As cesarean rates continue to climb in the United States and globally, it's imperative to understand the reasons and the repercussions and be willing to engage in charitable and intentional conversation on the topic. Every birth - vaginal or cesarean - has profound implications on the individual baby, mother, family, and community. It's critical for society as a whole, but specifically a call from God for the Church, to work towards a culture where birth is reverenced and where outcomes for mothers and babies (and therefore families and societies) reflect the design of God, the best possible care, and allow individuals and families to thrive. Birth is intimately and profoundly connected to the sacred act of conception, the Sacrament of Marriage, and to the physical, mental, and emotional health of every single human being. Should how babies are born then matter to the Church? Should the rate of cesarean births be of interest? And should the increasing rate of them concern the Church? Absolutely.
As a note going further, we know that these can be uncomfortable discussions to have and difficult risks to talk about. Any time we talk about something as personal and vulnerable as birth and the choices we make as mothers, it is very sensitive and can be emotional. That's because we know these choices DO matter and because we love our babies so much. But that's exactly why we need to have the conversations. Being uncomfortable shouldn't prevent us from having the conversations, however emotional or difficult, when the health of mothers and babies is at stake. It's not about shame, judgement, or guilt but rather knowing more and better so that we can make the best choices possible, not only for the better health and outcomes for our own families but to inform public policy, awareness, and to improve outcomes for society as a whole.
That said, discussion of risks, mortality, and morbidity can be intense. So if you are in a place where that would create an undue burden of fear or cause unhelpful anxiety for your situation, it may be best to skip this article for now.
1. As Christians, God's intelligent and intentional physiological design for our bodies should be our default, and we need not be afraid of saying so.
His design for our bodies is good and holy and demands respect (CCC 364 and 1004). Human beings are the summit of His creation and that includes our bodies, integral to who we are as human persons (CCC 343). The physiology He planned and intricately wrote into these bodies as women should be reverenced and respected, not pathologized or feared. We are called to use our bodies as He, the Designer, intended them to be used and this especially includes the life-giving acts of conception, pregnancy, and birth. Intervening in that natural and very intentional design should only be with great caution and clear need, when it appears that something has veered from normal healthy physiology. It should always be to support and, in as much as possible, return to healthy physiology. An intervention in the natural design, especially one as significant as major surgery cutting into a woman's womb, should always be with great discernment and grave reason, not simply because it is more efficient, profitable, or based on coercive, one-sided language or risk-based recommendations that ignore the present and long-term risks of the intervention itself.
The Catechism tells us, "By the very nature of creation, material being is endowed with its own stability, truth and excellence, its own order and laws. Each of the various creatures, willed in its own being, reflects in its own way a ray of God's infinite wisdom and goodness" (CCC 339). And so, too, God designed physiological birth with its own truth, excellence, and order, and it reflects Him. "Respect for laws inscribed in creation and the relations which derive from the nature of things is a principle of wisdom and a foundation for morality" (CCC 354).
This does not mean that every invasive intervention is always wrong. Of course not. Medical intervention rightly used can and should honor our bodies and our dignity. Medical care that restores physiology is a gift. Medical intervention that thwarts or disrupts it is not. Consider for a moment the analogy of eating. We as humans are designed to consume real food through our mouths, chew, swallow, digest, eliminate. That's normal healthy physiology. That's what God designed. However, there are some cases in which a person is not able to do that and they may need intervention such as to be fed only liquids or via a tube. When this is truly medically necessary to keep someone alive, we thank God it is medically possible. But we would hopefully all agree that someone should not be electively tube fed and it should only be used when clearly medically necessary and after other less invasive methods have been exhausted. We would hopefully do everything in our power to avoid that significant intervention to physiology and support the body's natural physiology. It is common sense and natural law and this same natural law applies to birth as well.
2. Cesarean surgery CAN BE life saving for either mother or baby.
Extremely important to note in this conversation is that Catholics do need to be concerned that a truly necessary cesarean IS available to any mother and baby who need one. In our fallen world, a cesarean rate of zero would not actually be desireable if it meant babies or women who truly needed them were not getting them. We WANT the babies or mothers with genuine medical need of one to have access to one! If a woman or baby are truly in need of a cesarean and are denied or do not have access to one, that becomes a life and human rights issue, and therefore of great matter to the Church. This lack of access could be because of lack of hospitals, not enough trained surgeons in an area, poverty or other financial restrictions, bias, obstetric or domestic abuse, and more. As Christians, we thank God that we have the modern ability to intervene in this way when it is truly in the best interest of the mother and baby. Ensuring that this intervention IS accessible when genuinely needed is a concern of the Church. The rate should matter on either end, being neither too high nor too low.
What that rate should be is debated. The World Health Organization says that it should be 10-15% of births. Currently the United States rate is 32.1%. However there are many who would say it should be 1-5%. In the United States our cesarean rate in 1970 was 5.2% and the maternal mortality rate was lower than it is today! The stillbirth rate has decreased a small 0.84%, however that was more so due to better prenatal care (a big factor was less women smoking) and advancements in care for premature babies allowing for a greater and earlier survival rate. Either way, we can safely say that the cesarean rate is at the very least 2-3 times what is healthiest and best practice and that well over half of the cesareans performed are preventable or unnecessary.
3. When there are no significant overriding risk factors at play, a cesarean birth puts the mother at greater immediate risk of death and complication.
Maternal mortality rates are shown to be 3.6 times higher for mothers having a cesarean than a vaginal birth. Increased morbidity risks include hemorrhage, infection, cardiac arrest, injury to other organs, severe postpartum pain, scar adhesions, blood clots, hysterectomy, and more. Women who have a cesarean are at 20 times greater risk of infection than women who have a vaginal birth. Thankfully, the actual mortality risk is still very low so it need not be something to live in fear of but the reality is that cesarean surgery poses significant risks to the mother that vaginal birth does not.
For a detailed look at the risks along with links to a wealth of studies establishing this, please see this link here.
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4. Cesarean surgery increases the short and long term complications for the baby.
Cesarean surgery increases the baby's risk of immediate breathing difficulties, blood sugar regulation issues, low birth weight, asthma, obesity, allergies, immune dysfunction, diabetes, respiratory disorders and infection, attachment disorders, injury from the surgery itself, and breastfeeding issues. Babies born by cesarean are 50% more likely to have lower APGAR scores than those born vaginally. For low risk mothers, cesareans are even associated with a 25% increase in childhood mortality the first few years of life.
Babies are designed physiologically to go through labor and go through the birth canal. The process itself is beneficial to their health in a myriad of ways and when that process does not happen, it affects them both immediately and long term. While sometimes the benefit of the surgery can outweigh the risks of it, they should not be ignored nor should those risks be withheld from the mother who is the primary decision maker in the birth. Working in the best interest of both mothers and babies means taking these very real risks and complications into account and avoiding them when possible.
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5. Cesarean surgery is shown to be associated with an increase in ectopic pregnancy, miscarriage, and stillbirth with subsequent pregnancies.
This makes avoiding unnecessary cesareans a life issue and absolutely necessary for an authentic culture of life that prioritizes the dignity and life of every baby in the womb.
For more research on this, see:
6. Cesarean surgery can impede the physiology and options of future births.
While vaginal birth after cesarean (VBAC) is absolutely possible and thankfully increasingly common and accepted, for future pregnancies, the scar now present on the uterus will often compromise the support a mother receives, the advice she receives, and the options she has for providers (some states place restrictions on licensed midwives attending VBACs). Many places and providers will automatically consider her "high risk" which will change how they treat her, the options they present to her, and it will place restrictions on how, when, where, and with whom she can birth in the future (despite that many of these restrictions are NOT based in solid evidence).
For diving deeper into the evidence available on VBAC and more support, we suggest the VBAC Link, VBAC Facts, and ICAN.
7. With each subsequent cesarean, the mother's risk of serious placental complications goes up exponentially.
This includes placenta previa, abruption, accreta, and percreta. Placenta accreta and percreta, where the placenta begins growing into the uterine wall or even into other organs, are significant issues. The occurrence of these truly dangerous complications is almost exclusively the result of previous uterine surgeries performed on a woman. When they do happen, another cesarean surgery becomes medically necessary and it becomes much more complex as the obstetrician must carefully remove the placenta surgically. In many of these surgeries a full hysterectomy becomes necessary. Avoiding unnecessary cesareans in the first place means greatly reducing the number of mothers and babies placed at extreme risks by these complications.
"The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose–response manner." from The Lancet
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For couples who value or desire larger families, who are open to life, and who are seeking to abide by the Church's teaching, the last two points are critical. It means that unnecessary cesareans can place a heavy and serious burden on their backs, as each pregnancy after more and more cesareans comes with greater risk. It can mean that they must or are now advised to limit their family size due to the possible risk when they otherwise would have had more children. It can mean they are tempted toward or advised to use contraceptives or be intentionally sterilized. It can mean that their fertility itself comes to an abrupt halt with a medically necessary hysterectomy. That hysterectomy itself poses future risks to the woman as well.
This is why it should be absolutely standard practice for a provider to understand a couple's approach to fertility and their plans for future pregnancies, though it is not. The question of how many children they hope to have and if they would be open to more after this current pregnancy should be part of every obstetrician and midwife's standard of care. For a couple that hopes to have a larger family and/or that will not use contraceptives, it is even MORE important that an unnecessary cesarean is avoided. Very often, the reasoning or risk assessment given for a cesarean for a current pregnancy only serves to kick the risk can down the road to a future pregnancy.
All of these reasons show why it is also imperative especially for Catholic and Christian obstetricians, midwives, nurses, and hospitals to do everything in their power to avoid unnecessary cesareans. Catholic providers with an understanding of this should have - or at least actively work toward - a cesarean rate far lower than the current norm. If it is claimed that their approach reverences the design of God, recognizes human dignity, and offers Christ-centered care, then that should be reflected in their birth protocols, treatment, and outcomes, including their cesarean rates.
In this entire discussion we remember and recognize that we are talking about real women, real babies, real families, and real experiences. Every statistic is a reflection of hundreds or even millions of very real human beings. We can offer compassion and celebrate every child's birth while also recognizing that the circumstances surrounding that birth may not have been ideal or in the mother's and baby's best interest, perhaps lacking of true informed consent or evidence, even coerced, abusive, traumatic, or the result of the provider's or hospital's own decisions, errors, or lack of skill. If we can look back on a cesarean birth and see clearly it was ultimately unnecessary or iatrogenic, it is still their valid experience. From a theological perspective, it can still absolutely reflect a mother's love and be a sign for the world of sacrifice, love, and the Paschal Mystery. We can hold two truths at the same time - being grateful to God for the birth of this new life while also recognizing that the experience itself was not of God's original design and was not ideal. We can also still be incredibly grateful for necessary cesareans and for the God-given ability to intervene in those cases and for the people with the skills and gifts to do so.
It is agreed from all different perspectives - from the most medicalized organizations to the least - that cesarean surgery, while sometimes necessary and life-saving, is widely overused and the majority of the times completely unnecessary or preventable. These unnecessary cesareans pose a risk of life and health to women and babies and as such, it is the duty of the Church and of society as a whole to be deeply concerned and proactive in their prevention. Promoting a culture of life and defending human dignity includes addressing birth outcomes, and whether standard recommendations from the allopathic and technocratic model of care serve God's physiological design or the best interest of mothers and babies. As a Church, it is imperative to work towards better models of prenatal and birth care, better access to nutrition and education, and better overall birth outcomes and thus better honor every life and glorify God through our bodies and through our births.
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