C-section Overuse Is Suppressing the Birth Rate

We need to improve maternity care if we want more babies

Cultural and economic factors dominate the conversation about falling birth rates, and the potential solutions. I read a lot of fascinating, well-written, well-researched articles on this topic here on Substack by authors like Elissa Strauss, Lyman Stone, and Darby Saxbe. Yet I don’t hear anyone talking about an important medical reason for declining birth rates. Unlike ambitious policy ideas like paid maternity leave, subsidized child care, or child allowances, which have been discussed for years but remain politically out of reach, addressing this medical issue feels far more solvable to me.

I keep waiting for someone else to make my argument for me since I’m not PhD trained, no one pays me to write, and I already have a full-time job as a midwife (the CNM variety). And honestly, I haven’t noticed fewer babies being born, especially during my night shifts🥱.

Anyway, I don’t want to bury my hook. Here’s my thesis:

Cesarean overuse (and bad, non-evidence based maternity care in general) is suppressing the birth rate. This is true both in the United States and worldwide. Addressing this problem would go a long way to increase the number of babies.

You might be wondering what qualifies me to make this argument. Here are four reasons you should trust me:

1. During my 18 year career, I have had thousands of conversations with women about their childbearing plans, wishes, fears and disappointments. This includes both foreign-born and American women.

2. I have done retrospective research on the topic of vaginal birth after cesarean (VBAC) over a prolonged (11 year) study period which helped me to see that access to VBAC increases the number of babies a person wants to have, and can safely have.

3. I am on my state’s Maternal Mortality Review Team (MMRT) so I’m acutely aware of the combination of factors that leads to the worst outcome of all possible pregnancy-related outcomes (maternal death).

4. I’m a graduate of Harvard Medical School (Effective Writing for Health Care Program, 2022). 😉

Before we begin, can I point out something I thought was obvious? Many pregnancies are unplanned—about half. And the majority of those unplanned pregnancies result in live birth, not abortion. So when we talk about the birth rate in a way that assumes people (mothers) are always making a conscious decision about whether to add another kid to their family, we’re wrong! Many women don’t put together a spreadsheet to weigh the economic and social costs, or discuss a “pros and cons” list with their partners. They just sort of do the deed, get pregnant, and accept the end result (a baby!)

I’m not sure if this point is overlooked because unplanned pregnancies happen more often to people who are Black and Brown, poorer, and younger? Much of the declining birth rate coverage I see focuses on the socio-economic costs of childbearing for college-educated white women. I’m not saying our plight doesn’t matter, but we are not the majority of women and we’re not even close to the majority of moms! Based on the conversations I’ve had with lower-income people—I work at a federally qualified health care center, so most of my patients are on Medicaid—“trying to get pregnant” is about as common as sort of just being in a relationship and accepting what comes.

I make this point because, in my experience, a mom’s emotional and physical health (including whether she gave birth by C-section) is a major consideration in her decision-making about an unplanned pregnancy.

The second point I want to make is that a lot of people want to have a baby but can’t. Over the years I’ve talked to dozens of women struggling with infertility, miscarriage, or who have chosen to forgo another pregnancy due to serious medical risks, often related to prior C-section. I’ve also met many women who gave birth by C-section and were sterilized with their second or third birth in their 20’s (one in her teens!) and who now wish for another baby but can’t have one. I will get into the strong association between C-section and tubal sterilization later.

I want to acknowledge that the first and only article I’ve been able to find about the impact of increased cesarean rates on declining birth rates was published by Lyman Stone in 2019 and since then I’ve seen no efforts to bring this point about falling birth rates into our national consciousness.

Ok, let’s get started. First I want to argue that C-section is overused. I would encourage you to read my piece in Scientific American where I lay it all out, but here is the TL:DR

• The U.S. C-section rate began to climb from just over 20% in the mid 90’s to around 31-33% by the early 2000’s and has hovered in that area for the last 16-17 years.

• C-section rates above 19% are not shown to improve maternal or neonatal outcomes. The difference between a 19% and a 32% C-section rate amounts to about 500,000 excess surgeries in the U.S. every year.

• Hospitals exhibit vast variability in C-section rates (7 to 70%) that cannot be explained by patient factors

Is there a relationship? I wish someone smarter than me would help figure it out.

Ok, but how do we jump from “the C-section rate is too high” to “excess C-section is contributing to lower birth rates?” This is where things will get a bit murky because I don’t have access to the fancy statistical models some other people have. But I do have access to the thoughts and worries of a lot of moms. Here are some themes:

• “I can’t go through another C-section. Please give me your most reliable birth control method.”

• “If I have a VBAC, I might want another baby, but if I have a C-section again I want to get my tubes tied.”

• “My doctor told me I can only have 2 (or 3) kids because I had a C-section.”

• “I just can’t continue with this (unplanned) pregnancy because I just had a C-section.”

You may not be convinced by anecdotes, which is ok. Let’s switch gears a bit. I was recently interested by South Dakota’s governor Kristi Noem bragging that her state has the highest birth rate, so I thought I’d look into the numbers in relation to a few maternal health outcomes that are near and dear to my heart. Here’s a graph of the 5 states with the highest birth rates. AI alert: I used ChatGPT to help me make this graph after using OpenEvidence AI to compile the numbers. Maybe SD has surpassed ND since these numbers came out?

*compiled with AI, used most recent data available, data for each column may come from different years. NTSV stands for “nullip=first time giving birth, term=being born at >37 wk gestation and not prematurely, singleton=one baby, not twins or higher, vertex=baby is head down.”

Are you noticing what I’m noticing? The U.S. states with the highest birth rates also have among the lowest C-section rates, highest VBAC rates, and lowest maternal mortality rates. Could it be that women in these states are having more babies because it’s safer to do so? Could it be that relatively lower C-section rates are part of what’s MAKING it safer?

Maybe you are thinking, “This is correlation, not causation. The women in these states are probably just trying hard not to have a C-section because they plan to have a lot of babies.” This is also likely/possible, but doesn’t that prove my point at least a little bit? Women intuitively know that if they have C-sections, their childbearing prospects change, and their reproductive futures are more limited.

Now I’d like to show you the same graph for the states with the 6th-10th highest birth rates and make another point.

Some states with high birth rates ALSO have high C-section rates. However, this is a deadly combination. Look at Louisiana. It has the highest C-section rate in the country, and also the 47th lowest (aka 4th highest) maternal mortality rate. The same general trend is observed with Oklahoma, Texas and Arkansas. And you can see here that Idaho, with it’s 7th highest birth rate and 4th lowest C-section rate fits in a little better with it’s top 5 buddies (4th lowest maternal mortality rate).

The point I’m trying to make is: the combination of high C-section rates and high birth rates is pretty dangerous for women.

This is well understood by people in my field. Just the other day I was on call at the hospital when my attending obstetrician warned me that they were about to do a woman’s 7th C-section, basically preparing for a blood bath, and that I should try not to need anything for the next couple hours. The tension on the unit was palpable. Everyone knows that the risks of severe hemorrhage, hysterectomy and maternal death go WAY up with an increasing number of C-sections. In contrast, when a woman comes in labor with her 7th child after 6 prior vaginal births, I do worry a bit more about postpartum hemorrhage, but mostly I worry about the baby being born in the toilet.

This is why I was so annoyed when Elon Musk tweeted “Heavy use of c-sections allows for a larger brain, as brain size has historically been limited by birth canal diameter.” So…women should always give birth by major surgery for some hypothetical, unproven benefit to their baby? Makes sense that a guy who thinks technology is always better, and who has no actual knowledge on the subject of the risks/benefits of C-section, would say this. But one wonders how many children he would have had if he had to endure abdominal surgery each time one of his 14 children were born. (Or if he would have even survived long enough to have a 14th child.)

Doctors aren’t wrong when they warn women not to have too many C-sections. You can pretty safely have one or two, but after that, all bets are off. That’s why I think it’s criminal that many hospitals in our country still ban VBAC on the basis that it is slightly less safe for the baby, even though it is much safer for the mom, but that’s a subject for another post.

Ok, now I want to revisit the topic of C-section and tubal sterilization. It’s not wrong for a mom to prefer combining these two surgeries, rather than thinking about it a while and then having a separate surgery, or choosing a less reliable contraceptive when she knows that another pregnancy and C-section could put her at serious risk. But this does make it rather easy to end fertility in a way that is quite final, and some people later come to regret. Tubal sterilization is 8.8 times more common for women giving birth by cesarean compared to vaginal birth.

This makes sense for a lot of reasons, and I’m not criticizing women for their choice here. I just want to say that I’ve talked to many women who strongly regret that they were encouraged or even coerced into tubal sterilization during their C-section, and now wish they could have more kids. I want to be transparent that many of the women I’ve talked to had their tubal sterilization in Latin America, where C-section rates are very high and the consent process for sterilization seems very dubious.

Last point I want to make: pregnancy is likely harder to achieve after a C-section. I do not want to overstate this association (which is why I’m putting it last). While there is evidence from several large cohort studies and meta-analyses that there is increased risk of infertility after a C-section compared to a vaginal birth, this may be due to confounding factors (maternal age, weight) and is not clearly casual. HOWEVER, I think it is important to note that there is a plausible physiologic reason fertility may be lower after a C-section. It’s noteworthy that among women undergoing IVF, prior C-section is associated with lower rates of pregnancy and live birth, higher miscarriage rates, and more difficult embryo transfer. This is likely related to uterine scar tissue that makes implantation less likely.

In conclusion, I am not sure I would use the word “pronatalist” to describe myself, but I really want my patients to be able to safely have the number of kids they want to have. And it deeply saddens me that this is not happening. The stats would show us that people are having fewer children than they say they want. While economic and cultural reasons probably play a bigger role, we should not write off overuse of C-section as an important reason that some people are having fewer kids.

It may sound shocking—a mom deciding the number of children she will have based on whether or not she has to give birth surgically—but it is neither irrational nor uninformed, and there’s pretty good evidence that it is happening.

Oh man, I got to the end of my post and I haven’t even talked about what we could do to lower the C-section rate. Guess I’ll have to write about it next week! ✌️

UPDATE: I got curious about the state-by-state data because some of the numbers in the above tables seemed off to me. I guess it matters from which year you are pulling the data. Here’s an updated table created by OpenEvidence AI (it’s like AI for healthcare professionals) with the stats on the states with the top 10 highest birth rates in 2022. The overall trend is the same: higher C-section rates, lower VBAC rates, and higher maternal mortality rates seem to go together. LMK if you want the reference list.