The Overlooked Harms of Cesarean Birth

This common procedure can be a life saver—if it isn't overused
By Jennifer Margulis
Jennifer Margulis
Jennifer Margulis
Jennifer Margulis, Ph.D., is an award-winning journalist and author of Your Baby, Your Way: Taking Charge of Your Pregnancy, Childbirth, and Parenting Decisions for a Happier, Healthier Family. A Fulbright awardee and mother of four, she has worked on a child survival campaign in West Africa, advocated for an end to child slavery in Pakistan on prime-time TV in France, and taught post-colonial literature to non-traditional students in inner-city Atlanta. Learn more about her at JenniferMargulis.net
September 16, 2021 Updated: September 16, 2021

Aimee Wright and her husband Scott, who live in Lake Mary, Florida, planned to have a home birth seven years ago. Wright was 33 and had a lot of friends who had given birth at home successfully. She saw no reason for a healthy pregnant woman to birth in the hospital.

“In my mind, hospitals are where people go when they’re sick or dying,” Wright said. “I don’t think pregnancy and childbirth require that.”

But Wright didn’t go into labor until two weeks after her due date. Then, after 24 hours of laboring at home, she felt like she was hitting a wall. At first, her husband encouraged her to stay home, but Wright intuitively felt as though her labor wasn’t progressing.

They went to the hospital, where Wright labored for another 12 hours. She was initially able to rest after being administered some pain medicine through an IV, but the two epidurals she was then given to help manage the pain both failed, she said. Finally, Wright had dealt with enough. She knew she needed a C-section.

“Go get a surgeon,” she told the labor and delivery staff.

Teddy, her son, weighed 8 pounds 12 ounces. He was born with an unusually long umbilical cord that was wrapped all the way around his body.

“I truly believe that it saved our lives,” Wright said of the cesarean birth.

Ashley Burke, who lives outside of Houston, Texas, is also a C-section mom. But unlike Wright, Burke feels as though her first birth shouldn’t have been surgical. Burke was 30 years old and the picture of good health: eating well and exercising every day. She was decidedly low risk. But when she was 39 weeks pregnant, her doctor warned her that the baby was “too big,” and was “only going to get bigger” and insisted the baby needed to be born right away.

The nurse used Cytotec (misoprostol) to induce the labor. But when she tried to put the small white pill on Burke’s cervix, she lost it in her vagina. So she tried again and lost that pill as well, Burke said. The third pill was placed correctly, according to what the nurse told Burke, but a few hours later she was given a fourth dose.

Burke later found out that Cytotec is an abortion drug used off-label to jumpstart labor and considered by many to be dangerous. That was the opinion of the late Dr. Marsden Wagner, a perinatologist (a specialist in maternal-fetal medicine) and former director of Women and Children’s Health for the World Health Organization. She warned that using Cytotec carries the risk of uterine rupture.

Cytotec inductions have also been linked to both fetal and maternal demise because of amniotic fluid embolisms. Burke’s Cytotec-induced contractions were excruciatingly painful. Then, when the labor didn’t progress as fast as the hospital staff wanted it to, she was told the baby’s heartbeat was too slow,  and she would have to have a C-section or the baby would die.

“They put such fear in me. They kept saying, ‘The baby’s going to die. The baby’s going to die. You need a C-section,’” Burke said.

At 6 a.m., the doctor came in to do the surgery.

“I felt like the whole induction and everything was timed for the doctor. All lined up perfectly for her to get to work and see her patients in the morning,” Burke said.

Burke may well have been right. As reported by Scientific American, most women who birth in U.S. hospitals do so during business hours, a phenomenon that’s linked to doctor convenience, not human physiology. In Burke’s case, as with 90 percent of women who are told their babies are too big, there was certainly no issue with the baby’s size. Despite her doctor’s insistence that he was dangerously big, her son Cooper weighed just 8 pounds 4 ounces.

“My baby was a normal, perfect size,” Burke said. “There was no reason I should have been induced. None. But I didn’t know that at the time.”

Of the 3.75 million babies born in the United States each year, more than 30 percent of them are delivered via cesarean birth, according to the Centers for Disease Control and Prevention. At the same time, the World Health Organization estimates that a country’s optimal cesarean birth rate should be much less: between 10 and 15 percent.

There’s no question that, when used judiciously, cesarean birth can be a life-saving operation. However, while Wright’s cesarean may well have been the safest way for her son to be born, it’s likely that hundreds of thousands of cesareans performed each year, like Burke’s, aren’t medically necessary. In fact, if the WHO’s recommendations are correct (and many providers believe that a 15 percent C-section rate is actually too high), that means that at least 620,000 cesareans performed in the United States each year are unnecessary.

“There’s definitely a time and a place for a C-section, and I’m grateful it’s an option, because it certainly can be required for the safety of the baby and/or the mother,” said Dr. Jani Rollins, a family practitioner based in southern Oregon.

Rollins estimated that she has delivered about 3,000 babies in 23 years. Before she retired from obstetrics, despite having some high-risk women in her practice, her C-section rate was only 6 percent.

“It is a surgery, however, and there are complications,” Rollins said. “And the risk of complications goes up the more C-sections a woman undergoes.”

Problems With Surgical Birth

Rollins said it’s important for expectant moms to know about the possible problems that can arise with cesarean birth, both short- and long-term, for both the mother and the baby.

“One of my concerns about a C-section versus vaginal birth relates to the exposure of the baby to the mother’s vaginal flora,” she said.

Several studies have linked a disrupted microbiome in infants with cesarean birth. In a 2010 study published in the “Proceedings of the National Academy of Science,” a team of scientists found that babies born via C-section have several potentially pathogenic bacteria in their gut microbiome, including Staphylococcus (a Gram-positive bacteria commonly found on the human skin that, when out of balance, can cause serious infections, including sepsis).

Another study from 2015,  published in the peer-reviewed journal “Microbiome,” found that a baby born via C-section is colonized by bacteria from the hospital and from the mother’s skin instead of by the beneficial bacteria from the mother’s vaginal canal. Exposure to healthy microbes, the researchers wrote, “are altered in mammalian infants born by C-section who lack vaginal exposure during birth.” This may be one of the reasons that C-section babies are more likely to have gastrointestinal problems in infancy and why birth via cesarean has been correlated with obesity in childhood and later in life.

A growing body of scientific literature from several different countries, including Canada and Turkey, has shown that cesarean birth is associated with lower breastfeeding success rates compared to babies born vaginally. Research from Israel, published in the peer-reviewed journal “Pediatrics” in 2012, found that infants delivered via cesarean are three times more likely than vaginally delivered babies to fail their first hearing test.

There’s also the risk of the baby being nicked by the doctor during a surgical birth. That’s what happened to a baby girl who was born via C-section in a Michigan hospital. The birth injury was so bad that she had to be treated by a plastic surgeon at birth and has permanent scarring above her eyebrow, according to the law firm that handled her family’s case.

But how common are cesarean-induced newborn injuries? A 2006 study of 37,100 surgical births found that 1.1 percent of the babies had identifiable injuries, including skin nicks, collarbone and skull fractures, and damage to the facial nerve. While this may not sound like a lot—and injuries can occur as well during vaginal birth, especially vacuum- or forceps-assisted births—if those numbers are correct, it means that more than 11,800 babies born in the United States each year suffer from cesarean-induced injuries.

Cesarean birth also puts mothers at greater risk. Injury to the mom’s internal organs, the need for emergency hysterectomies, complications from anesthesia, and severe infection are among the well-documented adverse outcomes of surgical birth for mothers.

But perhaps the biggest concern is that a woman is as much as four to six times as likely to die during childbirth during a C-section than she is during a vaginal birth, according to research done in both the United States and in Europe. That’s what happened to Doreen Plunkett, who died of an amniotic fluid embolism after undergoing a C-section in a Georgia hospital in August, according to Newsweek.

Sadly, about 800 women die during or just after childbirth in the United States each year. While the absolute risk of dying in childbirth in the United States may be low, our country has the highest maternal mortality rates of any country in the industrialized world, according to a 2020 report by The Commonwealth Fund.

If that’s not concerning enough, while other countries have been successful in lowering their maternal mortality rates, childbirth-related deaths have been rising in the United States. Many factors may be contributing to that and the medical community tends to blame the mothers themselves (for being too old, too heavy, or too unhealthy during pregnancy). But the countries that have the lowest maternal mortality rates, such as Norway and Japan, are also places where midwife-attended vaginal birth is the norm and surgical birth is only used as a last resort.

Being Proactive

Rollins attributes her low cesarean section rates to several factors. She said she worked closely with expectant mothers to help them be as healthy as they could be before getting pregnant and to maintain good health practices—such as eating whole foods and daily exercise—during pregnancy. She also feels as though her close relationship with the families (she was always on call for her patients and delivered them herself) helped them feel more empowered and less fearful when it was time to give birth.

“I knew them very well when they went into labor with their first baby or their sixth,” Rollins said. “I also paid close attention to the position of the baby during the pregnancy, especially in the third trimester, and encouraged moms to stay active, eat a healthy diet, and do pregnancy exercises or yoga. I was careful to identify breech babies early on so that moms would have time to change the baby’s position, and, if needed, we would schedule an appointment to turn the baby to head down.”

Another key factor was that the hospital where her patients delivered had doulas, according to Rollins. Those on-call birth attendants were available for free to any mother who wanted one. Several studies show that having a constant companion while giving birth not only puts women at lower risk of having complications, but also shortens labor and helps women feel more positive about their birth outcomes, whether the birth was vaginal or surgical.

Rollins helped develop a water birth program, so mothers could labor or even birth in the tubs. Rollins’s second child, who’s 18 now, was the first baby born in that waterbirth program.

“The benefits of water birth are mainly around allowing the mom to be comfortable and relaxed, which accelerates labor when used at the appropriate time during labor,” she said. “Moms are able to move around and change their position easily, because they’re floating, which allows the baby to move into the birth canal, rather than laying in the bed and not moving. We used walking, showers, hands and knees, yoga balls, all kinds of different positions. I had women crawling on the floor on a mat.”

Freedom of movement is a key factor for women to birth vaginally, according to Rollins.

“My doctor told me that by the time my kids have kids, the majority of the births will be scheduled C-sections,” said Jana Hollingsworth, a mother of three who lives in Brentwood, Tennessee.

Though her mother gave birth to her vaginally, all three of Hollingsworth’s children were born via C-section. The family was living in Athens, Georgia, at the time. Each experience was harder than the last, she said.

On the one hand, she’s grateful to have three healthy children. On the other, she didn’t tolerate the pain medication well, the recovery from the C-sections—especially the first—was brutal, and she still remembers the unkind bedside manner of the hospital staff. Her last baby, who was born blue, didn’t breathe for six minutes and was taken directly to the ICU.

The doctors mistakenly told Hollingsworth that her daughter had Down syndrome. Though she didn’t, the baby was sent home with a heart monitor, and Hollingsworth was told that she needed early intervention. A year later, Hollingsworth wrote a letter to the hospital describing how bad her birth experience had been. Though she didn’t ask for any compensation, the hospital sent her a check for more than $40,000 as a partial refund for the birth.

Jennifer Margulis
Jennifer Margulis
Jennifer Margulis, Ph.D., is an award-winning journalist and author of Your Baby, Your Way: Taking Charge of Your Pregnancy, Childbirth, and Parenting Decisions for a Happier, Healthier Family. A Fulbright awardee and mother of four, she has worked on a child survival campaign in West Africa, advocated for an end to child slavery in Pakistan on prime-time TV in France, and taught post-colonial literature to non-traditional students in inner-city Atlanta. Learn more about her at JenniferMargulis.net