Until recently, my vision of childbirth was driven by television. Situation comedies taught me to imagine a woman reclined in a bed. The husband stands slightly behind her and to the left, holding her hand, which is squeezed every time the birthing mom hears “push!” from the doctor.

Nearly every part of that picture was fabricated for television.

I have only recently come to understand that, while we imagine the mother or birthing person to be the center of the picture of birth in the United States, in fact, she is sometimes pushed to the side while the doctor takes over.

Prevalence of the C-section in the United States

Nearly one in three babies are born through a process that is almost never shown on TV — they are born through Caesarean section.

A C-section is, according to the National Institutes of Health, “the most common surgery performed in the United States, with over a million cesarean deliveries performed every year.” It has, over the past fifty years, skyrocketed as a way of delivering a child. Again, according to the NIH, rising from 5% of all deliveries in 1970 to 31.9% in 2016.

There are many factors that could explain why C-section has become more popular. Birthing people are getting slightly older, and people are giving birth later than ever before, we know — into their forties. With age comes increasing complications in birth.  The same may be true of other demographic factors. As Americans get heavier, moms and birthing people get heavier. As Americans experience hypertension at greater rates, so do moms and birthing people. All these factors make birth more complicated.

Still. A 600% increase can’t be explained by these demographic changes, especially when most European moms and birthing people in industrialized nations receive C-section around half as often, according to the World Health Organization.

What has changed is our perception of risk and the perception of risk among doctors delivering babies.

Do doctors suggest C-sections because it’s right for the baby, or right for them?

According to the NIH, there are more than two dozen reasons why a doctor and patient might decide to give birth to a baby through C-section. These include cardiac or pulmonary disease in the birthing person and malpresentation by the fetus. There are many, many reasons why a doctor might suggest a C-section is the best way to give birth to a child.

At the same time, there are, according to the NIH, “no true medical contraindications to the cesarean section.” From the doctor’s perspective, a C-section is perceived as the choice for birth without risk. “While there are ideal conditions for cesarean, such as the availability of anesthesia and antibiotics, and appropriate equipment, the absence of these is not a contraindication if the clinical scenario dictates.” Any place and time where one of the indications for C-section is present, a C-section is, then, the best and safest option, according to the NIH.

In our litigious society, there are no circumstances where an evaluation of the choice to deliver by C-section would be questioned by colleagues, by family, or, notably, by lawyers. Instead, the choice to avoid a C-section and attempt a vaginal delivery is perceived as electing to “take a risk.”

Do birthing people recognize the risks to C-sections?

C-section Risks and Consequences

Studies like Valentina Tonei’s study in Health Economics tell us that “mothers having an unplanned caesarean section are at higher risk of developing postnatal depression.” Families, doctors, and even mental health providers just do not understand how to support moms after C-section.

C-sections are believed to increase the rate of placental problems, reduce fertility and increase the risk of a future C-section. So birthing people and babies in future pregnancies bear the weight of the last decision to go to C-section. According to Oonagh E. Keag, Jane E. Norman, and Sarah J. Stock, (writing in PLOS Medicine), C-section is associated with “with increased odds of asthma and obesity in the child. Cesarean delivery is associated with future subfertility and several subsequent pregnancy risks such as placenta previa, uterine rupture, and stillbirth.” According to the American College of Obstetrics and Gynecology, “Cesarean birth also increases risks for future pregnancies. These risks include placenta problems, rupture of the uterus, and hysterectomy. Some placenta problems can cause serious complications.” It’s a lot to think about.

I don’t have any clear sense of why or when someone should or should not get a C-section. (Remember, I’m still surprised it doesn’t look like what I imagined on TV.)

What Now?

I have learned a lot about birth by talking with the birth workers at Aspirus St. Luke’s through the Plus One Doula program funded by the Bush Foundation.

I encourage moms and birthing people to talk with their doctor (and with other birth workers, like midwives and doulas) about the conditions under which they will agree to a C-section. As moms and birthing people who should be at the center of the story, they should be prepared with questions if the doctor recommends a C-section. There is a document called a “birth plan” that can be developed to help think these things through.

I’m a writing teacher. I like documents as a way to think. A birth plan is a way to think for yourself and with your care professionals. And this is a lot to think about.