The C-section Rate Doesn't Have To Be This High

Here's what we could do about it

In my last post I made the bold claim that C-section Overuse Is Suppressing the Birth Rate. If you didn’t read that post, I promised at the end that I would go into more detail about what can be done to reduce the C-section rate. Afterall, even if I’m wrong about high C-section rates suppressing the birth rate (which I’m not!) there are plenty of other benefits that could come from dropping the U.S. C-section rate from, say, 1 in 3 births to 1 in 5 births. But before we begin, I want to reiterate something.

C-section can be a life-saving surgery for mom, baby or both.

Sometimes when I write about the C-section rate being too high, I get responses from women who feel criticized or “less than” because they had a C-section. That is definitely not my intention. I’ve had many patients over the years who needed C-sections, and there is nothing about needing a C-section—or accepting one from trusted medical authorities who tell you it’s necessary—that makes a mom less worthy. There is inherent risk to pregnancy and childbirth, so I have the utmost respect for anyone who chooses to roll the dice and walk this path of parenthood, no matter how they give birth.

Furthermore, C-section doesn’t have to be an awful, traumatic experience, and for some people it is literally the best outcome possible. In a previous post called “Lessons from a Bad Birth” I wrote about a labor I attended that ended in C-section. I learned a lot from the mom’s really beautiful response.

Anyway, my point is, when I discuss how we could safely lower the C-section rate, I am talking about it on a population level. That being said, there is a possibility that reading this will tip people off as to the ways they did not get ideal maternity care. If this ends up applying to you, please know that it is not your fault. Rather, it is the responsibility of maternity care staff (doctors, midwives, nurses) to appropriately recommend C-section. The onus is on us as the people who went to school for this, not you.

It’s like when I take my car to the mechanic. I don’t know much about cars, so if they say I need a repair, I usually trust them and shell out the cash—because if I don’t, my car might break down, or worse, I could get into a serious accident and die. If they’re lying just to save time or upcharge me, that is obviously unethical. (I hope you’re reading this HONDA DEALERSHIP!)

My goal in this post is to talk about the C-sections occuring in our country that don’t meet evidence-based standards, and how we could change that. Of course, there is always some gray area in determining when a C-section is truly necessary, but from my perspective, that uncertainty isn’t what’s driving the high rates we see.

Let’s start with why I believe that non-evidence based cesareans are common. A few reasons…

Before I was a midwife (CNM), I worked as a nurse (RN) in two hospitals where doctors had total liberty to recommend and perform unnecessary C-sections. Due to “failure to progress” when the mom had not been given anywhere near enough time to dilate in labor. Due to “fetal intolerance,” a highly subjective diagnosis that seemed to mysteriously happen a lot more during the day shift. Because the baby was deemed “too big” or the woman’s pelvis “too small.” Because vaginal birth after cesarean (VBAC) “wasn’t allowed” in that hospital. Because the doctor “had a flight to catch.” I even remember a C-section that was done for breech presentation, only to find the baby was actually head down. 🙄

You’re probably wondering why we nurses put up with that. Well, we did bring our concerns to management at times—but almost nothing was done. The hard truth is, doctors are in short supply, and hospitals rely on them to bring in patients and therefore, profit. So even if doctors are practicing outdated, non-evidence based medicine, it can be hard for the system to challenge them and get them to stop. Also, a hospital’s incentive to avoid unnecessary C-section is often low—they get reimbursed more for C-sections than vaginal births.

So perhaps you’re thinking, this is probably just one bad hospital. But I genuinely believe there are hospitals like this across the country. I believe this based on conversations I’ve had with mothers who’ve shared surprising and troubling stories about their experiences, from personal accounts I’ve read online, and from patterns that are evident in the data.

I also want to be clear that not all hospitals are part of the problem. Some have made meaningful efforts to reduce or avoid unnecessary C-sections, like Intermountain Healthcare System in Utah. (If you recall from my last post, Utah also has among the highest birth rate states. Coincidence? I think not!) I’ve also had the privilege of working as a midwife at two hospitals where non-evidence based C-sections were simply not an issue. That experience showed me firsthand that a 20% C-section rate is possible. I will get to that later!

And as an FYI, this link can be used to find your hospital’s NTSV C-section rate. Oh look, here’s mine 😊:

So let’s talk data. My second reason for believing that C-section not supported by clinical evidence is a problem in our country is that I’ve read a lot of journal articles on the subject and there are some pretty incriminating findings.

• Here’s a study showing the timing of “unplanned” C-sections cluster around certain times of day and days of the week (So make sure you go into labor on a weekend! I did this with my 3rd child, born on a Saturday, and had the whole unit to myself. 😊)

  Three temporal peaks of total and primary cesarean delivery were seen on weekdays, corresponding to immediate preclinic, lunch time, and immediate postclinic timeframes. These peaks were not seen on weekend days. The risk of nonelective primary cesarean delivery during a weekday was approximately one third higher than on a weekend

• This one called “Drivers of Racial Differences in C-sections” found that:

  Black mothers with unscheduled deliveries are 25 percent more likely to deliver by C-section than non-Hispanic white mothers. The gap is highest for mothers with the lowest risk and is reduced by only four percentage points when controlling for observed medical risk factors, sociodemographic characteristics, hospital, and doctor or medical practice group. Remarkably, the gap disappears when the costs of ordering an unscheduled C-section are higher due to the unscheduled delivery occurring at the same time as a scheduled C-section. This finding is consistent with provider discretion—rather than differences in unobserved medical risk—accounting for persistent racial disparities in delivery method.

• This one found that only 40.6% of NTSV (nullip=first birth, term=not premature, singleton=only one baby, vertex=head down baby) C-sections met Obstetric Care Consensus guidelines for when C-section should be done

• This one found that hospital C-section rates vary ten-fold, between 7-70%:

  Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals.

• This one looked at areas in the country with significantly higher or lower C-section rates than average (see map below: red areas=high CS, blue areas=low CS) and concluded:

  Our findings show that there is remarkable variation in C-section rates across the United States. These findings are not random, but also are not easily explained by any single factor. There is a strong connection between the American South and increased C-section rates. This trend is true in both rural and urban areas of the South and is true across regions of varying racial demographics. Additionally, in general, the American West and Midwest have more regions of decreased C-section rates than the Eastern United States. However, the trends have major exceptions to the above generalizations. These outlier regions, such as Michigan’s upper peninsula and the Kansas-Nebraska border, may deserve further investigation to determine the exact cause.

Here’s looking at you, UP Michigan, NYC, Kansas and the American South. My guess: “further investigation” will reveal a lot of non-evidence-based cesarean in these areas.

You might be thinking, “Well, of course C-section rates are higher in the South where people tend to be less healthy—they have higher rates of obesity, hypertension and diabetes.” And you’re not wrong to make that connection. I agree that certain higher-risk populations can actually have improved outcomes with higher C-section rates. But we’re talking about the difference between 20% and 25%—not 40%.

Let me move on to some of my own experiences as a CNM. During my 18 year career, I have belonged to a practice of midwives and physicians, backed up by wonderful collaborating obstetricians, wherein the C-section rate has never exceeded 19%.

If you’re thinking “well, you’re a midwife, so you probably only care for completely low-risk, healthy women who practice yoga every day and drink kombucha,” you’re wrong.

I work at a federally qualified healthcare center (FQHC) serving a diverse community. Many of my patients are Medicaid recipients and come from racial and ethnic groups that, on average, experience higher c-section rates compared to non-Hispanic White populations. They also face higher rates of obesity, gestational diabetes and hypertensive disorders during pregnancy. Our clinic provides care for people living with HIV, opioid dependence, and mental health challenges. We welcome patients who come to us late in pregnancy with limited care. With very few exceptions (twins, preexisting diabetes) we strive to provide care for everyone who walks in the door.

So if we can maintain a low C-section rate in spite of all this, I think other places in the country could as well.

I read a lot of takes on why the C-section rate in the U.S. is so high, and what we can do about it. One argument I find unconvincing is that “nothing can be done” and that the overuse of C-section largely beyond the control of physicians or hospitals. For example, a 2018 clinical opinion by five physicians from Texas—a state that consistently ranks in the top 10 for highest C-section rates—suggests that the U.S. cesarean delivery rate results from “forces largely beyond the control of practicing clinicians.”

While I want to be charitable—and these doctors bring up many good points about their litigation fears, women’s sometimes unrealistic expectations during childbirth, and the limitations of technologies currently used to predict healthy birth—I fundamentally disagree with their conclusion that clinicians are powerless in this situation. These factors are real, but they don’t erase professional responsibility of making the right recommendation to the person that’s in front of you.

I attend hospital births too. I worry about lawsuits. I understand that certain outcomes are simply beyond my control. And I agree—our current fetal monitoring technology is woefully inadequate at predicting which babies are compromised. It’s also clunky, uncomfortable for moms, promotes lying on the back (which isn’t ideal for labor), and is basically the same difficult-to-use technology we had 20 years ago when I started my career in maternal health. Seriously—scientists and engineers, please get on this.

But saying that you, as an obstetrician, have no control over whether someone has a C-section is a little bit like a judge claiming they had no choice but to hand down a harsh sentence because of media pressure or public opinion. Yes, those external forces are real—but justice still relies on the person behind the bench. Similarly, birth outcomes still hinge on the clinician’s ability to navigate complexity without being swayed by fear, personal convenience or systemic incentives. In the end, the decision still comes from the person holding the scalpel…

So, with all due respect, it’s hard to justify looking past the state of Texas’s 34.7% C-section rate, especially when there is good evidence that neither maternal nor neonatal outcomes improve when the population level C-section rate exceeds 19%. At some point, not engaging with the data becomes difficult to defend.

There’s not “nothing we can do.” In fact, there are many meaningful steps we could take to lower the C-section rate.

For example, I think the C-section rate would plummet if we did these simple things:

1. Stop permitting non-evidence-based, non-medically indicated C-sections. This includes ending reimbursement for hospitals and physicians who consistently perform them without medical justification.

2. Require hospitals to support vaginal birth after cesarean (VBAC). Hospitals should not be allowed to ban VBAC. Instead, they should have a plan to support VBAC safely by calling in necessary personnel.

3. Integrate midwives into all maternity care settings. This means ending a hospital’s right to deny admitting privileges to certified nurse-midwives (CNMs), ensuring that Medicaid and private insurers reimburse midwifery care equitably, and expanding midwives’ presence across the U.S. healthcare system.

4. Provide continuous labor support to all people in labor. This could be through a doula, a midwife, or 1:1 nursing care—from someone who is actually present and engaged in the labor room.

Yikes, I did it again! I got to the end of my post, and really wanted to expand upon these last 4 items, but I don’t have time. Gotta go to clinic and take care of some pregnant people. 🤰 But I will plan to address these last 4 points in a future post!

If you have any questions, concerns or counterpoints, I’m happy to address them in the comments, provided you’re willing to engage in a respectful way. ✌️🧡👶🏽👶🏻👶🏿