Cut It Out

Cut It Out: The C-Section Epidemic in America

Theresa Morris
Copyright Date: 2013
Published by: NYU Press
Pages: 255
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  • Book Info
    Cut It Out
    Book Description:

    Engagingly written, rigorously researched, and compellingly argued, this book [is] a must-read not only for women's health advocates and scholars of reproduction, but also for those engaged in health care policy. - Susan Markens, author ofSurrogate Motherhood and The Politics of ReproductionCut It Outexamines the exponential increase in the United States of the most technological form of birth that exists: the cesarean section. While c-section births pose a higher risk of maternal death and medical complications, can have negative future reproductive consequences for the mother, increase the recovery time for mothers after birth, and cost almost twice as much as vaginal deliveries, the 2011 cesarean section rate of 33 percent is one of the highest recorded rates in U.S. history, and an increase of 50 percent over the past decade. Further, once a woman gives birth by c-section, her chances of having a vaginal delivery for future births drops dramatically. This decrease in vaginal births after cesarean sections (VBAC) is even more alarming: one third of hospitals and one half of physicians do not even allow a woman a trial of labor after a c-section, and 90 percent of women will go on to have the c-section surgery again for subsequent pregnancies. Of comparative developed countries, only Brazil and Italy have higher c-section rates; c-sections occur in only 19% of births in France, 17% of births in Japan, and 16% of births in Finland.How did this happen? Theresa Morris challenges most existing explanations of the unprecedented rise in c-section rates, which locate the cause of this trend in physicians practicing defensive medicine, women choosing c-sections for scheduling reasons, or women's poor health and older ages. Morris's explanation of the c-section epidemic is more complicated, taking into account the power and structure of legal, political, medical, and professional organizations; gendered ideas that devalue women; hospital organizational structures and protocols; and professional standards in the medical and insurance communities. She argues that there is a new culture within medicine that avoids risk or unpredictable outcomes and instead embraces planning and conservative choices, all in an effort to have perfect births. Based on 130 in-depth interviews with women who had just given birth, obstetricians, midwives, and labor and delivery nurses, as well as a careful examination of local and national level c-section rates,Cut It Outprovides a comprehensive, riveting look at a little-known epidemic that greatly affects the lives, health, and families of each and every woman in America.Theresa Morrisis Professor of Sociology at Trinity College in Hartford, Connecticut. She is the mother of two children, the first born by c-section and the second by vaginal delivery.

    eISBN: 978-0-8147-6308-7
    Subjects: Sociology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Acknowledgments
    (pp. ix-x)
  4. Introduction
    (pp. 1-28)

    This book tells the story of how organizational changes constrain the decisions and behaviors of maternity providers and women in a way that has resulted in an epidemic of cesarean sections—commonly, and in this book, referred to as c-sections. Physician Bianco’s statement about the c-section rate aptly represents the ideas of many maternity care providers.¹ They feel that they cannot do “the things” they used to do to facilitate a vaginal birth. Such things include: monitoring the fetal heart rate during labor intermittently rather than continuously; encouraging women with twins and multiples, women who have had a previous c-section,...

  5. Part I. The Root of the Problem
    • 1 The Liability Threat in Obstetrics
      (pp. 31-52)

      Doctor Chism, an obstetrician of twelve years at the time of the interview, is quite frank about his concern with being blamed for a bad vaginal birth outcome. His is not alone in this concern. The American College of Obstetricians and Gynecologists (ACOG), the professional association representing most obstetricians and gynecologists in the United States, has named malpractice liability a crisis for the profession and physicians’ practice of defensive medicine a consequence. In a September 11, 2009 press release announcing findings from a survey of its members about professional liability, Albert L. Strunk, ACOG Deputy Executive Vice President, stated, “The...

  6. Part II. Control Systems Embedded in Hospitals
    • 2 The Tyranny of the Rules
      (pp. 55-82)

      Midwife Morey’s tale gives us a glimpse into how women experience birth in hospitals. Their choices are determined by protocols, or rules for care of patients, put in place by hospital administrators, voted on by nurses and physicians, but based on organizational recommendations, typically ACOG and risk management departments of hospitals. Protocols guide the standard of care, which is considered the minimum care a provider is expected to give. Maternity providers feel they must strictly follow protocols to protect themselves from a lawsuit in the case of a bad outcome. In short, a breech of protocols defines medical error, and...

    • 3 Too Much Information: How Technology Raises the Stakes
      (pp. 83-108)

      Physician Spalding tells me this during our meeting in a basement office of her busy urban practice. Doctor Spalding is upbeat, friendly, and, of the physicians I interviewed, one of the least anxious about liability risk. She has a very go-with-the-flow attitude as she jubilantly greets me, shows me pictures of her children, and assures me that my late arrival because of a forgotten audio recorder is not a problem. “Don’t worry! Don’t worry!” she tells me. Yet, even with this seemingly unflappable attitude, she tells me how maternity providers use technology not only to avert the occurrence of a...

  7. Part III. The Effects of Organizational Constraints
    • 4 The Big Kahuna: Repeat C-Sections
      (pp. 111-134)

      Physician Hinson’s statement is sullen, matter of fact, and true. Once a woman has a c-section, there are two ways she can give birth to a subsequent baby: repeat c-section or vaginal birth after c-section, commonly referred to as VBAC (pronouncedvee-back). As Doctor Hinson suggests, women in the United States with a prior c-section overwhelmingly give birth by repeat c-section. In fact, one half of c-sections are performed on women with a cesarean scar.¹ VBAC has fallen significantly since its all-time high of 28.3 percent in 1996 (i.e., in 1996 28.3 percent of women who gave birth with a...

    • 5 Women’s Lack of Choice in Labor and Birth
      (pp. 135-152)

      Physician Homan is correct about this shift in society, which has been pointed out by medical sociologists as a move toward a consumer relationship between physicians and patients, with patients having more autonomy to make health care choices.¹ This idea of choice in birth is rampant in the stories we commonly hear about reproduction. Women are told they can choose abstinence, birth control, abortion, in vitro fertilization, c-sections, and the list goes on and on. Choice is consistent with the American focus on neoliberal individualism, yet scholars of reproduction have pulled apart this rhetoric of choice to suggest that choice...

  8. Conclusion: A Roadmap for Change
    (pp. 153-174)

    I have demonstrated in this book that the escalating c-section rate cannot be explained by blaming women or maternity providers. Women are not choosing to have c-sections and physicians are not performing c-sections because they believe it is the best health option. Rather, organizational change and constraints are responsible. Hospital administrators, ACOG, courts, malpractice insurers, and reinsurers have defined c-sections as the best practiceto protect themselves and maternity providers from blame in the case of a bad outcome. Further, hospital administrators and risk managers have put in place control systems by way of protocols to align the decisions and...

  9. Methods Appendix
    (pp. 175-180)
  10. Notes
    (pp. 181-200)
  11. References
    (pp. 201-232)
  12. Index
    (pp. 233-244)
  13. About the Author
    (pp. 245-245)