Drugs, Knives, and Midwives

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While an episiotomy is a minor -- albeit painful and often unnecessary -- procedure, a cesarean section is major surgery, and 32 percent of Listening to Mothers II respondents had one. That's a higher rate than the 29 percent cited by Wagner, itself a steep increase from the 21 percent reported five years earlier. Given that WHO has calculated that the optimal rate of C-section for saving the most women and babies is between 10 and 15 percent, what's driving this trend?

Certainly, in this age of rising malpractice insurance costs, obstetricians want to protect themselves from being sued. But Wagner also thinks that C-sections offer doctors a way to bring the most time-consuming part of their practice under their control. 'It means they can split their time between seeing patients in the office, doing gynecological surgical procedures in the hospital, and attending births, on a timetable of their choosing, and reduces the chance that they will be required to attend births at inconvenient times,' he writes. 'For some, it is perhaps their only chance to have a decent personal life.' Wagner also believes that our skyrocketing C-section rates are driven by the internal politics of the birth industry. By promoting cesareans, doctors are choosing a procedure that midwives cannot perform.

Even in an elective cesarean, a woman is almost three times more likely to die than in a vaginal birth. Beyond the immediate health risks, having a C-section decreases a woman's chance to become pregnant again and doubles the risk of an unexplained stillbirth in later pregnancies. In 2 to 6 percent of cesareans, a doctor accidentally cuts into a baby. Babies born from an elective C-section are twice as likely as babies born vaginally to end up in neonatal intensive care.

The widespread use of labor-inducing and painkilling drugs is another by-product of what Wagner sees as the rampant medicalization of American births. According to Listening to Mothers II, four labors in ten were started artificially. The most common method used (80 percent) was synthetic oxytocin, more commonly known as Pitocin. There is no disputing that induced labors can be medically necessary. But they also are done at the request of anxious mothers who are so exhausted by their pregnancies that they just want to be done with them. In theory, there is nothing wrong with trying to jump-start labor; since human life began, women have been walking, squatting, rubbing their nipples, swallowing castor oil, snorting sneezing powders, and having sex to give their babies a nudge. But nearly 20 percent of the women in the study who were induced said that they felt pressured by their doctors.

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