GRSJ224/Cesarean Section

The Cesarean section (commonly known as the C-section) is a surgical operation used to deliver a child by opening up the abdomen - it is the the most common surgical intervention in the world. The C-section is intended for when vaginal birth would pose a health risk to the mother or the child. Although in some cases C-sections are necessary to prevent further harm, the procedure comes with its own risks. In line with modern medical ethics, the decision to continue with a C-section should be taken only with the patient’s informed consent, respecting the patient’s bodily autonomy.

Prevalence

The World Health Organization recommends that C-section rates should remain between 10-15% per 10 live births. However, research has indicated that the recommended rate may need to be revised upwards. A study published by the Journal of the American medical association has indicated that increases in c-section rates up to 19% may decrease maternal and neonatal mortality rates. C-section rates vary globally, ranging from extremely low levels - suggesting women are not receiving sufficient medical attention - to very high levels - suggesting that C-sections are being performed for unnecessarily or for non-medical reasons. Rates are increasing in most regions, which may have consequences on reproductive health and resource distribution. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. World health report, 30, 1-31</ref>.

Socio-economic Disparities

Research has shown cesarean section percentages vary based on a country's income rating, as measured by GNI. Many low income countries have C-section rates below 10%, while middle and high income countries often have rates above 20%. C-section rates also vary as a function of intra-national income disparity. A country's overall C-section rate may not accurately reflect the rates for all communities in that particular country. Those from lower income communities generally have the lowest cesarean section rates, indicating that many are not getting proper access to the procedure. A 2006 study collected data on socioeconomic status and cesarean rates from countries in Sub-Saharan Africa, Southeast Asia, Latin America and the Caribbean to determine the relationship between socioeconomic status and C-Section rates. C-section rates were below 1% for the poorest quintile of the population in twenty of the countries studied, and below 1% for all but the richest quintile in six of the countries studied. On the other side of the spectrum, some Latin American countries have cesarean rates above the recommended rate of 15%, despite comparatively lower income. Paradoxically, in these countries both low and high income women have C-sections at rates higher than 15%, although lower income women undergo the procedure at rates closer to the WHO’s recommendation.

Effects of Increasing Rates

Increases in C-section rates have different effects on overall health outcomes depending ona country’s income: In low income countries, increasing more C-sections lower mortality, but this isn’t the case for high income countries, because most high income countries meet or exceed the recommended rate . Despite this, Northern America has shown the highest rate of recent increase, (6.4%), as rates increase rate globally. Brazil has shown a particularly dramatic increase in C-section rates - data collected in 2014 showed that the rate has increased to 57% overall, with a 35-45% rate in the public healthcare system and a staggering 80-90% rate in the private system.

Incentives to choose Caesareans

The high rate of cesarean sections is often portrayed as an outcome of women actively choosing to undergo the procedure. Research contradicts this explanation and points to the influence of other factors. A study conducted in Brazil found that although 70% of participants had no initial preference for a C-section, 90% of them underwent the procedure. A postpartum survey was conducted to measure the factors influencing women to choose C-sections, included fear of pain from vaginal delivery, fear of compromising their sex life, and belief of increased safety for the newborn. The survey found that aesthetic, sexual, and safety concerns did not strongly influence the decision for cesarean sections, that women believed recovery time to be faster for vaginal birth, and that they did not believe vaginal birth would impact sexual enjoyment for them or their partner. Nevertheless, 72% of women in the private sector who wanted to deliver vaginally ended up delivering by cesarean and 80% of women in the public system who wanted wanted to deliver vaginally delivered by cesarean.

Power Imbalances and the Medicalization of Childbirth

It has been suggested that the power imbalance between doctor and patient, the ability to schedule cesarean sections for financial expedience, and the medicalization of childbirth may be biasing doctor’s preference for cesarean sections. During labour obstetricians seem to reinforce the fear of pain associated with childbirth to sway the direction of delivery towards a cesarean section, which, in some cases are justified by pain alone, despite the lack of explicit requests for a cesarean or initial requests during pre-natal care. This is a clear example of the medicalization of childbirth, resulting in unnecessary surgical intervention. This process of medicalization combined with power imbalance between doctors and patients blurs the line between choice and obligation, at the expense of women’s bodily autonomy.