The alarms are beeping, doctors are voicing commands aloud, sounds of metal instruments banging are resonating in the background, and the pregnant woman is screaming out in pain. This is the image I always saw in movies and TV shows, so this is the image I always imagined childbirth always looks like. These always end up as C-sections in the movies.
C-sections are the most common procedure I see in media because of how urgent they are and how easily they fit into plots. In real life though, C-sections fit into a bigger problem: unexplained overtreatment. How did the number of C-sections increase so dramatically between 1996 and 2016? What is different now?
In the winter of 2019, I went on a journey to Vadodara, India. It was here, in a land busy with noise and life, far from the silence of America, where I learned more about the American medical system by comparing it to what I saw in India. One of the biggest shocks was when I was in an obstetrician-gynecologist (OB GYN) hospital, where people go to give birth.
This is a place where life comes into existence. It is constantly lit by the squeals of newborns taking their first breaths in this world. It seemed more natural than the hospitals in America. The majority of the rooms were almost empty rooms with soft floors, a table, some chairs, a yoga ball, and a rope hanging from the ceiling. These were all supplies that cost less than 50 dollars, and were available thousands of years ago when hospitals did not exist.
The doctor there told me the hospital’s mission is to give as many live births as possible, and they have 2 C-section rooms for when it is absolutely dangerous to give live birth. To assist in giving as many live births as possible, the hospital encourages giving birth in one of the positions shown on the poster above. These are the positions that humans gave birth in for the longest time. Other animals like chimpanzees have similar positions because these positions truly are the easiest for the hominids to do. Years of evolution have led to the mechanisms of giving birth, and every animal is inclined to give birth in the easiest way that leads to the best outcomes. A study called Position in the second stage of labor for women without epidural anesthesia showed that people who give birth with upright positions are 25% less likely to have a forceps or vacuum assisted birth. They are also 25% less likely to need an episiotomy, and 54% less likely to have abnormal fetal heart rate patterns.
These procedures are not harmless. Vacuum assisted birth involves using a suction cup to pull the baby’s head, and often results in a bruise at the baby’s head. Episiotomies are conducted by making a surgical cut at the posterior vagina wall. Avoiding procedures like this is beneficial for everyone involved in the childbirth process.
Other animals use different birthing positions and techniques. Chimpanzees put their heads down to the ground and hold their vaginas pointing upwards. When it is time for them to give the final push, they bring their heads up and their vaginas close to the ground and the baby chimpanzee comes out. If this position is the best, why do people give birth laying down in a bed, a position that no animal ever does?
The answer boils down to King Louis XIV, who wanted to better observe how women give birth. He encouraged people to give birth in that position, and the influence of the royalty led to the popularization of the laying down birthing position. Since then, the laying down birth position has become the most popular way in America (Dundes, 1987).
If there is evidence that the standing positions are clearly better, why does the laying down position still prevail? Doctors and hospitals encourage live births, and often encourage other birthing positions to assist with the live birth, but the C-section rate has only grown. In 1965, 4.5% of births in America were C-sections. In 2016,the rate jumped up to 32.9%. (Why is the U.S. Cesarean Section Rate So High?, 2016). There may be several factors contributing to this. First off, it is possible to schedule a C-section before the birth even happens. Why are there ways to have a C-section before it is even known that it is absolutely necessary? Why do 18.6% of pregnant women prefer caesarean delivery in first pregnancy? Even though hospitals encourage live birth and provide options and information to women, the rate is still high.
One factor may be that women feel like C-sections are safer than live birth. This may be motivating them to do a medical procedure rather than a natural body function that is interpreted as unsafe. Major societal norms need to be changed in order to make progress.
Another reason may be that doctors and hospitals are placed in an interesting position where their decisions cannot be easily checked by others. They can be punished for undertreatment, but not for over-treatment. Thus, it is much safer to over-treat.
How does this culture of overtreatment affect doctors, and what are the repercussions for patients? I do not know how this problem can be solved in America, but I hope that eventually, we will be seeing more natural births with different birthing positions on TV and in movies.
Dundes, L. (1987). The evolution of maternal birthing position. American Journal of Public Health, 77(5), 636-641. doi:10.2105/ajph.77.5.636
Why is the U.S. Cesarean Section Rate So High? (2016). Retrieved November 6, 2020, from https://www.nationalpartnership.org/our-work/resources/health-care/maternity/why-is-the-c-section-rate-so-high.pdf
Gholami, A., & Salarilak, S. (2013). Why do some pregnant women prefer cesarean delivery in first pregnancy?. Iranian journal of reproductive medicine, 11(4), 301–308.
Gordon, M. (2019, April 19). Why Do Doctors Overtreat? For Many, It's What They're Trained To Do. Retrieved December 07, 2020, from https://www.npr.org/sections/health-shots/2019/04/19/715113208/why-do-doctors-overtreat-for-many-its-what-they-re-trained-to-do