Public Health Ethics Research Paper

Public Health

The rate of Caesarian sections has skyrocketed in recent decades in the United States, placing it far ahead of other industrialized nations.

Historical overview of C-section rates in the U.S.

Breakdown of C-section rates by race and access to insurance

Why is this a public health issue?

Higher morbidity and mortality rate for C-sections.

Poor and minority women (and their families) affected at greater rates.

One of the costs driving up healthcare in the United States.

Medical and behavioral issues.

Does the medical establishment benefit from increased C-sections?

What behaviors on the part of physicians and other medical professionals push up C-section rates?

How do fears of malpractice lawsuits weigh in this issue?

What behaviors on the part of patients push up C-section rates?

How does obesity factor in to C-section rates?

How does pregnancy education affect C-section rates?

How does prenatal care affect C-section rates?

What is the cultural attitude toward C-sections that has made this a silent problem and how can this be changed?

The American Way of Birth

Americans like to believe that our system of healthcare is one of the best in the world. Indeed, one of the refrains of the recent debate about healthcare in the United States was that as a nation we have the best healthcare in the world. Setting aside the larger questions that such a claim raises, when one looks at the medical care given to women during pregnancy and labor, it is hard not to believe that a range of improvements could be made to this particular corner of American medical care. The rates of Caesarian sections in the United States are quite high compared to the rates in other modern industrialized countries. Moreover, the rate of C-section deliveries has been rising in recent years and disproportionately affects different populations of women.

Given that C-sections can pose a higher level of risk for mothers than is true for women who give birth without surgical intervention, that infants also face potential risks with surgery and its associated drugs, and that C-sections are much more costly than are vaginal deliveries, the high rate of C-sections must be considered a public health issue. This paper examines why the rate of C-sections is so high in the United States, looking at both possible demographic causes for the increase in C-sections (such as an increase in mean maternal age and an increase in maternal obesity) as well as aspects of the ways in which medicine is practiced (such as physicians acting in ways to reduce potential liability rather than in the clear best interests of their patients). Not only do C-sections have important personal consequences for the women who undergo them, but given the financial cost of C-sections makes this procedure of especial concern as the American health system as a whole is analyzed for ways in which better healthcare can be provided at the same time that costs are being reduced.

History of C-Section Rates in the United States

A just-released survey of C-section rates in the United States found that in the period between 2002 and 2009, rates for this surgery rose about 27% in the United States, with over a third of all American women delivering by Caesarian rather than non-surgically (Nordqvist, 2011). Even more striking, the rate of C-section has increased by 50% since 1996. Rates were higher in some parts of the country than in others, with the states of Texas, New Jersey, and Florida -- distinct both geographically and culturally -- having the highest rates of Caesarians. In these states, women had almost a four-in-ten chance of having a C-section (Nordqvist, 2011).

This survey of 5000 hospitals across the United States offered a number of possible reasons for the increase in C-section rates. These include the following (after Nordqvist):

C-sections are often seen as being more "convenient" by both medical professionals and mothers, especially when the mothers have older children to take care of.

The average age at which American mothers is giving birth is going up, and higher Caesarian-section rates are positively correlated with increased age. While this correlation is well established, why it should be the case is far less clear. Far more than many other medical procedures, C-sections are linked to cultural factors rather than purely medical ones. (This does not mean that cultural beliefs and values do not affect other medical procedures or that C-sections are performed without any regard to medical conditions.) Older mothers may need surgical intervention during labor for a number of medical reasons, but it is at least as likely that older women are influenced by non-medical factors into having C-sections.Older women may feel especially vulnerable to giving birth in the "wrong" way, especially if they are delivering their first child, and so may be especially susceptible to a variety of pressures to have C-sections.

American women are more and more likely to be affected by a number of risk factors than was true a generation, or even 10 years, ago. Primary among these are obesity and diabetes (or the two together), both of which can make a C-section medically necessary or at least advisable.

Women giving birth to more than one infant are more likely to require C-sections (or at least to benefit from a C-section). Multiple births are increasingly common both because older mothers are more likely to give birth to more than a single infant and because women (mostly older mothers) are more likely to undergo fertility treatments.

Medical culture has shifted over the last few years so that physicians seem more accepting of performing Caesarian sections in circumstances under which their predecessors (or even their younger selves) might not have thought to do so. It is also the case that more women are asking to have C-sections performed, although the data in this survey do not allow for an analysis of whether patients are independently more inclined to ask for C-sections or whether they are simply responding to either encouragement or pressure from medical professionals. Given that most women see medical professionals with at least some regularity throughout their pregnancy, it seems highly improbable that these women are not guided by their physicians' preferences.

These preferences include a number of practices that are now common during labor, such as induction of labor and a high rate of use of epidural anesthesia -- that increase the possibility that a C-section will become medically advisable or necessary. These practices can increase the risk to the mother's health, future fertility, and even life. Of lesser significance but still highly important is the fact that such procedures in and of themselves increase the cost of healthcare in the United States, and if they lead to Caesarian sections then the costs rise even higher.

Finally, and this is at the core of why the issue of rising C-section rates is an important public health issue today, many women are ignorant of the risks that they face if they choose to have a C-section. Women who deliver by C-section rather than vaginally face a range of complications even if the surgery is successful (in the sense that both the mother and the child/ren are alive) are more likely to suffer from blood clots (which can be fatal), bladder injury, infections (which increase the chance of future infertility), and a longer recovery time, which may make it harder for the mother to nurse and to bond with her infant/s.

Morbidity Associated with C-sections: Implications for Public Policy

Public health is often thought of primarily in terms of the pitting of medical technology and expertise against disease, the type of scenario in which doctors and researchers are the heroes of the stories. But while it is certainly true that doctors and scientific researchers are often doers of heroic deeds, in the case of rising C-section rates, it is often the actions of medical staff that increase the morbidity and mortality of pregnant women and sometimes their infants. A study just released about maternal health and death rates in California demonstrates the importance of tracking C-section rates as part of an overall vigilant public health program.

In the last decade in California, maternal death rates have doubled, a terrible statistic in any nation, but one that is nearly inexplicable in such a wealthy nation. The study by the state's Department of Health cites a number of possible contributory factors to this rise in maternal death rates, including the increased rate of C-sections. It is impossible, according to this study, to disentangle the different reasons for the rise in maternal death rates given that they are not independent from each other. For example, rising rates of obesity would increase maternal mortality rates. Rising obesity levels also increase rates of C-sections, which in turn increase maternal death and injury rates.

Many of the factors that increase the risk for a woman's having a C-section are interlinked with factors that would on their own increased maternal mortality. The concatenation of all of these factors results in….....