The troubling epidemic of unnecessary C-sections around the world, explained

“Your baby is going to die. You’re putting your baby at risk.”

This is what Jill Arnold remembers her doctor telling her over and over, while she was in labor in August 2005.

Around 7 pm, Arnold started having regular contractions and was admitted to Kaiser Permanente in San Diego. A few weeks earlier, her doctor had recommended a planned cesarean section, which Arnold declined because she wasn’t convinced by her doctors’ reasoning. “I kept asking questions,” Arnold says, “and didn’t really think what they had to say” merited a C-section.

But a doctor insisted and, at one point during the labor, even asked Arnold’s husband to sign forms saying he consented to the risk of losing his child if his wife refused a C-section.

She did refuse, and less than five hours into her (unremarkable, uncomplicated) labor, with her husband and doula at her side, she delivered her healthy baby girl. The only scar that lingered from that day is the “unnecessary stress” of repeatedly being told her daughter could die.

We’ve long known that many C-sections — like the one Arnold’s doctor tried to pressure her into getting — are unnecessary, and that the unnecessary ones have become a problem in the US. The C-section rate in the US shot up by 60 percent between 1996 to 2011. Though it’s declined slightly in recent years, a third of all births in the country still involve the operation.

A new series on the procedure, published in the Lancet, suggests the US is by no means an outlier: The global C-section rate has almost doubled in less than a generation, from 12 percent of all births in 2000 to 21 percent in 2015.

While women in some areas still die during childbirth from conditions that could be addressed with C-sections they couldn’t access, “overuse and its implications are now of growing concern,” a Lancet editorial says.

In Latin America, C-section rates are 44 percent, compared with only 4.1 percent in Western and Central Africa. Optimal rates are generally considered to be between 10 and 15 percent of births, and the World Health Organization just put out new guidance on how to bring the global C-section rate down.

“There’s certain cases where everybody would agree a cesarean is appropriate,” says Gene Declercq, a professor of community health sciences at Boston University. “And there are cases where only a few fanatics would say a C-section should be done. But there’s this large number of cases in a gray area.”

Understanding that gray area is crucial to understanding how cesarean sections became a global epidemic, and what patients and health care providers — who usually make the decisions about when to do a C-section — should be doing about their overuse.

C-sections, explained
Over the last century, medical advances have transformed childbirth from the most common cause of death for young women and infants into a much more survivable one. And the C-section has been an important tool in an ob-gyn’s arsenal.

“It’s the most common major surgery that’s performed in humans,” Neel Shah, an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School who was not involved with the Lancet series, tells Vox.

No one is more eloquent on what a C-section involves than surgeon and New Yorker staff writer Atul Gawande, who described the procedure in extraordinarily vivid detail in a 2006 article about childbirth:

Another uterine contraction, and doctors deliver the placenta through the cut. The mom is sewn up, and the procedure is over.

When a mother has placenta previa (when a baby’s placenta covers the mother’s cervix), when a baby is in a breech (upside-down) position, when labor isn’t progressing at all, or when the umbilical cord may get pinched or compressed — C-sections, without a doubt, save lives. That’s why it’s a tragedy of maternal health that in certain areas of the world, particularly in sub-Saharan Africa, C-sections are still out of reach.

The risks of an unnecessary C-sections
But according to Lancet, in cases where cesarean sections aren’t truly medically necessary, there are no health benefits for moms and only potential harms. The risk of maternal death and disability is higher after the procedure, recovery tends to be longer, and there’s a greater chance of complications in future births.

A woman’s bowels can get lacerated accidentally — and so can her child. Infections in the wound are a regular occurrence. And while vaginal birth is no cakewalk, it’s associated with “reductions in length of hospital stay, the risk of hysterectomy for postpartum hemorrhage, and the risk of cardiac arrest compared with planned [c-section],” according to the Lancet.

After a cesarean section, a woman is also at a greater risk of complications in future births — and with every C-section, these risks increase. For example, the rates of placenta accreta, a dangerous condition that can cause the placenta to grow out of control like a cancer, have exploded — because more women are getting the procedure.

The condition was exceedingly rare in the 1950s, occurring in only one in 30,000 deliveries in the US. Today, it shows up in about one in 500 births. One in 14 American women with accreta die, usually from excessive bleeding.

So if C-sections are an immensely serious surgery, with potential risks and complications for mom and baby, why do doctors do them so often?

Some people blame mothers (some of whom may be considered too old and too overweight to have normal births); others blame doctors, who might prefer to get out of the hospital before 5 pm instead of working through weekends and who receive higher reimbursements with C-sections.

But the story of the rise in C-section is a lot more complicated than that. As researchers pointed out in the Lancet, their explosion has “virtually nothing to do with evidence-based medicine.”

Why the C-section rate rose dramatically
There were 141 million babies born around the world in 2015, and 29 million of them — or 21 percent — started life with a C-section, according to the Lancet. Rates of the procedure have also skyrocketed in the last two generations of moms.

As for why, “some people argue moms looked different in the 70s than they do today,” Harvard’s Shah says. “There’s more obesity, moms are older, more hypertension and diabetes.”

But Shah has parsed the data, and found “this explosion” of C-section rates occurring in every demographic category. “They’ve gone up in young, healthy 18-year olds and in 35-year-olds,” he adds. “When you only look at only low-risk women, you see 15-fold variation” in rates of the procedure.

It’s also not that women are requesting more C-sections. According to a nationally representative survey, Listening to Mothers, only 3 percent of women elect to have the procedure because they are afraid of vaginal birth. “And there’s no health care service in the US that varies as much as this one: Cesarean rates by hospital go from 7 percent to 70 percent,” says Shah.

So after investigating the rise, he’s boiled the cause down to one thing: Over time, the cost for health care providers of waiting for a woman in labor has increased.

“If you are a clinician, you face the dichotomous choice — persist with a woman in labor whose labor has lasted longer than average, whose fetal heart monitoring is giving you an ambiguous reading,” he says, “or you can pull the rip cord.” Performing a C-section can offer a certain outcome through an uncertain process.

When it comes to cost, on average C-sections are reimbursed at 50 percent more than vaginal deliveries in the US, Shah says. Eighty percent of the cost of labor and delivery is staffing, and C-sections generally require a much small staff working for fewer hours. “So it’s not the additional money doctor makes. A vaginal delivery, from a resource point of view, just costs more.” These lower costs, and better reimbursements, are also found in other middle- and high-income countries.

Together, those two benefits of the surgery have far outweighed even the wishes of moms, though unlike Arnold, many moms don’t fight back. And they help explain why researchers have found that while C-sections driven by more objective criteria — like a baby being in a breech position — have been pretty stable over time, C-sections driven by less objective criteria — like a slow labor — have risen sharply.

How to stop the epidemic of unnecessary C-sections
Doctors are well aware of the unnecessary cesareans problem, and they’ve been studying ways to reduce them. Several approaches are described in the new Lancet series, including in a paper from the International Federation of Gynecology and Obstetrics, as well as by the WHO:

  • Hospitals need to address perverse incentives: If being reimbursed more favorably than vaginal births is driving the rise in C-sections, The Lancet argues “delivery fees for physicians for undertaking [the procedure] and attending vaginal delivery should be the same, using a mean fee.”
  • Doctors need clear, evidence-based standards — and feedback: Since more subjective criteria — like a labor that’s going too long — are driving the rise in C-sections, the Lancetseries also suggests standardizing exactly when C-sections should happen, and making sure physicians adhere to those standards and even seek out a second opinion before performing the surgery. The WHO recommends Cesarean audits — looking at doctors’ and nurses’ C-section rates, and why they decided to opt for the procedure — including giving feedback on those decisions.
  • Hospitals should be transparent about C-section rates: The Lancet again: “Hospitals should be obliged to publish annual rates [of the procedure], and financing of hospitals should be partly based on c-section rates.”
  • Midwives can help: They are trained to view birth as a normal process, and seek out ways to limit unnecessary medical interventions. And researchers have found the presence of more midwives and midwife-led units in hospitals correlates with fewer C-sections.

What women can do
If your doctor recommends a C-section, don’t panic; it may be completely appropriate. But unnecessary cesareans are a widespread problem, and there are some things women can do to reduce their chances of an unneeded procedure.

1) Ask what your provider and hospital are doing to promote vaginal birth. Christian Pettker, an associate professor of obstetrics, gynecology, and reproductive sciences at Yale School of Medicine, suggests asking questions like: Do you have criteria for admission to make sure a woman isn’t admitted too early? Do you do external cephalic versions to try and turn a breech baby around? Do you do vaginal births after C-sections? What criteria do you use for performing a cesarean if a woman’s labor is stalling? Hospitals that are addressing these issues — and have clear standards in place — are promoting vaginal births, he said.

2) Show up at the hospital as late as possible. “In movies, the depiction of labor is somebody breaks water, jumps into a car, runs red lights, and [the baby arrives],” Shah says. “Real labor takes hours. If you show up in active labor, you’re much less likely to get a Cesarean.”

3) Consider a midwife or supportive partner such as a doula who is experienced at serving as a coach during labor. “Places that rely more heavily on midwifes have fewer cesareans,” Declercq says. “They are trained not to intervene until it’s necessary.”

4) Research your hospital’s C-section rate: “The biggest risk factor [for a C-section] is not a woman’s personal risks — it’s what door you walk through,” Shah said. While a higher rate can mean the hospital is dealing with more complicated births, it might also be an indication of too many unnecessary surgeries.

There are also several sources that compare state- and hospital-level C-section rates. Jill Arnold was inspired to launch, a website that tracks state-level data for women, after being pressured to have the procedure. The Leapfrog Group, a national non-profit focused on health care quality, has C-section rates for many hospitals across the US. Simply Googling and asking around at your local hospital might yield additional information.

“I didn’t anticipate that the need for would still exist in 2018. I was really banking on its eventual obsolescence,” Arnold said. For now, she wants to remind women that they can question a C-section recommendation. “It’s okay to say no and to ask what their doctor, midwife, or nurse thinks will happen if they wait and watch.”

Breast cancer awareness products profit off survivors’ suffering

Pink ribbons, pink candles, pink sweaters, pink yogurt labels, pink lipstick: There’s an endless array of products sold in the name of breast cancer awareness, appealing to shoppers’ sense of advocacy and activism by offering an easy way to support a cause. Pink products — which proliferate especially during October, designated since 1985 as Breast Cancer Awareness Month — supposedly give a percentage of profit to cancerresearch or awareness. The idea is that the money contributed by buying these branded items helps bring the disease one step closer to eradication.

But the actual benefit to this pink overload isn’t so rosy. There’s been backlash for years now over “pinkwashing” and the commodification of breast cancer. Activists have pointed outthat the money trail of allocated funds to cancer research is nearly impossible to track, and survivors have spoken out about how they feel their disease is being exploited in the name of profit. Medical experts also fear that breast cancer awareness products do just that — bring “awareness,” without offering any tangible information about the disease to help educate the public.

Gayle Sulik, a medical sociologist with the University at Albany, has spent years researching the pink products industry and how companies have turned breast cancer awareness into big business. Her 2011 book, Pink Ribbon Blues, won awards and critical acclaim for taking on the shadowy industry.

Sulik has since gone on to start the Breast Cancer Consortium, a research group dedicated to highlighting critical health literacy and evidence-based medicine. I spoke with her recently about the history of pink products, why the idea of shopping for a cause is rooted in sexism, and how shoppers can make educated decisions about how to advocate with their dollars. This interview has been edited and condensed.

Chavie Lieber

How did you initially get into this field of research? What tipped you off to it?

Gayle Sulik

I started looking into breast cancer when I was in graduate school. A friend of mine was diagnosed with breast cancer at age 35. She was treated, cancer-free for a few years, and then had a recurrence that spread to other parts of her body. She was treated for metastatic breast cancer until she died at age 40.

During her last few years, we talked a lot about what she was going through. She had no interest in support groups or pink ribbons or cancer walks; she just wanted to live. She didn’t see the point, beyond the possibility of raising money for research. So I started to look into [money for research]. The more I looked, the more I learned that something else was going on and it had nothing to do with research. Breast cancer got “branded,” and companies were using the pink ribbon as a logo, not the rallying call it was intended to be.

Chavie Lieber

Where does the pink ribbon as a symbol for breast cancer come from?

Gayle Sulik

[The idea started with] Charlotte Haley, a 68-year-old activist [whose mother and sister battled cancer]. She was giving out peach ribbons [in the early ’90s] to raise awareness about the lack of federal funding for breast cancer prevention. She tied peach ribbons by hand to notecards saying, “The National Cancer Institute annual budget is $1.8 billion; only 5 percent goes for cancer prevention. Help us wake up our legislators and America by wearing this ribbon.” Haley wrote editorials, contacted public women, and gave out the peach ribbons at local venues in her community to spread the message.

Evelyn Lauder [whose family owned the beauty company Estée Lauder] asked Haley to use her peach ribbon for a Self magazine [campaign], but Haley declined because she did not want her message to be watered down or commercialized. The simple solution? Change the color. Evelyn Lauder and Self magazine introduced the pink ribbon as their official symbol for breast cancer awareness during National Breast Cancer Awareness Month in 1992.

The color pink symbolized the virtuous and blameless aspects of breast cancer and the femininity the disease threatened. By 1993, breast cancer became the darling of corporations, and the pink ribbon was its logo.

Chavie Lieber

Why is October associated with breast cancer?

Gayle Sulik

The first national breast cancer awareness movement was in 1985, and it was a week long. It was helped started by Betty Ford, [a breast cancer survivor], with the idea to spread information. It eventually moved to the month of October, although now the timeline to profit off of breast cancer awareness is all year long. Mother’s Day is a big time for breast cancerawareness, and Komen races happen all throughout the year. Avon [which also runs breast cancer awareness events] has said that they, too, are not confined to October. But this time of year is when you start to see pink products everywhere.

Chavie Lieber

Can anyone use the pink logo to make money off products now, or is it trademarked?

Gayle Sulik

Some groups have trademarked a certain style of ribbon. Susan G. Komen has trademarked their style of pink ribbon, for example, so if you see their ribbon on a product, it means that item is partnered with Komen. But a general pink ribbon is not trademarked, so, yes, anyone can put a ribbon on anything. The industry is completely unregulated, so anyone can make products that are pink and say they are donating money to breast cancer, and no one is held accountable.

Chavie Lieber

Who are the players in the breast cancer awareness economy, and how big a market is it?

Gayle Sulik

It is everywhere. You could say that the pink ribbon has helped create a cottage industry surrounding breast cancer awareness, because companies are “riding the tails” of the pink ribbon. Everyone you can imagine is making pink products. There’s pink clothing, grocery items like eggs and yeast with pink labels, pink tech. There was even a pink fracking drill bit from Baker Hughes a few years ago — that is going into the ground, so what sort of awareness does that bring? That also caused a lot of scrutiny on behalf of Komen, which has a history of questionable partnerships.

To give you a good picture of how pervasive this pink industry is, I’ll walk you through a trip I took to Pennsylvania two weeks ago: I took a flight with American Airlines, where they had pink ribbon napkins. There were pink ribbon signs at the rental car agency. A few hours later, I passed a tow truck in a little town in Pennsylvania that said “Towing for Tatas” with a pink ribbon too. Then I passed a bank with a sign of people wearing pink ribbons. And this was all in a few hours! There were so many pink products, but none of it actually tells me anything.

Chavie Lieber

Does anyone know where the money going to breast cancer awareness actually goes?

Gayle Sulik

The vast majority of funding for breast cancerresearch comes from the federal government, not from cause marketing campaigns. With money coming from pink products, the numbers are difficult to track because they’re not all part of official cause marketing programs. That’s the main issue with this industry: Anyone can buy anything that says it’s related to breast cancer awareness, or has imagery about it, but it could just as easily not be related to the cause at all. For a lot of companies, it’s just another way to profit, since October is the season of breast cancer.

Think of companies like Estée Lauder or Ann Taylor. They both have big connections to breast cancer. Go into Ann Taylor and there will be a promotion to have a percentage off that goes to the Avon Foundation, so breast cancer is a promotion for the shopper. Every other time of year, they will market with some other type of promotion. So the way I see it, it’s just another advertising campaign. It’s marketing to make a certain amount of money, which they can write off through advertising.

Chavie Lieber

But what’s wrong with spending money on marketing that goes to awareness about the disease?

Gayle Sulik

While awareness campaigns stimulate interest in breast cancer as a trendy social cause, they do little to promote knowledge about breast cancer. The commercialization of breast cancerhas contributed a lighthearted approach to awareness and advocacy that very often centers on fun-filled activities in the name of breast cancer awareness. This trivializes breast cancerand limits our ability to comprehend what it’s really like to face the disease, live with medical uncertainty, and accept the difficult realities of risk, recurrence, treatment, and even death.

In the book Hiding Politics in Plain Sight, Patricia Strach shows how cause marketing in particular waters down problems like cancer, transforming advocacy into individualized, easily marketable products and services that limit how we think about these problems and what we can do to solve them.

Chavie Lieber

What does raising money for awareness even mean? I’ve been told by other breast cancerresearch experts that a lot of the money just goes back into T-shirts and bracelets that are given away at races and stuff.

Gayle Sulik

What does awareness mean? We don’t know. What I personally think it means is brand recognition: seeing a pink ribbon and knowing it has to do with breast cancer. But it doesn’t necessarily mean the money is going anywhere trustworthy, and it doesn’t mean that it’s going to research or to helping people.

Companies use the breast cancer brand and its association with the color pink to market to women during awareness season. It’s an intentional strategy to sell more stuff and gain consumer loyalty. Consumers seem to like supporting causes with their purchases.

Over the years, “pinkwasher” has become a common term used to describe the hypocrisy and lack of transparency that surrounds Breast CancerAwareness Month and fundraising. It was coined by the group Breast Cancer Action in response to growing concerns about pink ribbon commercialization and the glut of pink ribbon products on the market. This has been going on since 2002.

Chavie Lieber

Do you think all companies that make pink products are doing it for the wrong reasons?

Gayle Sulik

No. I think across the board, some people have good ideas, and some companies want to give money. There are those with good intentions. But in this industry, it’s not about intentions; it’s about following the money and seeing where it lands. I’ve seen companies get specific, like saying they are raising money for a specific research project or helping someone pay off their medical bills. But because of the ubiquity of this, people are not looking to see where the money is going. Now there’s this watered-down message, and it’s hard to find a meaningful campaign that is actually trying to do good things.

Chavie Lieber

In your research, what have you found is the reaction cancer survivors have to this industry?

Gayle Sulik

I’ve heard survivors say they feel like companies are making money off their suffering, off their disease. It makes people angry because they are being used as profit. These companies don’t really care about the people suffering; they care about the advertising effects. I’ve also seen a chasm with women who’ve been treated and have no evidence of disease and those for whom cancer returned and are now in treatment until they die from the disease. Anyone who doesn’t fit the mold of the triumphant, plucky breast cancer survivor doesn’t have much of a place in the pink industry.

Chavie Lieber

So you think this industry also objectifies women?

Gayle Sulik

Absolutely. The images of races and walks, and products, show a very specific type of woman. The difficult realities of cancer are much less palatable for public consumption, and that’s why the look of a woman in the breast cancer awareness industry is sexualized.

Chavie Lieber

How is she sexualized, though? Isn’t this disease literally about breasts?

Gayle Sulik

No, this is about a systemic cancer. What kills people when they have cancer is not a disease of the breast; it’s when it spreads to other organs. This is a huge issue with breast cancerawareness because it is all about the boobs.

The other thing, though, is that you can talk about breasts with objectifying them. I have never seen in any disease-oriented campaign the amount of skin that gets shown with breast cancerones. There is tons of cleavage; women are always touching their breasts. Even serious subjects, like covers from Time magazine, have this type of imagery. Women’s bodies and their breasts are always the focus point. I think it’s important to see this disease as something that’s full-body, not just homing in on chest level.

Chavie Lieber

Do you think this concept of shopping and spending money on breast cancer has anything to do with the fact that this is largely a woman’s disease?

Gayle Sulik

Absolutely. I’ve seen some similarities with the “Movember” movement, which is for prostate cancer awareness. There’s overlap, with a mustache and the ribbon, in that people don’t know what they are aware of. But in terms of the sheer amount of product, it’s not at all similar between men and women.

Part of this is because women have been more consumers of the kind of stuff that’s being marketed. Women, as a target, niche group, are a driver, especially when you look at what sells the most, like cosmetics “for a cause.” Even the NFL got into breast cancer awareness. Why? Because they wanted to increase women football fans. When you start to pick apart the layers, the motivations for this industry become pretty clear.

Chavie Lieber

What can shoppers do? Do you recommend avoiding all pink products?

Gayle Sulik

I would say that if there’s a campaign, they should actually look into what organization the money is going to. Look and see if the organization actually exists, if it’s actually named and is credible. If a product says it “supports breast cancer awareness” but is really vague, that’s probably a red flag (or pink flag!) and you should walk away.

People should also try to find a timeline, because one big issue we see a lot is that companies will give a percentage of sales of something until October 31, but then the leftover stuff is being sold and they money isn’t being donated. But overall, do your due diligence. There’s no federally mandated rules for best practices of marketing campaigns, so it’s up to consumers to hold companies accountable.