it is accurate that countries with a high C-section rate have a low rate of both maternal and neonatal mortality. But is that the only difference between countries like the United States and Sierra Leone? or between Great Britain and Kenya?
Let’s look at the major causes of maternal mortality in the world (from 2002):
Nearly two thirds of maternal deaths worldwide are due to five direct causes: haemorrhage, obstructed labour, eclampsia (pregnancy-induced hypertension), sepsis, and unsafe abortion. The remaining third are due to indirect causes, or an existing medical condition that is worsened by pregnancy or delivery (such as malaria, anaemia, hepatitis, or increasingly, AIDS).
This document echoes the above statement, and says that “80% of [maternal] deaths are related to anemia,” and that “99% of maternal deaths occur in developing countries.”
So, would a C-section help reduce maternal deaths? It obviously wouldn’t help in the enumerated “indirect causes” nor for “unsafe abortion.” It obviously would help in cases of obstructed labor. The others are a little more difficult to tease out, but there is one major thing to consider — a C-section in the United States is quite a bit different from the way it would be in many areas of the world. Here, C-sections are relatively safe, although in developed countries (such as France), “the risk of postpartum death was 3.6 times higher after cesarean” than after vaginal birth. With so many maternal deaths related to anemia — which is easily prevented or treated in developed countries — it is obvious that in much of the world, there is no such thing as a “safe” C-section. They don’t have the resources for things we take for granted like prenatal vitamins and iron supplements. If a woman has a postpartum hemorrhage in the United States, it can be quickly and easily stopped by giving a shot of Pitocin — many midwives carry this to home births — and if bleeding doesn’t stop quickly, more aggressive measures can be taken, and the woman can be given a blood transfusion if necessary, or even a hysterectomy. Many countries don’t even have these lesser interventions — how can they manage C-sections? Here in the United States, most women live within 30 minutes of a hospital, or at least an hour’s ride by car. In many areas of the world, women don’t even have cars, and calling the paths to get to their villages “roads” is an overstatement.
This document defines postpartum hemorrhage as any blood loss over 500 ml, which is the typical amount lost in a C-section. If many women in the world cannot handle the blood loss of a typical C-section, how could it save their lives? It’s obvious that countries that can safely perform C-sections also have access to all the lesser things that save more women’s lives, in managing or preventing hemorrhage, eclampsia, and sepsis. How are women’s lives supposed to be saved by C-section, when a major cause of death is sepsis, which could only be exacerbated by abdominal surgery?
This document, on the association between high maternal mortality and a low C-section rate says the following:
It is likely that in low-income countries, cesarean section rates are highly correlated with availability of health care services and actual provision of health care to the population, which are the main determinants of health outcomes…..
Our findings should be compared with a WHO international survey conducted in 120 hospitals in 8 Latin American countries (34). The survey collected prospective individual data on all births for a period of 3 months at each hospital and found that increasing rates of cesarean section were positively associated with maternal and neonatal mortality and morbidity, especially above 10 percent.
So while women who need C-sections will find them life-saving, when C-sections are overused, they may be more of a burden than a blessing.