The Caesarian Conspiracy

The (almost) futile quest for scientific facts about the “miracle” of birth

Of the five friends whom I spoke with at some length about their first birth, every single one reported a birth “gone wrong”. Of the five, one had underestimated the birth pain, compared it to the feeling to be cut open by a chain saw, and screamed so loud that she could be heard on the ground floor of the hospital. Another had such a long torture in the birthing center that she longed for a caesarian, which was however prevented by her midwife. Another had to suffer all day until it was eventually too late for a PDA or a caesarian. Yet another had looked forward to her natural birth so much that she experienced the then required caesarian as a trauma. My fifth friend as well had to undergo a secondary – that is a non-elective – caesarian instead of the natural birth she had planned for.
Lastly, there is my own mom, who because of her difficult birth involving a vacuum extraction had to endure terrible pain and late effects – not to mention my own burst head, which a big scar still reminds me of. I do not know about the experiences of two other friends of mine who also gave birth in the last years. However, even if one generously supposes a “normal” birth, the quota of “abnormal” births in my circles would be 5/7 or 6/8, if one considers my mom. Given this stunning statistic, one is inclined to question whether the common idea of a “normal” birth is correct.

Already about two years ago, I started having first doubts regarding the prevalent opinion that a natural birth is usually the best choice. But my quest for truth since mostly hits borders.

When I suggest a primary, i.e. planned caesarian as a useful way to give birth, women often react shocked, wondering how anyone would voluntarily be “cut open”, subliminally accentuated with that hint of morality, whereby it is a good mother’s duty to suffer for her child. “With pain you will give birth to children”, the Bible already knew. If one is not willing to make this sacrifice, then maybe it is not a good idea to have children at all, such the tenor.

How a child would benefit from the superfluous suffering during birth, I always ask, but only hear answers about the “stronger bond” that natural births craft between mother and child. How can this be biologically explained, whether there are any corresponding facts? No, that would naturally be very difficult to measure; it probably had to do with hormones that are only released if the child passes through the birth channel, or something like that. I see. So it is measurable then? Silence.

I don’t give up and suggest: Well, giving birth could be considered a life and death situation where the mother produces endorphins upon survival – maybe that is mistaken with love for the child? On this, only a vague reaction stating that it is only logical that a birth would bind one stronger to the child. I: Oh, you mean like a couple that is more likely to stay together if they had endured a life threatening situation together? Restrained consent. So you seriously suggest that I should artificially put myself in a life-threatening situation, as else I would not develop enough feelings for my child, I ask incredulously. No, not as exaggerated as that, I hear in response. But a real answer never comes.

If the argument about the bonding does not work out, the second oft-quoted benefit is the “faster recovery” and the fact that after a natural birth the mother is usually able to move around sooner. Where they took this information from, that one about the faster recovery? From friends, or the midwife. Ah. And whether that one-day or even one week that one has to lie down longer really justifies the tortures and possible late effects of a natural birth, I ask. Well, so they say, if you have a caesarian you are all immobile after birth, with that cut in your belly, so you can’t even take the baby into your arms, and is surely traumatizing for the baby. Surely – and where is that written? Silence.

One may not have concrete scientific arguments, they argue, but after all Mother Nature planned for a birth in this way and she certainly had her reasons. It surely would not be good to just rip the child out like that, without it having triggered contractions; and who knows, what hormones mother and child are foregoing with a caesarian. Well, that could be checked scientifically, I am sure there are studies on that subject, whether they read them? No, one does not have to make this thing into a scientific study – they rather trust their midwife, who is an old hand whose art is thousands of years old. Whether she otherwise also prefers thousand year old medicine to antibiotics and chemotherapy? That would not be comparable in such a fashion. Really?

They had also heard that after a caesarian birth, newborns often have breathing problems and the child would overall become a bit feeble, which would only be natural given the fact that it did not have to struggle for survival. What “breathing problems” means exactly, and where they heard about it? Some doctor told them, that much is remembered. At least. And that thing about the struggle for survival… even if the baby could subconsciously remember something later: would one otherwise put their child in a life-threatening situation to make it “tougher”?

Equally unclear, but not less relevant for me as a woman is the question how things “down there” look like after birth. It all shrinks back together, I hear everywhere. How then is it that every following birth happens faster, if not for the worn out tissue? In online forums I read all kinds of things, ranging from the “lost penis” syndrome and incontinence to women who swear that everything has become “even tighter” for them. Even more confusing however is the fact that in my circles nobody seems to give a thought to this, or only in secret – as if it was a shame towards the child to protect their own health and sexuality. Also in online forums, I noticed that the collective often punishes women who dare to consider the state of their genitals. Articles condescendingly mention the vast majority of Brazilians, who opt for a caesarian “just” to protect their “honeymoon vagina”. What insolence of these Brazilians!

Even two gynecologists whom I consulted are not able to explain to me, based on scientific evidence, what the actual pros and cons of natural birth versus caesarian are. Instead, I hear the usual slogans about how cutting should always be avoided (“it is a real operation after all” – really!) and that it is a totally individual decision and so forth.

For any other treatment, it is normal that a physician informs his patient about its real risks – this rule however does not seem to apply to births, as they are “natural”. The rumour prevails that a majority of female gynecologists prefer a caesarian for themselves. No statistic or doctor could confirm this claim to me yet though. A female doctor only smiles quietly in response and a male doctor replies that his own wife had had a natural birth, that should be evidence enough. Is it?

Shouldn’t the growing number of secondary cesareans be seen as an indicator for the fact that medical staff knows about the higher security of a caesarian? Well, one would rather assume that this has to do with the profit orientation of the hospital. Of course, again any evidence is lacking. Often, the medical usefulness of a cesarean in case of birth complications is interpreted in such a way that the responsible doctor is lacking the necessary courage. Birth as a test of courage?

Since neither individual statements in my circles, nor in online forums, nor from doctors seem to contribute to well-founded knowledge, I continue my quest by researching scientifically sound information on the topic. On flyers from the German NGO “pro familia”, websites of birth clinics and Wikipedia I find a bit more substance: There, possible pelvic floor injuries and complications of natural births are mentioned and contrasted against possible breathing problems of the child as well as thrombosis, scarring problems as well as post operative pain of the caesarian birth. The lethality of the caesarian is sometimes given as higher, sometimes as the same as that of natural births.

But again, data are not quantified, and no difference is made between primary, elective caesarians, secondary, non-elective caesarians in case of mild complications, and emergency caesarians in life threatening situations. Sources are rarely mentioned at all and very often, hypotheses are presented as facts.

In the end, the same overall hypothesis of the “maybe unpleasant, but ultimately more healthy” natural birth and the Ceasarian birth “for emergencies” prevails, without having been argued properly. Consistent with this, all official recommendations seem to agree: There should be a severe medical indication like too narrow hips or wrong position of the baby, before choosing the scalpel. Thus the WHO quite randomly advises to “keep” the caesarian birth rates below 15%.
Should I be afraid of the pain, so I am informed on clinics’ websites, I should better get therapeutic assistance. Millions of women had done it before, so I would be able to do so as well!

The less information I was able to find on the topic, the more it occupied my mind. And with every suboptimal natural birth over those two last years in my circles, my skepticism grew.

Last week now, coincidence made me stumble across a German e-book which was finally able to address at least, say, 80% of my open questions adequately, with supporting data and statistics mainly from German-speaking countries. Granted – its title “Ceasarian – the silver bullet” by author Dr. Martina Lenzen-Schulze (“Königsweg Kaiserschnitt”) does not sound very objective. However, every mentioned fact and number is supported with studies or statistics, some of which I checked. Here are its most important findings with my comments:

1. Today’s birthing reality:

• According to representative studies from Bavaria and North Germany in 2013 only 28% of babies were delivered without any medical intervention (the rest: 33% ceasarians, 7% forceps or vacuum births, 32% with at least an episiotomy, medical labour induction or PDA). According to the German association of midwives, the percentage of totally natural births is actually only 7%
  -> Why are medical interventions during a vast majority of natural births (72 or 93%) necessary, if the normal birth is such a desirable ideal? Can this high number really be attributed to the profit orientation of clinics, lack of courage of doctors or some kind of mistake?

• The German average age during birth in 2011 was 30.2 years. 40% of these women are overweight (14% obese), 11% have smoked until delivery, and 4% were multiples births.
  The best age for birthing is between 25 to 30 years, and obese women have a significantly higher complication risk (heavy babies and belly difficult to scan manually.
  -> In view of this “unideal” reality it can be questioned if a natural birth is truly better than a caesarian

• 31% of 282 female gynecologists of London have stated in 1997 already to prefer an elective caesarian – mostly to avoid a pelvic floor trauma. For babies with a weight exceeding 4 kg, 70% of their US colleagues have done so in 2011, and for babies exceeding 4.5 kg 88%.
  Among German midwives, this percentage is 20% all the same. Consistent with this, an above average tendency can be seen among related professionals to prefer a caesarian birth for themselves.
  -> People who know and who are acquainted with the subject tend to have a caesarian more often than the average woman. That is some food for thought.

• Related to this: Gynecologists have caesarian births about twice as often as they advise to their patients (unfortunately this is not quantified).

• 97% of Chinese women who have delivered the caesarian way are satisfied with their birth. For natural births, the rate is only 55%.
  -> The Chinese may tick different from us, but the statistic is still insightful. However, no further info is given on what kind of caesarian the women had

• About half of a representative group of British women tried to have a vaginal birth after their first Caesarian. The high rate is mostly attributed to whether or not the caesarian had been voluntary – if it had been secondary, they were likely to attempt a vaginal birth afterwards.
  -> Not only the Caesarian itself, but also its circumstances seem to play a big role in how a caesarian is judged by mothers. Maybe the mentioned Chinese had all had a primary Caesarian?

2. Consequences of a vaginal birth:

• As of today’s scientific status, the outcome of a natural birth is not well foreseeable. Accordingly, 46% of births are predicted incorrectly. More than 50% of physicians are not able to correctly determine the position of the baby’s head or the opening of the uterus’ neck.
  -> Before and during a natural birth, there is no reliable information base and involved staff simply guesses a lot.

• In the Netherlands with their traditionally low caesarian rate, 18% of the babies have to be delivered using vacuum extraction or forceps
  -> Because the caesarian birth is avoided, almost every 5^th woman is expected to endure pelvic floor injuries

• At Berlin’s reputed hospital “Charité”, in 2009 22% of all vaginal births involved episiotomies, 9% vacuum or forceps extractions and 2% were emergency Caesarians. 32% had a perineal tear, 3% had placenta abruption issues, 17% had vaginal tears and 11% had tears on their labia or clitoris. 34% of all births have been classified as having “complications” and 25% “involved “other pelvic injuries” (multiple answers possible).
  -> At least a third of women have at least some incident during their births. 

• Some women’s womb muscles are genetically unfit to perform effective contractions, which leads to overdue babies and difficulties to implement the midwife’s instructions.
  -> Despite a lot of preparation and ambition, these women will have a long labour that may end in a secondary caesarian – they are not to blame for this
• Quote of a chief physician: „The first birth takes about 12 to 18 hours, the second 6 to 8, the third 20 minutes, during the fourth the child practically falls out. That is due to the stretching of the birth canal. Nobody can tell me that everything remains ‘intact’.”
  -> Makes sense. However this does not seem to have been checked scientifically, which in itself I find quite odd.

• Quote of another chief physician with more than 30 years experience: “It is my opinion that a natural birth is an assault.”
  -> Again, this is no evidence what so ever, but it once again shows that medical staff’s view on natural birth is not homogenous

• 20 years after a vaginal birth, the risk of incontinence is 67% higher compared to a caesarian birth

• 31% of all women are affected by some kind of incontinence after a natural birth (including a weak bladder)

• 11% of all women incur injuries to their constrictor

• None of the common midwife practices for avoiding injuries to the perineum has proven to be effective

• The birth experience of women after a birth involving forceps or vacuum extraction was significantly worse than after an unwanted caesarian.

• Whether the “Lost Penis” syndrome occurs more often after natural or caesarian births is still under debate and yet unproven. It is assumed that not (only) the stretching of the birth canal contributes to this phenomenon, but the weakening of the pelvic floor, which happens during pregnancy
  -> Thus, fear of a weakened pelvic floor should not be the only reason for a caesarian, as it is not clear yet if it can be avoided this way

3. The course of home births, the ideal of naturalness:

• In the Netherlands, 89% of women attempt a home birth or a birth in a birthing center. Only 17% of all home births actually stay away from a medical clinic, and only 10% are done under the exclusive supervision of a midwife. 73% are finished as a clinic birth.
• The mortality rate of babies during house births increases by a factor of 7

4. Caesarian birth:

• After a Caesarian, in rare cases the tissue along the scar can tear during a second vaginal birth (6% possibility), which may involve heavy bleeding and danger of life for mother and child
  -> It is not very advisable to attempt a vaginal birth after having had a caesarian

• After a Caesarian, the placenta tends more often to block the mouth of the uterus and prevent future vaginal births (probability of 0.8% versus 0.3% of a natural birth)
• After a Caesarian, the placenta is much more prone to grow together with the uterus (8 to 14 times more often), which can cause severe bleeding and in the worst case a full removal of the uterus. This is however very rare (0.06%)

• After a Caesarian, it is recommended to take a break of one year before conceiving another child in order to protect the scar.
  -> People in a hurry have to take a risk or have a vaginal birth the next time

• Caesarian-delivered children of diabetics are more prone to get diabetes than their naturally born counterparts is proven (probability of 4.8% versus 2.2%)
• There is a positive correlation between work experience and degree of specialization of a doctor and the likeliness of him advising for a Caesarian.
  -> Thus it is more likely that experienced doctors are aware of the real risk of natural births and thus are more likely to avoid them rather than trying to make more money.

• In earlier times, caesarians were done quite early (37^th/38^th week) to avoid spontaneous births. Because of this, the baby’s lungs were often still underdeveloped and required additional respiration after birth. Today, most caesarians are done in or after the 39^th week and the risk of severe breathing problems is 1%, which is the same as that of vaginal births
  -> The mentioned breathing problems don’t seem to be a real issue and not Caesarian specific. However, this also means that for early Caesarian babies there may be breathing problems, even if not severe.

• The Caesarian reduces life-threatening risks for the child by 66% and also the probability of severe damages (like paralysis, brain damage)

• Of 150 mothers with an elective Caesarian in Vienna, 4% had a headache from the anesthesia and one woman suffered from breathlessness. Overall, there were 5% complications.
  -> There are significantly less and also more harmless complications after a Caesarian birth. However, this statistic does not mention operation risks such as blood loss or thrombosis, thus the statistic may be evaluated with caution (also given the small data base)

• In more than 70% of the cases, secondary and emergency Caesarians are done because the natural birth did not proceed or because damages could be expected.
  -> This failure however is normally not attributed to natural births – instead the increased complications are included in the Caesarian statistic.

• During a study done between 1997 and 1999, 63 of 100.000 women died, 29 after vaginal births and 34 after Caesarian births. 28 Caesarians were emergency interventions.
  -> The cause of death of the emergency Caesarians is likely to (also) have to do with the previous complications and the late stage of birth, which can make Caesarians very difficult. Again, those 28 cases that were “lost” to natural birth should have been mentioned in the natural birth list and not one-sidedly attributed to the Caesarian section. Also, the study is quite old and the Caesarian techniques have developed since.

• The complication risk during a secondary Caesarian is 1.6 to 4 times higher than during a planned Caesarian
  -> It is important to differentiate between a primary, secondary and emergency Caesarian

• A study done over 22 years shows that clinics with the highest Caesarian sections have the lowest death rates

• A comparative study about the wellbeing of babies shows that children with a planned Caesarian were as well as those after a natural birth without incidents

The book does not properly cover the operative risks of a Caesarian, such as bleedings, infections, tissue injuries, wound healing/scarring including a feeling of numbness, and thrombosis, for which I could – as always – not find any quantification. It should also be added that due to the fact that I have only referred to one book, it is natural to think that the author has done some “cherrypicking” of studies to support her view – however, in light of the extensive base of sources referred to and listed in the annex of the book, I don’t deem this to be very likely. I do welcome any contradicting evidence from the reader though.
As a last limitation of this overview, some doubt remains regarding unproven claims about allergies, possible advantages of baby-triggered labour and a better immune system of natural born babies – these will have to be studied in future to deliver a complete overview of advantages and risks of both birthing techniques.

Still – based on above facts and the current state of knowledge, I believe it can be said that from an objective-medicinal point of view the primary Caesarian is the best choice for all women, who do not wish for more than two children and do not have an especially negative predisposition for operations in general.

Anyway, I have made my choice, even if I will probably stand alone with it for some time. At least in Germany – in India, the Caesarian is common practice.