Avoiding Cesarean: Introduction

“Once a low-risk woman has a cesarean delivery, she will never have a low-risk pregnancy again.” (source? Lisa is this your own quote?) 

The origin of this series of posts about avoiding Cesarean birth dates back 17 years. The reason  I’m writing about avoiding Cesareans hasn’t changed; there were too many before, and there are still too many now. According to the World Health Organization, the cesarean delivery rate in the US is 1 in 3 (32%) of all childbirths. 

I live in New Jersey, where cesarean birth happens almost as often as vaginal birth. We have so many cesareans in New Jersey that our state has a specialized Center for Abnormal Placentation. Abnormal implantation of the placenta is when the placenta grows into the uterus and even beyond it, instead of just the uterine lining (endometrium). 

This is most commonly caused by cesarean surgeries, which can cause significant damage to the lining of the uterus. Placenta accreta, increta, and percreta used to be extremely rare, but due to the rise in primary cesarean delivery and repeat cesareans, they’ve become common enough in New Jersey to require a dedicated treatment center. 

“Department of Obstetrics and Gynecology at Hackensack University Medical Center has been developing a program to serve the growing need for the comprehensive care of patients with placenta accreta. Given the significant increase in births by cesarean section each year, which directly contribute to problems with placental formation in subsequent pregnancies, the incidence of placenta accreta will continue to rise, as will morbidity and mortality rates for pregnant women“(Source).

History of Cesarean Section in the U.S.

Before discussing how a woman can avoid a cesarean section, cesarean section should be defined from a contemporary point of view. The earliest cesarean deliveries were done as a last resort to save the baby when the mother was dying or had already passed away during labor.

Cesarean delivery didn’t become a safe and practical option until hospital births introduced antibiotics, medications to control bleeding, better surgical techniques, and regional anesthesia. According to information from the NIH, in 1970, only about 5% of births in the U.S. were by cesarean. By 2022, that number had climbed to 32% or roughly one in every three births. In 1970, women were told to gain less weight during pregnancy, smoking while pregnant was still common, and doctors were skilled at using tools like forceps to help with delivery. Breech babies and twins were usually delivered vaginally, and overall, people saw vaginal birth as the norm and were more cautious or fearful about cesareans.

Fast forward almost 50 years, and many things have changed. C-sections have become so common that no one is surprised when it happens. Today, many women are having children later in life, which means they’re more likely to have health issues like diabetes or high blood pressure. These conditions can make pregnancy more complicated.  

Women also have a greater need for infertility treatments, which can result in more risky pregnancies, like multiple gestation. Obesity is much more common now and can complicate pregnancy as well.

Less Recognized Reasons for Cesarean:

When we talk about why cesarean births are becoming more common, we usually focus on clear medical reasons like a breech baby, problems with the baby’s heart rate, or labor that stops progressing. But many less obvious reasons play a big role.

Some of these have to do with how our healthcare system handles birth. Others come from fear, convenience, or beliefs about safety that may not be accurate. These factors are just as important to understand if we want to decrease unnecessary cesarean births.

• Medical-led view of pregnancy and birth, leading to higher rates of interventions
• Fear of birth and labor pain
• Fear of medical litigation
• Belief that C-section prevents trauma and damage to the pelvic floor
• Belief that C-section is less traumatic to the baby
• Convenience for the  care provider and mother
• Low tolerance of anything less than the perfect birth outcome
• Cultural considerations, such as birth date being lucky for the future 

Source: Sam McCulloch Dip CBEd in Birth 

The need for surgical birth HAS increased over the years. There are birth outcomes that are now considered unacceptable by most childbearing families and their providers because surgical intervention is relatively safe and very available. A cesarean section is major abdominal surgery and should be avoided whenever safely possible.

Modes of Delivering a Baby

The three ways a baby can be born are:  spontaneous vaginal birth, operative vaginal birth and surgical abdominal delivery. All modes of delivery have advantages and disadvantages but it is undisputed that vaginal birth is the gold standard. 

The typical surgical birth has the woman entering the operating room alone. Her partner waits for the operating room to be set up and the regional anesthesia  (such as spinal block) to be completed before they can come into the operating room. 

The surgery takes about 45 minutes. The baby is usually born in the first 10 to 15 minutes, and the rest of the time is spent closing the incision. During that time, the baby and partner are often in the nursery. The baby is usually returned to the mother to breastfeed and bond in the recovery room. 

After most cesareans, a woman has a catheter and IV for about 24 hours, stays in bed for 12 to 18 hours, and stays in the hospital one or two days longer than after a vaginal birth.

A Cascade of Interventions

I am interviewed by women looking for Vaginal Birth After Cesarean (VBAC) every week. In so many of their stories, I hear their frustration with the assembly-line type care they found themselves receiving. The women had no idea how little their provider and hospital staff knew about promoting normal birth. Even if these women were familiar with the concept of the “cascade of interventions”, they were shocked at how easily they were caught up in it. 

Then, when it is all said and done, most women express their disappointment in the overall experience. They were expecting more respect and more involvement in decision-making, but came to find out that EVERYONE at the hospital knew better about what she and her baby needed than she did. Instead of growing stronger as a woman and mother, they left for home feeling a little, or even a lot, beaten up by the whole process. 

Most women are happy about or at least resigned to their surgical birth immediately postpartum because it is hard to be unhappy with the long-anticipated babe in their arms. But I do know as time goes by, women begin to question more and more the reasons for their surgical delivery. In the moment, it may have seemed easier to just go ahead and get the baby out but later they wonder what would have happened if they had pressed on for a little or even a lot longer.

Our clients who work very hard for their vaginal birth are not always immediately thrilled with the amount of hard work it took to deliver their baby, especially during the recovery time. But ultimately, women stop focusing on the pain and the fatigue and remember feeling powerful and accomplished for doing something as challenging as childbirth. 

Whether a woman “liked” birth or not is not necessarily as important as whether she was treated with respect in the decision-making. And women rarely question a cesarean for which they worked very hard and in which they shared the decision-making.

I sense that women have no idea of the risks surrounding a surgical versus vaginal birth. Cultural fear of labor pain is so pervasive that women will go to great lengths to avoid the pain. 

Unfortunately, the mothers are not given informed consent about the impact of epidural anesthesia on the progress of labor and increased risks of fetal distress, forceps or vacuum delivery, or cesarean section. But even knowing the risks of regional anesthesia, many women will still make the choice to avoid pain because our culture also believes that cesarean and vaginal birth are equal. 

Let me be clear. The Cesarean delivery is no more equal to vaginal birth than formula is equal to breastmilk. And not nearly as safe.

Risks Associated with Cesarean Delivery

Cesarean delivery can be lifesaving in the right circumstances, but it’s not a risk-free alternative to vaginal birth. While it’s often presented as a convenient or controlled option, the cesarean procedure is still major surgery, and like any surgery, it carries short- and long-term risks for both mother and baby. Many of these risks aren’t communicated properly to women making birth decisions. Here are some of the risks of cesarian delivery that may occur.

1. Increased Risk of Infection

Even with laparoscopic surgery, cesarean incisions are still some of the biggest cuts made in the body. That’s because a baby needs a much larger opening to be born than something like a gallbladder or appendix. Larger incisions come with a higher risk of infection.

Over time, bacteria exposed to antibiotics can change and become harder to treat. That’s how MRSA (a tough kind of staph infection) developed—and it’s often picked up in hospitals, where cesareans are done. Most serious infections after childbirth happen after surgery, not vaginal birth. The vagina is built to keep bacteria from moving up into the body; the abdomen is not.

2. Increased Risk of Hemorrhage

Cesarean delivery significantly increases the risk of excessive blood loss during or after birth. The uterus does not contract in the same way after a cesarean, which can make it harder to control bleeding. Severe hemorrhage may require blood transfusions or additional surgery. 

3. Increased Risk of Hysterectomy

In situations where bleeding cannot be controlled or when there’s severe placental attachment from previous surgeries, the uterus may need to be removed entirely. A hysterectomy ends a woman’s ability to carry future pregnancies and comes with its own long-term consequences. 

4. Increased Risk of Postpartum Pain

Cesarean recovery typically involves more pain and physical limitation than recovery from a vaginal birth. Women may need more time and support to resume daily activities, and some experience ongoing scar pain or adhesions long after delivery. 

5. Less immediate bonding with Baby

Physical separation after birth, brief or extended, can interrupt the critical early window for bonding. That first hour of skin-to-skin contact influences breastfeeding success, emotional connection, and even long-term infant development.

Even in the situation where a baby remains in the OR after they’ve been born, the baby is still almost never greeted by its mother immediately. The baby is greeted by the surgeon and then the nursery staff before being handed to his parents. Even this amount of separation can be detrimental to the mother-baby bond.

6. Less successful breastfeeding

Research suggests that cesarean births are associated with delayed milk production, less skin-to-skin contact, and lower breastfeeding rates overall. When babies are separated from their mothers or groggy from medications, early nursing can be more difficult to establish and maintain.

7. Increased risk of postpartum depression

There are studies showing that women who undergo cesarean sections, especially those who feel it was unnecessary or traumatic, are at higher risk for postpartum depression. The combination of physical pain, disrupted hormones, and unmet expectations can take an emotional toll.

8. Each Successive Cesarean Becomes Riskier; Posing Risks for Higher Morbidity and Mortality to Both Mother and Baby.

The risks of complications grow with every additional cesarean. These include adhesions (scar tissue that can fuse organs together), uterine rupture, and dangerous placental conditions such as accreta. For many women, this increased risk influences whether they can safely have more children and how they give birth to them.

9. Obesity and the Risk of Cesarean Delivery

Women who enter pregnancy with obesity are more likely to have a cesarean birth. Even when hospitals follow special protocols designed to reduce unnecessary C-sections, studies show that the cesarean rate remains high among women with obesity. According to the Society for Maternal-Fetal Medicine, this is especially true for women giving birth for the first time.

Obesity can increase the chances of complications during labor, such as slower progress or issues with anesthesia, which may lead doctors to recommend a surgical delivery. But SMFM emphasizes that standardized care and supportive labor practices can still help many women with obesity give birth vaginally and safely. 

10. Limited Family Size

Because of the risk of abnormal placental implantation and significant surgical complications after repeated cesarean sections, most women are advised to stop having children after 3 surgical births. Understanding that many women do not wish more than 3 children, this could be viewed as a non-issue. It just seems that a woman should be able to choose her family size, not her obstetrician.

Labor is good for the baby-especially when allowed to start on its own and progress naturally. The onset of labor is signaled by the baby, which means that the baby is likely ready for extra-uterine life, or if not ready, that it expects the outside world will be more favorable than its intrauterine world. This is the reason babies exposed to toxins like cigarettes, illegal drugs, or poor nutrition will choose to be born early.

The bowel flora of a vaginally-born baby is completely different than that of a cesarean baby. The vagina helps to colonize the baby’s gut with friendly bacteria. This is the first part of a healthy immune system, which will dictate health for this person throughout their lifetime.

Babies born vaginally transition more easily. Again, the fact that it takes a section baby a little longer to breathe normally and maintain its body temperature independently, means it is more likely that the baby will be separated from its mother for extended periods of formative time. 

The mother-infant bond is the most significant relationship in a human’s life. The relationship is a biological imperative, meaning that survival is dependent on the mother and baby attaching to one another. But it is even more than just surviving, it is supporting optimal mental and physical health for both parties, which should be the goal of both families and health care providers.

Listen Carefully

My experience is that women are not as concerned about this low-risk status before their section as they are afterward. Motherhood has a way of making women more opinionated about a wide range of childbearing and parenting decisions. 

They often begin to research their options for their best birth with their SECOND pregnancy and are truly distraught to find out that their Cesarean birth eliminates many of their options. 

The search for the healthiest birth must begin before the first pregnancy so women can position themselves for the healthiest birth for themselves and ALL of their children.

Delivering babies vaginally must be a priority for women, Midwives and Physicians, medical centers, regulating bodies and our culture as a whole. Avoiding the first cesarean is a huge agenda item for both the American College of OB/GYN and the American College of Nurse-Midwives. Very simple changes in a woman’s pregnancy care and birth management can improve outcomes for mothers and babies dramatically. 

As it stands today, women do not have the luxury of relying on our healthcare system to give them the best chance for a low-risk delivery. They must be their own advocates. This blog series is intended to equip families with the information about avoiding cesarean and achieving a positive birth experience, no matter the route the baby ultimately takes.