Why is the C-section rate so high?

From Fixin' Healthcare:

For example, what is going on with care during pregnancy and delivery? This is a biological process that in the absence of complications cannot be improved upon with technology... Yet, beginning in the 1970s the incidence of C-sections rapidly increased.

As an obstetrician, there is very little that makes me angrier than attempts to blame the outrageous C-section rates on obstetricians.

First there is the pernicious blather about how pregnancy as a “natural condition”. Doctors, especially, should know better. Pregnancy is the single most dangerous phase of the average woman’s life, excluding old age. That’s despite the fact that modern obstetrics can successfully treat virtually all pregnancy complications. Historically, pregnancy was extremely dangerous. All you have to do is take a stroll though an old cemetery and see how many young women are buried there, victims of the “natural” state of pregnancy.

Complications in obstetrics are common, not rare. That’s in keeping with the fact that human reproduction on the whole is an extremely wasteful process. The gross excess of gametes, the high miscarriage rate, and the incidence of deadly pregnancy specific diseases like pre-eclampsia are just part of this.

Pregnancy is not “designed” to turn out fine; it is not “designed” at all. It is the results of millions of years of evolution balancing competing evolutionary benefits. For example, it is better for babies to be born with greater neurological competence (and therefore bigger heads), but it is harder for women to walk with a pelvis larger than certain dimensions. Those evolutionary needs have been in tension for millennia. The result is that often babies are too big to fit. In the good old days, women who could not accommodate a large baby died after an agonizing three days of obstructed labor. Or perhaps, they didn’t die, but the dead baby was removed in pieces and the woman suffered a recto-vaginal fistula that left her a pariah. Nowadays such women have a C-section and never stop to consider it a life saving procedure.

Before the advent of modern obstetrics, the most common causes of death in pregnancy were eclampsia, hemorrhage, infection, ectopic pregnancy, embolic phenomena and cephalo-pelvic disproportion. None of these are lifestyle issues. Many of these have benefited from the liberal use of C-sections.

Pregnancy demands a healthy diet.

No it doesn’t. More than 99.9% of all babies ever born were born to women who lived on subsistence diets. The impact of diet on pregnancy is minimal.

Yet beginning in 1970, the incidence of C-section rapidly increased.

You bet it did, and it had absolutely nothing to do with lifestyle. It’s because obstetricians are trying to prevent malpractice suits. It is virtually impossible to defend yourself in a “bad baby” case if the baby was born by vaginal delivery, even if C-section would not have made any difference at all. Pregnancy in its “natural” state results in many dead babies. Pregnancy in its modern state considers dead babies unacceptable and physically or mentally compromised babies are even worse.

Any risk of any kind is now unacceptable. The incidence of C-sections was rising in the 1990’s because of the safety of VBAC (vaginal birth after C-section). That was completely derailed when administrative organizations like ACOG announced that the risk of VBAC warranted in house anesthesia and 24 hour doctor attendance. For most small hospitals, it thereby rendered (unnecessary) repeat C-sections mandatory.

The role of lifestyle in health is grossly exaggerated (it’s wishful thinking more than anything), but the role of lifestyle in pregnancy is, if anything, even more grossly exaggerated. There are a lot of problems in modern obstetrics, and the outrageous C-section rate is indicative of this, but these are not lifestyle issues and these are not the fault of obstetricians.