If you are pregnant in the US, if you know someone who is, or who wants to be, read this. It will give you some idea how much Caesarean section – heavy-duty abdominal surgery designed to help a baby live when the mother cannot give birth vaginally – depends, not on medical emergency or advice, but on culture. Yes, within America.
In order to avoid “but the patient wanted it” whingeing, let’s first take a look at who has the power in childbirth and Caesarean sections.
One can give birth by oneself. Alone in the woods, within an earthquake-devastated building, in a cave while fleeing rapacious soldiers. All have been done. On the other hand, no one can perform a Caesarean section on herself. Not one person. With that kind of surgery, there must be a practitioner. That puts that second person in charge. No one is holding an IED to physicians’ heads to demand that they slice. Obstetricians (obstetrics is a surgical specialty; historically, few female medical students have been encouraged to specialize in surgery) have the power to just say “no” to a medically unnecessary request or demand for Caesarean section. They have every right to do so – pointing out that the patient shows no risk factors to indicate it – and they have the power. They alone.
That takes care of the whinge. Now:
Recently, much has been made of the fact that the American C-section rate is quite high. This nation is #15 from the top in global high section rates, and its rate of 30.3 is significantly higher than in other first-world nations.
It has been observed that of the top 10 countries worldwide, in terms of high C-section rates, eight have Roman Catholic majorities. (The remaining two high blade users are Iran and South Korea.) Eighty percent of the nations where a person is most likely to undergo C-section with its attendant risks – shock and sepsis; developmental harm to newborns; longer maternal recovery – and extra expense, have high or very high populations identified as Roman Catholic. Clearly, then, that religion and/or its physician adherents are somehow driving the C-section rate to much higher levels than the 15% recommended by the World Health Organization (WHO). In Brazil, which stands at #1 in the world, the rate is an alarming 45.9; nearly half of Brazilian births happen under the knife.
The C-section rate in the United States varies up to 15-fold. Some states have very low rates. Yet some – see this graph – have rates that rival the highest global rates (New Jersey’s extraordinary C-section rate is nearly equivalent to #2 Dominican Republic and #3 Iran, where over 41% of people in labor are cut). Those states pull the US average up.
From the graph, there are 19 states (plus the District of Columbia, making 20 data-specific areas in all; they are listed in order at the end of this article) whose rates exceed the American average. As noted above, that US average is already high compared to other first-world nations. I wondered what cultural effects could be driving these very high rates of abdominal surgery, so I examined graphs and maps.
What I found is this:
Of those 20 areas with high C-section rates, three states also hold high percentages of residents who are Roman Catholic (3 million people or more): California, New York, and, as mentioned above, New Jersey. Only three. How, then, do we account for the remaining areas? Is there some distinguishing cultural “mark” common to them?
There is indeed. If we examine the pre-Civil War slave status of these high C-section districts – where legal ownership of human beings was permitted – we find that 14 of them were slave-holding at the start of hostilities in 1861. From lower percentage of C-sections to highest, bearing in mind that all these states’ rates surpass the US average, they are: Tennessee, Georgia, District of Columbia, Virginia, Arkansas, Maryland, Alabama, South Carolina, Texas, Kentucky, West Virginia (which broke from Virginia during the Civil War, but prior to it had been the western portion of that “slave” state), Mississippi, Florida and Louisiana.
Note that Maryland and Kentucky were among four “slave states” that remained in the Union. Nonetheless, both permitted the ownership of human beings in 1861.
That is an extraordinary commonality.
There are, however, three states remaining of the 20 with higher-than-US-average rates of Caesarean sections, and these three – from lower to higher C-section rates they are Nevada, Oklahoma and Connecticut – seem to have nothing in common.
However, each of these three high C-section states borders at least one state noted above.
Nevada shares along border with California (with a high Roman Catholic population). Oklahoma borders both Arkansas and Texas (both former slave-holding states). Connecticut’s western border runs along New York State (with a high proportion of Roman Catholics).
It seems reasonable to conclude, therefore, that high C-section rates in Nevada, Oklahoma and Connecticut are due in part to the cultural influence of their neighbors. It is worth noting that California has an outsize cultural influence on Nevada; New York impacts the most populous areas of Connecticut, in the southwestern section of that state, where many commuters live; and despite sports rivalries between Oklahoma and Texas, the latter sends thousands of its residents north to the former.
As others are doing, we can speculate what it is about Roman Catholicism that encourages, absent medical emergency, slicing into a laboring person rather than allowing her to labor and give birth vaginally. It could be institutional disrespect. Women are not yet allowed to be RC priests and are permitted only minor roles in the church. It could be a continuation of the cult of Eve-like and Marian suffering. A Caesarean section is so painful it requires anesthetic, and the recovery period is long and arduous – these new mothers must struggle to rebuild their abdominal muscles. It could be that Roman Catholicism encourages a mindset that rewards male intervention (nearly all obstetricians are male) and denies female bodily integrity and power.
What of the former slave states? There, too, we see a history of power inequities. Pre-Civil War, the dichotomy between the influential and those who had little say in their lives was much starker than in states where slavery had been abolished. It takes little effort to note the transition from imposing on vulnerable people who were black to imposing on vulnerable people – the hours of childbirth put one at risk – who are female. It puts the obstetrician in control of a process he normally would simply observe. He inserts himself into the labor and is thus in control of a person’s life and health, just as slave owners were in 1860.
To those who protest – “hey, what about all those obstetricians who aren’t Roman Catholic, who aren’t descended from families that owned other human beings?” – you’re right. However, when one enters into a culture, and wants to fit in, one adapts. One adopts the customs and traditions of the culture. Fail to do that, and you risk being considered a dangerous renegade. Of course there are physicians in all areas who are not Roman Catholic; likewise, some obstetricians in former slave-holding areas are descended from ancestors who never lived there.
To get along, go along. There is pressure on obstetricians. Patients apply some, but there is more from the culture they work in. If fellow obstetricians are posting high C-section rates, and you’d rather not, how do you become what Australians call the tall poppy – reducing your section rate to the WHO-recommended 15%, or lower – without getting cut down and criticized?
Probably, you don’t. Most likely, you make excuses to yourself. You look for aspects of the labor, or the pregnant person, to blame. You form a foundation on sand before you slice.
That’s unethical and unnecessary. It harms both the patient and the new child.
As a society, we need to make Caesarean sections dependent not on culture but on true medical necessity. That means insisting on all levels – grassroots to hospital to national watchdogs – that obstetricians just say no to cultures that encourage appallingly high C-section rates.
Note: The 19 states (plus District of Columbia) whose C-section rates exceed the already high US average are (from lower to highest): California, Tennessee, Georgia, Nevada, District of Columbia, Virginia, Oklahoma, New York, Arkansas, Maryland, Alabama, South Carolina, Texas, Connecticut, Kentucky, West Virginia, Mississippi, Florida, Louisiana, New Jersey.