Obstetrician/gynecologist Lauren Plante has a remarkable essay in the International Journal of Feminist Approaches to Bioethics in which she condemns the rising cesarean rate and compares current U.S. childbirth practices to the industrial revolution.

Critical of the drive to standardize and medicalize obstetrics, a phenomenon that is reducing choices within hospital settings for childbearing women, she writes:

…despite the implied promise of safety if all the rules are followed — ID bracelets, intravenous lines, electronic fetal monitoring — labor may follow an unpredictable path. The definition of  ‘normal’ becomes ever narrower, and toleration of deviance ever lower. The final stage of this philosophy takes the process of birth away from the woman entirely and turns it into a surgical procedure performed by the doctor. Childbirth becomes a manufactured experience, shorn of any real risk or real power, one in which the woman is so far alienated from the capabilities of her body that she is only a package on an operating table for a professional to open.

Plante notes that while the “choice” may be available to have a “maternal request” cesarean (something that does not appear to happen in demonstrably high numbers), this does not equate to increased real choice or autonomy for women.

In the US, we have heard arguments that women are entitled to autonomy in making their birth choices, and that therefore it is ethical to perform cesarean for no reason other than maternal request. Curiously, this vaunted autonomy stops at the door of the labor room. Women are implicitly allowed, or encouraged, to make only those choices which increase the power of the physician and which decrease their own.

Plante explores some possible reasons for the narrowing of women’s choices.

The drive toward fewer delivery options appears at first glance to be supported by upper-middle-class women, who have the least number of social and economic obstacles to autonomy.  In fact, cynical staff at hospitals delivering large numbers of well-insured upper-middle- class women often refer to their institutions as baby factories: these are the places in which cesarean rates are highest. It is, after all, a paradox: women with higher incomes, higher levels of education, and commercial insurance have higher rates of cesarean delivery. If cesarean is a response to any perceived risk, why would women at statistically lower risk of a poor outcome have higher cesarean delivery rates? New Jersey has the highest cesarean rate among states, but no lower levels of maternal or perinatal mortality. What it does have, however, is the highest median household income.

Plante notes that a “new normal” has been created:

…seduced by the promise of pain-free, risk-free childbirth, women and their doctors are driving the cesarean rate ever higher. Rates approaching—or exceeding– fifty percent are now seen in some hospitals. This is the normalization of deviance. This is the new normal.

She describes what a full spectrum of childbirth choices entails:

Women can give birth at home unaided; at home with family or with trained assistance; in a birth center, either freestanding or hospital-based; in the hospital delivery room with trained assistance; or in the operating room where they are acted upon.

Then she remarks:

The American College of  Obstetricians and Gynecologists calumniates not only women who want a home birth but anyone who advocates leaving that option open. Once in the hospital, women who might like to exercise their right to self-determination by choosing vaginal birth after cesarean, or vaginal breech delivery, will have a hard time of it. Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?

Plante includes a sober look at the challenges we face as we try to restore choices in childbirth:

The paradox is this: women wish to be treated as individuals, and assert for themselves a wish to exert control, yet in the commodification and industrialization of childbirth they are so much more likely to be treated as units of production. I know of one large community hospital revamping their labor floor and planning for a 50% cesarean delivery rate: and just as we learned in the 1989 movie, Field of Dreams, if you build it, they will come. The staffing and scheduling patterns for a 50% cesarean rate, as well as administration plans for hospital length of stay, can’t be turned on a dime. Hospital administrations like predictability, in patient patterns, patient care pathways, and everything else. If we normalize this industrialized approach to childbirth, we are likely to be stuck in it for a very long time indeed—and we can’t look to the medical profession to correct it.

Her conclusion is shared by those of us at Our Bodies Ourselves:

We must clearly understand that real autonomy does not mean cesarean on request, but instead a spectrum of birth options that honor women’s authentic choices. Real autonomy also means, to borrow a sentiment from Gandhi, that women should bring forth the change they wish to see in the world.

The full article is available online (for a fee).

Plante, an ob/gyn at the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology at Thomas Jefferson University, has written a number of other articles supportive of choice in childbirth.

For more information on how to preserve women’s choices in childbirth, see the OBOS statement Choices in Childbirth, now signed by more than 400 clinicians and educators in the maternal and child health field.

Citation: Plante, L. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. 2009 Spring;2(1):140-147.