Choose Wisely: Studies Show Increased Risk of Cesarean Linked to Choice of Doctor

By Jacqueline Levine

The cesarean rate in the United States has leveled off, as reported last year by the Center for Disease Control and Prevention (CDC). The information came from the National Center for Health Statistics, and it says, in sum: “After 12 years of consecutive increases [1998 to 2009], the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011”;  the report cites the current rate as 31.3%.  That the rate has stopped rising is good news. And that the rate is too high is not in dispute. The World Health Organization and other organizations that promote and support optimal maternity care have been making that case for a long time.

Most recently, the American Congress of Obstetricians and Gynecologists (ACOG) has come out with a report entitled “Safe Prevention of the Primary Cesarean Delivery,” with guidelines meant to prevent a first-time c-section. The study calls for revisiting the list of the common indications for cesarean. The various rationales for cesarean have held sway in maternity care for years.  These new guidelines can be seen as an admission that the rate of surgical birth is indeed far too high, and that current practices do not promote the ideal health of women and babies.

Added to this news are two studies that reveal additional factors that can affect a woman’s chance of having a cesarean. News from the American College of Obstetricians and Gynecologists’ (ACOG) 57th Annual Clinical Meeting, as reported in Medscape Today (Medscape Medical News, May 12, 2009), discussed an article entitled “Liability Fears May Be Linked to Rise in Cesarean Rates.”  The following is a direct quote (bold emphasis is mine):

“It has been suggested that medical-legal pressures are a factor in the high number of cesarean deliveries. A number of studies have borne this out.  Localio and colleagues (JAMA. 1993; 269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery.   Murthy and colleagues (Obstetrics & Gynecology 2007; 110:1264-1269) found an association between professional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean(s) delivery.  Dr. Barnhart said “First of all, I applaud the abstract, in that it quantifies a perceived problem,” ”We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case,”  ”So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” Dr. Barnhart concluded.”

The study implies that what’s being done in the way of care might indeed be for the welfare of obstetricians who practice defensive medicine, and may not be for the best welfare of the woman in his care. The results of this study are not addressed in the recently released ACOG guidelines to eliminate the overuse of c-section, but it’s helpful to acknowledge the possible affect of malpractice insurance on women’s birth options.

We assume that the most fundamental tenet of care is that what a doctor does is for our benefit, and not for her or his well-being, convenience or safety. A doctor who picks up a scalpel and performs surgery for defensive reasons is behaving in a way that is the antithesis of ethical behavior, a betrayal of our trust in the doctor-patient relationship.

The other study addresses how an obstetrician’s personality affects your risk of having a cesarean. The article, “Women’s Risk of Having C-section May Depend on Her Obstetrician’s Personality,” discusses a study published in the Journal of Obstetrics and Gynecology in 2008. (Allcock, C., Griffiths, A., & Penketh, R., The effects of the attending obstetrician’s anxiety trait and the corresponding obstetric intervention rates. Journal of Obstetrics and Gynecology, 28(4), 390-393. [Abstract]). “Trait anxiety” is an integral and unchanging part of the human personality and is very different from “‘state anxiety’” which happens in response to a particular situation.

The results of the study are very concise (emphasis mine):

“Obstetricians were asked to complete a validated survey that measures ‘trait anxiety’ which is stable and enduring… The obstetricians with the least anxiety had the lowest emergency cesarean rates.  The obstetricians with the most anxiety had the highest rates.”

Statistical analysis revealed that the doctor’s trait anxiety levels were highly correlated with cesarean rates. 

These studies document just two of the many factors that affect a birthing mother’s chances of having a cesarean — factors that have nothing  to do with a mother’s or baby’s actual health status. The more we know about what influences doctors in the decisions they make about our care, the better our ability to recognize and request best-evidence care for ourselves and our babies. And so the question becomes, how can a birthing woman understand and avoid the influence of lesser-known factors on her chances of avoiding cesarean?

As our own best advocates, we must seek out the ethical caregivers who do not rely on routine interventions and who use surgery only to save the lives or health of babies and mothers. Before deciding  on a caregiver , it’s of critical importance to become familiar with best-evidence, optimal maternity care, so that you’re able to
question her/him about all the health care practices that will affect labor and birth. Knowing the facts about normal, healthy birth and conservative reasons for c-section based on our genuine health status help you make informed choices about your care.

Recommendations for OBs, hospitals and midwifery care from women across the United States can be found at the non-profit, all volunteer website Question your prospective OB or midwife about his/her c-section rate, induction rate, episiotomy rate, and other routine and common practices that may not confer best-evidence care. If you perceive a defensive posture about his stats, or an air of reluctance to tell you what you want to know, consider it a red flag warning and seek a new caregiver for optimal care.


Looking for more information and resources surrounding cesarean and VBAC? Check out this list of online resources and test-your-knowledge quiz from Science & Sensibility.


About the Author

Jacqueline Levine, BA, LCCE, FACCE, CD(DONA), CLC has been a DONA doula and  lactation counselor  for 10 years, a Lamaze educator for twelve years, and a WIC educator.  She teaches Lamaze childbirth education at Planned Parenthood of Nassau County, where she volunteers birth doula services to the clients of Planned Parenthood, an underserved population.  She won the Lamaze Community Outreach Award for these services to the community, and she has taught and supported pregnant teens in local high schools.

She’s been a contributor to Science and Sensibility, the Lamaze research blog, since 2009, and writes for BreastfeedingUSA, the online peer-to-peer breastfeeding site as well.  Some of her articles for breastfeeding teens have been on the US Breastfeeding Committee site, and she is a guest lecturer in the Sociology Department of CW Post College of LIU, teaching a class in the History of Childbirth in the United States, as well as breastfeeding classes for DONA doula certification that stresses best-evidence care for mothers and newborns.

She is mother of three and grandmother of five, and came to the world of birth after she retired from a career as artist and designer in the Garment Center in NYC.

April is Cesarean Awareness Month

April is Cesarean Awareness Month — a time to learn about and share important information about how to avoid a first-time cesarean, discover your options for VBAC, and find resources for support in healing from a cesarean. Where to start? ICAN - the International Cesarean Awareness Network — is an excellent place to find several resources related to cesarean, including educational white papers, ways to get involved with advocacy, and links to your nearest ICAN chapter where you can find local resources and information about hospitals and caregivers in your area, as well as connect with other women living near you who have experienced cesarean and VBAC.

What are your favorite resources for cesarean? Please share them in the comments!

In Celebration of World Doula Week – 10 Things Doulas Do During Labor

This week marks World Doula Week, a celebration of the wonderful things that doulas do for families during pregnancy, birth, and in postpartum. Giving Birth with Confidence recognizes doulas with this list of 10 great things birth doulas do for women and their partners during labor. Keep in mind, too, that many doulas also offer excellent assistance in the postpartum period.


1. Suggest position changes to keep your labor progressing and help you find optimal comfort.

2. Serve as a resource to help you find answers to your questions about medical procedures, interventions, and labor and birth.

3. Help your partner remember the comfort measures learned during childbirth classes.

4. Water refill duty — yours, your partner’s, and her own!

5. Provide you with a few healthy snacks or drinks from her labor bag if you’ve forgotten your own.

6. Call on her knowledge of comfort measures and position changes to help ease and improve back labor.

7. Offer emotional support through encouragement and understanding of where you are and what you’re going through in labor.

8. Know your birth plan/preferences to help you communicate them to the nursing staff and your care provider.

9. Stay with you continuously through labor and after birth, usually until you have fed your baby for the first time.

10. Provide tips and assistance with the first time you breastfeed.


Do you plan to hire a doula, or have you had a doula at a previous birth? How did your doula help you?

Keeping it Simple: An Alternative Birth Plan

When writing a birth plan, it’s important to keep your list of preferences simple and succinct. Using bullet points and including the most critical information (ie: please don’t offer pain medication; I’m allergic to latex; please keep mom and baby together after birth, skin to skin; we are delaying Hepatitis B shot) will help ensure that your birth plan is read and heeded. The traditional birth plan format includes a one-page list of information grouped into categories like, “Labor,” “Birth,” “Newborn,” and “If Cesarean is Necessary.” For an alternative format, consider using the following graphic to lay out your birth plan. This visual four-square birth plan helps the reader find information quickly and simply, and leaves just enough room for the most important information.

birth plan squares














Ideas for filling in the four square birth plan:


  • Please don’t offer pain medication
  • Shower/tub for comfort
  • Experiment with many positions for pushing

Special Instructions

  • Mom is allergic to perfumes
  • Partner would like to cut cord and announce gender
  • Please delay cord clamping

In an Emergency

  • Please allow partner and doula to be present in case of cesarean
  • Partner will be skin to skin with baby if mom cannot
  • If baby requires NICU, mom will pump colostrum – please, no formula

Newborn Care

  • Please delay bath
  • No eye ointment
  • Please give vitamin K shot


These are just a few ideas to populate the squares — and perhaps your squares will have different categories! Experiment with the best format and contents to fit your preferences for birth.

Red Light, Green Light – A Quiz on Getting the Best Care

Are you getting the best prenatal care from your provider (midwife, OB, or family doctor)? Take this “red light, green light” quiz to find out. Red light indicates care that is not evidence based or respectful of your choices. Yellow light indicates care that should make you question your provider further to see if she is the best fit. Green light indicates great care!

What to Pack in Your Labor Bag

At some point during your pregnancy, you will start thinking about what to pack in your bag for the hospital or birth center. Many moms focus on what they’ll need for for their stay after the birth — change of clothes, toiletries, baby’s outfit, etc. It’s just as important to think about — and pack a separate bag for — what you’ll need during labor. The following list provides suggestions for items that can help bring you comfort during labor. Please add to our list with your own suggestions in the comments!

For you:

  • A copy of your birth plan
  • Socks/slippers
  • Flip flops or other “shower shoes”
  • Your own pillow with a case that is not white and that can get dirty
  • Birth/yoga ball and pump (bring ball already pumped)
  • Chapstick
  • Toothbrush and toothpaste
  • Massage oil/lotion and massage tools
  • Your own clothes to wear in labor (if desired and if you don’t mind getting them dirty)
  • Robe
  • Reference guide or printouts for labor comfort reminders (Labor Lab and The Birth Partner are great!)
  • Focal point or special item to hold in your hand
  • Water bottle
  • Nourishment: solids, liquids, easy to digest, hard candy – bring a variety
  • Mints or gum
  • Hair ties or clips
  • Music (create a playlist or use a service like Pandora)
  • Phone/iPad/laptop and chargers
  • Heating pad or rice sock
  • Essential oils or scents
  • Anything else to make you feel comfortable ____________________________________

For your partner/birth support:

  • Change of clothes
  • Food & drinks for your partner
  • Camera
  • Phone
  • Pillow
  • 5 Hour Energy, coffee or something similar to help stay awake

Provide Good Labor Support with 5 Easy Tips

When learning how to be a good labor support person, it can be overwhelming for a partner — How will I remember everything, How will I know what to do, How can I help her? It’s true that there is a lot of information to know when it comes to labor and birth. But you can rest easy knowing that providing good labor support can be as easy as remembering this acronym: DEPPS. Drink, Eat, Pee, Position, Support/Soothe. Birth partners, when mom is in labor, you officially take on the role of DEPPS Manager. Good labor support can be boiled down into five easy tips:

Drink – Staying hydrated in labor is so important. Encourage mom to drink water after every contraction so she can stay hydrated throughout labor without the use of IV fluids.

Eat – No one would run a marathon without refueling, and the same is true in birth (which is generally much longer than the average marathon!). Keep track of the last time she had something other than water. If it has been longer than 2-3 hours,  offer and encourage mom to eat something, even if it’s light (honey sticks, juice, apple sauce, nuts, granola). Be sure to pack your labor bag with a range of nutrition options. And yes, it IS safe to eat during labor!

Pee – Seems silly that a person would have to be reminded to pee, but a mom in labor has other things on her mind! Emptying her bladder once an hour can help labor progress — an empty bladder makes more room for baby to come down.

Position – Changing positions frequently in labor (about once an hour) helps labor progress and allows mom to continue to find comfort in different ways. For resources on different positions to use in labor, check out this resource from Lamaze, or this guide from Penny Simkin.

Support/Soothe – This one is HUGE. Providing continuous support to a laboring woman is the key to a better birth experience. This can be done in a variety of ways, but usually includes hands-on soothing through touch and massage, and verbal encouragement (you’re doing great, you’re so strong, you’re almost there). You can learn and practice the most effective ways to support a laboring woman by taking a quality childbirth class.

Test Your Knowledge on Comfort Measures for Labor

How well do you know the best comfort measures to use during labor? Test your knowledge below with this quick, free quiz we created. Did you know that the best place to learn ALL of the comfort measures for labor (yes, ones that really work) is in a quality childbirth class? If you are pregnant and haven’t signed yourself up for a class yet, do it before the big day!


photo credit: HoboMama via photopin cc

When Your Water Breaks and You Aren’t Having Contractions

In Hollywood, nearly every pregnant woman goes into labor with her water breaking, usually somewhere hilariously embarrassing like aisle 6 of the grocery store. In reality, only 8-10 percent of women’s water break as the first sign of labor. Generally for those women, contractions will begin naturally in the following 12 to 24 hours. But for some of the women in that group, their water breaks without any contractions in the first 24 hours. Because prolonged ruptured membranes increase the possibility of infection, it’s good to keep in mind a few important considerations:

Call your care provider. Let your care provider know that your water has broken — she will want to know the time, amount, color, and odor (TACO). Different care providers have different guidelines for what to do once your water has broken. Some are comfortable with waiting on labor to begin up to 48 hours after your water has broken. They may ask that you come in the office to verify that your water has broken (by testing the fluid in your vagina), and to be monitored periodically for your and baby’s health.

If induction is suggested, learn your options. If induction is suggested after your water has broken, find out about all of your options for induction. How long can you safely wait at home for contractions to begin? How long can you wait if you come in the office periodically to be monitored? Can you try natural induction methods (nipple stimulation, for example)? What are the different, safest ways you can be induced with medication at the hospital?

Limit the number of vaginal exams. If your water has broken, the possibility of infection increases. With each vaginal exam, bacteria is introduced, further increasing the risk of infection. It’s important to limit the amount of vaginal exams you have during labor once your membranes are ruptured.


Have you experienced a labor that began with your water breaking as the first sign? Tell us about it in the comments!


New Medical Guidelines Released to Prevent Cesareans

Earlier this week, the American Congress of Obstetricians and Gynecologists (ACOG) along with the Society for Maternal-Fetal Medicine (SMFM) released a joint Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery, in response to rapidly rising first-time cesarean birth rates that have shown no improvement in the death rates for moms or babies. (Complete details on the consensus can be found on ACOG’s website.) In the statement, the two groups put forth several new recommendations that propose to help prevent the first cesarean for women. If you are pregnant, you can use these new guidelines as a conversation starter during a prenatal appointment — find out how these new suggestions measure against your care provider’s routine practices. A sample summary of the recommendations is below.

A long first stage of labor — more than 20 hours in first-time moms — should not be cause for a cesarean. Many women are put on a time clock to dilate to 10cm, when in reality, a long labor alone should not be cause for a cesarean. If you hear statements like, “Your labor has stalled,” “You are not progressing,” or “Failure to progress,” followed by a recommendation for cesarean, ask: “Is my baby OK? Am I OK? What’s the risk in waiting or doing nothing right now? (or, what’s the alternative?)”

First-time moms should be permitted to push for at least 3 hours (2 hours for second-time moms) before recommending a cesarean. Unlike what Hollywood and The Baby Story show us, pushing can take a while. It’s important for moms to be given enough time to push out their baby, as long as mom and baby are both doing well.

Because induction raises the risk of cesarean, it should not be performed before 41 weeks unless medically indicated. Yes, 41 weeks! Allowing  baby enough time to continue developing and for your body to gear up for labor will give you the best chance of having a healthy mom and baby.

Ultrasounds performed late in pregnancy to determine your baby’s weight should be used only if there is clear indication, as these ultrasounds are linked to increased rate of cesarean for a “big baby,” which is rarely a good reason for cesarean. Ultrasounds have been shown, time and again, to be off by up to (or more than) a pound in either direction. If cesarean is suggested because your baby is estimated to be too big — get a second opinion from a care provider in another practice.

Continuous labor support — like that provided from a doula — is “one of the most effective tools” in improving birth outcomes. Good labor support is not just a “nice to have,” but a key component to improving your care during birth. Lamaze has known this for quite some time — check out our Healthy Care Practice number 3, “Bring a loved one, friend or doula for continuous support.

Being pregnant with twins does not automatically mean a cesarean, if twin A is in a head-down position for birth — even if the second twin is not head down. Vaginal birth for twin mamas — it IS possible!

Baby’s position in labor should be determined — especially if there are problems with baby moving down the birth canal — and if possible, an attempt should be made to manually re-position baby before suggesting a cesarean. A posterior baby (where baby faces toward your front instead of your back)  can cause problems in labor. Often, a baby will correct its position before birth, but not always, and this can cause issues. If you suspect an issue with your baby’s position during labor, mention it to your care provider. You can ask for ultrasound in labor to verify. Ask for help with trying to get baby in a better position for birth.