C-Sections and Chronic Diseases: I Fucking Love Science Article Gets Study Wrong

We Have No Idea if C-Sections Lead to Chronic Diseases in Kids, but Thanks for the Guilt Trip

We Have No Idea if C-Sections Lead to Chronic Diseases in Kids, but Thanks for the Guilt Trip

The XX Factor
What Women Really Think
June 12 2015 9:11 PM

It’s Cruel to Blame Moms for a Link Between C-Sections and Chronic Diseases in Their Kids

Baby being born via Caesarean Section
Even if there is a higher risk of chronic diseases among babies born via C-section, mothers rarely have a choice about delivering that way.

Photo by Martin Valigursky/Shutterstock

The latest article making the parenting rounds from the popular website I Fucking Love Science should have been posted on I Fucking Hate Science instead. Titled “Study Suggests Newborns Delivered by C-Section Have a Higher Risk of Developing Chronic Health Problems,” the story, and others like it, would make any mother who has given birth by cesarean section feel guilty, terrified, and (for me anyway) very angry.

The story is based on an analysis piece—not, in fact, a study, as the article suggests—published in the British Medical Journal by researchers at New York University and Peking University in China. The BMJ authors highlight previous research linking C-sections to higher risks of health problems later in life, but they also discuss a number of important caveats that make it difficult to determine, without additional research, whether C-sections actually cause these health problems. These caveats were largely omitted from the IFLScience article. More alarmingly, the IFLScience piece argues that because elective C-sections are to blame for the explosion in C-section rates in countries like the U.S.—actually, they are not—women might, in light of these scary risks, want to make more of an “informed choice” about how they deliver their babies in the future. Here’s the thing: Most women in the U.S. who have C-sections do not want C-sections. They agree to the surgeries because they are advised to do so by the doctors in whom they have placed their trust and because, ultimately, they want to do what is best for their baby. And while it’s true that some American women who have C-sections may not actually need them—I’ll get into that later—it is cruel to make women feel guilty for making a choice that, at the time, is hardly much of a choice.

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Let’s start by talking about these “risks” and what they really mean. The discovery that children born via C-section are at an increased risk for health problems is hardly surprising. Women often have C-sections for medical reasons, such as because they themselves suffer from chronic diseases that make vaginal births risky or impossible.  For example, women with type 2 diabetes are often advised to have C-sections because their babies can grow to be too large to birth vaginally. It makes sense that children born to women with chronic health problems might also be at increased risk for chronic health problems. Other women have C-sections because of pregnancy or labor complications, and those issues may directly affect a baby’s long-term health. Birth and pregnancy complications have, for instance, been associated with an increased risk for autism—although to be fair, we can’t be sure about causality from this correlation, either.

Observational studies that compare disease rates among babies born vaginally or via C-section do try to control for these “confounding factors,” but doing so is a highly imperfect science. Making things more difficult is the fact that, as the BMJ authors explain, “detailed information about indication for caesarean is generally not captured in clinical data.” In other words, researchers who study C-section outcomes don’t usually know why the C-sections were done—and that’s important if you’re trying to parse the effects of a C-section itself compared with the effects of the health issues caused that C-section.

I’m not saying there aren’t good reasons to try to avoid C-sections. Vaginas are teeming with commensurate bacteria that babies literally eat when they are traveling down the birth canal; babies born surgically don’t get this snack on the way out, and research suggests that as a result, their intestines become less colonized with some “good” bacteria for at least the first six months of their lives, which could have long-term effects. Women who have C-sections—even medically unnecessary ones—are also at an increased risk for infections and blood loss. And C-sections beget future C-sections, because few doctors are comfortable letting women attempt a vaginal birth after having had a C-section, despite the fact that in most cases the risks associated with these “trials of labor,” as they are called, are very low. The more C-sections you have, the riskier your next pregnancy and delivery become.

Which brings me to two questions: Why are there so many C-sections if C-sections aren’t so great? And what explains the fact that U.S. C-section rates have skyrocketed from a mere 4.5 percent of all births in 1965 to 32.7 percent of all births in 2013? The IFLScience author blames women who are “too posh to push,” noting that “a growing number of women—including high-profile celebrities—are now choosing to have a C-section.” That may be true in a few other countries, but in the U.S., only 2.5 percent of all births are estimated to be elective C-sections, and a 2011 paper concluded that elective C-sections do “not appear to account for the magnitude of the increased cesarean rate.” In a 2013 survey-based report, the nonprofit U.S. Childbirth Connection reported that 28 percent of women who delivered their first babies via C-section had felt pressured by their doctors to do so.

There are a number of potential reasons why C-section rates have skyrocketed. As rates of obesity and chronic disease have increased in the U.S., more C-sections have undoubtedly been required. But some doctors may also prefer C-sections. First: They are often paid more for the surgeries, and the more they are paid, the more likely they are to perform them. Second, OB-GYNs are the second most commonly sued doctors in the country after neurosurgeons. One 2008 survey found that before they even turn 40, half of all obstetricians have been sued at least once. In states where malpractice suits are more common, C-section rates are higher; nearly one quarter of OBs surveyed in 2012 conceded that the fear of being sued made them more likely to conduct C-sections. That’s probably because, when doctors are taken to court for a bad birth outcome, they are less likely to be found liable if they can demonstrate that they did “everything they could” to save or protect the mother or baby. (That said, fear of litigation does not actually help doctors deliver healthier babies.)

Rates of inductions have also been increasing the U.S., and inductions increase the risk of C-sections, too. When I was pregnant with my firstborn, I was induced at 39 weeks for medical reasons. After 28 hours, my labor stopped progressing, the fetal heart rate monitor indicated that my son was having trouble getting oxygen, and I was rushed into surgery. (Continuous fetal heart rate monitoring has also been implicated in promoting more C-sections because variations in the fetal heartbeat can be difficult to interpret and scare doctors into performing surgeries when they might not need to.) When several hospitals that were part of an integrated health system in Utah decided to stop doing labor inductions prior to 39 weeks in women who had never given birth, they found that C-section rates were 30 percent lower in those facilities than they were in facilities that still allowed these inductions.

Clearly a multitude of factors drive our country’s high C-section rate; we have yet to understand them all. One thing, though, seems clear: Women who are “too posh to push” are not the big problem here in the U.S., nor is there any evidence that C-sections are “becoming more common among parents for no medical reason,” as another recent story on the subject claims. To insinuate that women in general are to blame for the rise in C-sections—and to make those who had to go through these surgeries feel that they might be responsible for their children’s future health problems—is ridiculous. Let’s fight to lower the C-section rate, sure. But let’s fight the institutional causes and misaligned incentives instead of blaming the women who have been unwittingly caught in the middle.

Melinda Wenner Moyer is a science writer based in Cold Spring, New York, and is Slate’s parenting advice columnist. Follow her on Twitter.