Professor Theresa Morris sheds light on America’s extreme C-section rate
During a long flight in the summer of 2006, Trinity Professor of Sociology Theresa Morris struck up a conversation with the woman beside her. It only took introductions for Morris to discover they had something in common.
A graduate of Texas A&M University, where she earned her M.S. degree in 1996 and her Ph.D. in 2000, Morris had just been awarded tenure after teaching at Trinity for six years. An expert on sociological issues related to banking and economic policy, she had produced a solid body of scholarship on subjects such as institutional racism in banking and the sociological implications of corporate reorganization.
Now, tenured, she was poised to embark upon research into the increasing consolidation of the banking industry, a project that would occupy her for years. It was research for which she’d spent nearly a decade laying the foundation, and it would have pretty much defined the balance of her career. The trouble was, Morris found herself increasingly ambivalent.
Unexpectedly, she had developed an interest in something decidedly afield from banking and economics. It began as a personal inquiry but soon transcended that as she discerned much broader social implications. Now, every time she contemplated plunging into the banking project, the new subject gnawed at her.
“I was stuck,” she says. “I didn’t know what to do.”
On that long flight it was a relief to talk about it with her fellow passenger. The other woman was a patient listener. A labor and delivery nurse, she found Morris’s story compelling. It began with the birth of Morris’s son, Benjamin, in 2000.
A system out of balance
Only at the hospital, after Morris had gone into labor, was it discovered that her baby had flipped in utero and was presenting in the bottom-down, or breech, position. This is how Morris learned that few doctors and hospitals are comfortable with vaginal delivery of breech babies.
Caesarean delivery–commonly referred to as “C-section”–presents decided risks for the mother. It is, after all, major surgery. There is a greater likelihood of medical complications, including infection and maternal death. Recovery time is also greater. And a C-section costs roughly twice as much as a vaginal birth.
Nevertheless, it is rationalized as an intervention that can protect the baby and minimize lifelong health problems such as cerebral palsy and neurological impairment. Both disorders may result from complicated deliveries, and they are among the most common foundations for malpractice lawsuits, even when the cause is unclear. The practice of obstetrics is so high risk, says Morris, that almost every obstetrician can expect to be sued at least once during his or her career. Consequently, malpractice insurance premiums can run to $100,000 a year or more.
Though disappointed by her own C-section, Morris was undaunted. When she became pregnant again two years later, she was all the more determined to deliver her second baby–daughter Allison–vaginally. “Once you’ve had a C-section, you are automatically considered high risk,” she notes, “and you’re treated in a different way by both doctors and nurses.” Still, vaginal birth after C-section (VBAC in health care parlance) is not uncommon, although it may be difficult to find a doctor and a hospital that will support the decision to avoid Caesarean delivery.
Morris began planning early and reading anything she could get her hands on about VBAC. She learned about the arguments for and against VBAC, and she developed a careful delivery plan. The more she read, the more she became convinced that her Caesarean delivery might have been unnecessary. Moreover, she was soon convinced that she was hardly unique in that respect.
So, after the successful vaginal delivery of Allison, Morris kept researching the topic. “I couldn’t let it go,” she says. “Everything I read led to something else, and a picture began to emerge of a system out of balance, in which the most dangerous method of birth is widely encouraged, often required, for a host of reasons.”
That’s the story she told the nurse on the plane. “She suggested that I should follow what I was interested in,” says Morris.
Culture of safety
It was good counsel. That fall Morris began interviewing health care professionals and women who’d had Caesarean sections. Over the next five years, she would interview nearly 150. Their stories and insights–individually and collectively–are one of the strengths of Morris’s informative and highly readable new book, Cut It Out: The C-Section Epidemic in America.
According to the Centers for Disease Control, the rate of C-sections in this country has increased by 26 percent in the past decade. Fully a third of all births in 2012 were by Caesarean. Even more astounding is what happens to women who’ve undergone a C-section and then hope to deliver subsequent babies vaginally. Faced with the fact that a third of hospitals and half of doctors do not allow VBACs, 90 percent of all women who’ve had a C-section will go that same route with subsequent pregnancies.
“The principal clinical reasons for C-sections are fetal distress, labor that goes on for too long, and babies that are too large,” says Morris. “However, there are many situations where the decision to use Caesarean may amount to excessive erring on the side of caution.”
To illustrate the point, she explains the most surprising discovery she made while researching Cut It Out. Many C-sections result from a disagreement between doctors and maternity nurses over Pitocin, a synthetic form of the hormone oxytocin, which is used to induce labor.
“An estimated 40 percent of women giving birth in the United States receive Pitocin,” says Morris. “That may be excessive, and there’s a culture of safety that argues against use of Pitocin. However, the problem that I discovered while doing my research is that many women receive epidural anesthesia to deal with pain during labor. Those women often need Pitocin to augment labor, and often they don’t get enough. Since maternity nurses actually control Pitocin administration, doctors cannot give their patients more of the hormone than the nurses will allow.
“I was shocked to find out that this is the most common area of disagreement between doctors and maternity nurses,” she adds. “When the nurses, adhering to protocol for Pitocin administration, won’t give patients more of it, the next thing you know, the doctor orders a C-section.
There are, says Morris, a lot of untrue assumptions about Caesarean section. Perhaps the most prevalent is the widely held belief that greedy doctors cynically perform unnecessary C-sections to make more money. That’s not generally the case, she says. Most doctors genuinely care about their patients, but they find themselves ensnared in a web of regulations, insurance requirements, and legal constraints in which they may be quick–perhaps too quick–to order C-sections.
“I was sitting with a doctor at a local hospital one evening,” she recalls. “He was on call. He said something like, ‘Sometimes we’re monitoring a woman who has been in labor for a while, and I’m waiting to see how things will develop. I call my wife, and she tells me to just do the C-section. If something goes wrong, we could lose our house.’ That’s when it hit me that the link between C-sections and the fear of liability risk is not contrived.”
The cause for the “epidemic” of C-sections, Morris says, is not simplistic. In Cut It Out she uses her research findings to show that it is a procedure at the crossroads of many different influences–legal, medical, and political. Together these influences have engendered the “culture of safety” in which a procedure with many inherent risks becomes the standard of practice all too often.
Most books that deal with C-section are guides, Morris says. “My book is not like that. I am an organizational sociologist, and I look for commonalities. Over the past six years, I’ve discovered many of them. I know a lot of people care about this issue, and I think I have something important to share with them.”