Of course, we don't think twice about this happening to women for one out of three births.

And then we tell her she has to it all over again for another child, so it shouldn't be a surprise many won’t. We've known for decades there's a better way. It's past time to get serious about it.

More cesareans are done in the US than any other type of major abdominal surgery, even more striking because we’ve made huge strides preventing so many other kinds of major surgery. Cesareans, or C-sections, occur so frequently—one out of three births—that we think it’s routine. But it’s far from that, and one suspects if one out three men were expected to do this, we would have thought very differently about it a long time ago.

Why this should matter to all of us

Pregnant or thinking about it? At risk for a cesarean or had one and maybe still wondering about it? Have a wife, daughter or granddaughter pregnant or considering pregnancy? Never had kids or don’t plan to, but wonder why the US has such high health costs with such questionable health outcomes, even more so for moms and babies?¹ After all, we all end up paying for high health costs and poor results that require sometimes lifetime support. Through taxes and increased insurance rates, those costs come back to us.

Or you may just be wondering if maybe, just maybe, this is yet another area where women’s health issues have been overlooked, actually, routinely neglected.

This post is for you.

(And if you’re wondering about the header, particularly that “probably” with anesthesia, see the astonishing data here.² Can you imagine any other major surgery, for women or men, where medicine ignores up to one out four people whose anesthesia for surgery isn’t working ?)

Cesarean births save the lives of mothers and babies every year

…although with 32% of US births by C-section, you’d be forgiven for wondering how we all made it this far if—through the thousands of years of world history—one out of three births couldn’t have happened without a C-section.

We’re not the only country with a rate in the 30s; the UK is even higher at 40%. But other some countries have much lower rates: Sweden’s is 18% and it’s only 16% in the Netherlands. The World Health Organization (WHO) has long said 15% is safe and achievable. Recent US research reports optimal outcomes for moms and babies at 19%.

Even in the US, the C-section rate varies from a low of 24% in Alaska—where hospitals are few and far between—to a high of 40% in Mississippi. In fact, Mississippi, Louisiana, and Alabama are three of the most dangerous places to birth in the civilized world, not just the US. Expectant moms living there would be safer birthing in Libya or Iraq. (See more in footnote 1.) Interestingly, C/S rates are highest in wealthy countries and lowest in poor countries; that’s worth thinking about.

And yet we’ve known for years how to achieve lower rates and better outcomes.

In the US, one group of healthcare professionals has consistently stood out for their success in preventing unnecessary cesareans. Women who are cared for by a certified nurse-midwife³ (CNM) are 12% less likely to have a cesarean birth for a first pregnancy and 36% less likely to have a cesarean in successive pregnancies. Even in a major medical center—with the highest risk patients—when there is a major quality emphasis on reducing unnecessary cesareans, CNMs have a lower cesarean rate (11.7%) than the OB-Gyns (14.7%).⁴

CNMs focus on education, support and prevention throughout pregnancy, birth and post-delivery. During active labor, they are with the mom-to-be, physically supporting her. They don’t wait for delivery before they show up—and that’s critical. Labor is where you spot trends that can lead to a C-section in time to intervene. Starting with the first prenatal visit, that care is a lot more time and energy consuming, but it pays off with lower C-section and complication rates.

It’s more than just hoping things all work out. Here’s how to prevent unnecessary C-sections.

Ann Ledbetter holds a master’s degree in nursing and is a certified nurse-midwife, wife and mom of three, who walks the walk but also talks about it, helping all of us better understand issues around birthing today with her writings. She is in midwifery practice in Milwaukee⁵ and, importantly for this discussion, also serves on the Health and Human Services review committee on maternal mortality for the state of Wisconsin. She knows cesareans from professional, personal experience, and through reviewing thousands of objective data points for the entire state.

To start, here are two articles Ann published in national journals:

• In STAT, Maternity care in the U.S. is in crisis. It’s time to call the midwife.

• In Scientific American, C-section rates are way too high. We need to hold doctors and hospitals accountable.

And here are two recent posts in her Substack that show what we can do about the C-section rate, and how our it’s makeing our record low birth rate—a rising concern nationally—even worse.

• The C-section rate doesn’t have to be this high. Here’s what we could do about it.

• C-section overuse is suppressing the birth rate. We need to improve maternity care if we want more babies.

It’s up to all of us—and women in particular—to lead on these issues that are now being reported in research⁶ after being examained far more objectively than in the past. Our nation’s future is dependent on us leading on that; our record low birth rate is a threat to all of us. There are multiple complex issues impacting the birth rate, but this is one fix that is staring us all in the face, and we know how to deal with it. Spread the word. Encourage any woman considering pregnancy to do the research. Hoping for a good birth is one thing; taking action right from the start is far more effective.

1. US maternal and infant mortality (death) and morbidity (severe illness) rates are an international embarrassment. We spend far more on pregnancy and birth than our peer nations with much worse outcomes. Click here and here for more.

2. Here are some data points about the header for this post:

• “Major surgery” A caesarean is classified as ‘major abdominal surgery’, with the potential for significant, life-altering complications that can happen in seconds. I’d argue that because of the danger of abdominal surgery, outside of obstetrics, we exercise much more caution about performing it. When cesareans occur so frequently, it’s easy to take them for granted. That’s a big mistake.

• “Probably with anesthesia” Incredible as it may sound in this day and age, according to the American Society of Anesthesiologists, between 12% and 23% of women—as many as one out of four—experience pain during cesarean birth ranging from strong tugging to excruciating. Here’s the Society’s statement on that. This isn’t included to scare anyone, but rather to say we’ve taken every aspect of cesareans—even the very, very basic issue of pain—for granted for far too long. The data is clear we have ignored what women told us for decades, and particularly this year, this obvious abuse is roaring out of the closet. We’re finally talking openly and honestly about long-minimized pain during cesareans (and IVF procedures, and IUD insertions, and… )—LONG past the time anyone should have tolerated it. Click for Susan Burton’s astounding podcast on this or a related podcast from PBS here.

• “Complications” Significant complications occur in at least 14.5% of cesareans. The most common complication is infection—not to be taken lightly as it can impact fertility and cause life-long problems, as with cesarean scar disorder. Fortunately, severe complications like often-fatal uterine rupture remain uncommon. But again, with thousands of cesareans occurring every day, it’s too easy to accept complications as run of the mill. They aren’t if the cause—cesareans—is happening too frequently.

• “1-2 hours sleep at a time” I suspect you know about that, but just in case. Also, for brevity, I left out everything—and I do mean everything—about breastfeeding. Anyone who’s breastfed would likely delight in writing a job description for men on that.

• “Return to work 4 months before recovery” Look up time for recovery for “major abdominal surgery” and you’ll see it’s up to six months. For women and cesareans—major abdominal surgery—the time is often quoted as two months. Don’t get me started again…

• “$26K due with application” That’s the average health spending for cesarean birth. Click here for average health spending for vaginal and cesarean births.

3. A CNM is an advanced practice registered nurse (APRN) specializing in women's health, including reproductive health, pregnancy, childbirth, and postpartum care. CNMs are educated in midwifery programs accredited by ACME, certified by AMCB, and licensed in all 50 states, DC and US territories. Like Ann, many CNMs hold a master’s degree in nursing. CNMs provide comprehensive care, often in collaboration with physicians, and practice in settings like health system, clinics, private OB-Gyn practices and hospitals and birth centers. This article has a good over view of CNM training, qualifications, and health outcomes.

4. Disclaimer: I am not completely unbiased on all this—but the data is all there for you to see in the post, regardless of my opinion. The most rewarding (and most incredibly exhausting) years of my life were when I practiced as a CNM. And, yes, our patients had very low cesarean and complication rates, of which we were very proud. Unlike Ann, I only had a husband to worry about, not three kids as well. And the emotional and physical highs and lows were too much for me to do something as introspective as writing articles about it at the same time, so I’m a huge fan of the way Ann spreads the word about issues many women might never otherwise be able to consider.

5. Ann is with Sixteenth Street non-profit Federally-qualified community health centers (FQHC) that provide health care, education, and social services, particularly to low-income communities. The area is near the Sixteenth Street Viaduct, which played a significant role in the Civil Rights movement. Click for more about her.

6. The research reports we’re finally seeing now are on research conducted since 2001 as a direct result of multiple health organizations—from the National Academy of Medicine to the NIH—finally requiring research be conducted on women as well as men. That allowed the country to start catching up on decades of benign neglect in women’s health research. Now, most women’s health-specific research has been halted by the current administration and RFK Jr. based on the view that research on women’s health is DEI … not that other health research is doing any better. As scientists Drs. Jetelina and Marnik posted in an update today, “In just six months, more than 5,500 research projects have been halted. That’s 5,500 unanswered questions. Thousands of communities left behind. Researchers stuck in limbo. And a generation of training lost.” It will take decades to recover what’s been lost since January.