Cesarean. Once an Issue, Still an Issue.

By: Nicole Lassiter, CNM, MSN, WHNP (DNP class 28)


Sweat trickled down my skin like rain on a window pane, forming puddles underneath my thick blue nursing scrubs. In the little birth rooms in the free-standing birth center, the labors and births seemed to create more heat than the Texas sun, even in the middle of the night.  Hour after hour, the women stretched and strained, moved and made noise, opened and gave forth life.  For a year as an Americorps volunteer on the border of Mexico, hour after hour I learned how to provide support and to monitor and trust the normal physiologic processes of labor and birth.  The vast majority of the women delivered vaginally, and we transferred those few who needed cesarean sections to the local hospital.


The vaginal birth to cesarean ratio represented in that small nurse-midwife practice is considered normal and safe for the general population as well.  According to the World Health Organization (2015), since 1985 both national and international healthcare standards have identified an ideal target cesarean rate of 10-15% as safe and reasonable, yet the rate is exceedingly higher in many countries, including the United States (U.S).  The rate of cesarean sections in the U.S. has largely been increasing since 1996, reaching 32% in 2015 according to the most recent governmental statistical data reports (Martin, J.A., Hamilton, B.E., Osterman, M., Driscoll, A.K., & Mathews, T.J., 2017). In other words, about one in three women gives birth by caesarean section.


Make no mistake, caesarean sections have saved many lives -- both for mothers and babies, and when medically necessary, they are an essential surgical procedure.  However, the mistake is that they are performed too often, and often unnecessarily.  If a woman or an infant does not require a caesarean, this surgery will not benefit her and her infant, and will instead expose both to short and long-term risks, some of which are quite serious. Not to mention, many risks extend beyond the current pregnancy, to future pregnancies. This is not a good set up for women and babies, many of whom do not have ready access to obstetrical care (World Health Organization, 2015).


All right then, you may ask, what do we do? The answer lies both in the individual, and in the larger healthcare system.  Key contributors to both the problem and the solution include: Individual providers and medical staff, professional organizations, administrators, governmental agencies, community advocacy groups, and the patients and families themselves. For example, the professional organizations representing the majority of obstetrical providers in this country, The American College of Nurse Midwives (ACNM) and The American Congress of Obstetricians (ACOG) must continue to address this issue, educate their memberships, and provide resources and tools for change in their practice areas. Hospital administrators must support both providers and patients to give and receive safe, evidence-based care, and one of the most profound examples is the essential role of the nurse-midwife and nurse-midwifery education.


Nurse-midwifery education and practice is designed to offer care that inherently provides solutions to those issues associated with high caesarean section rates. Maternity care in the U.S. relies heavily on procedures, many of which are harmful, unnecessary, and not evidence-based, yet they are practiced routinely. Patients often lack the information to make informed decisions, or the power to chose when they are educated about their options (Declercq,E.R., Sakala,C., Corry,M.P., Applebaum,S., & Herrlich, A., 2013).


The basic hallmarks, core values and competencies of midwifery care identify labor and birth as normal physiologic processes and advocate for refraining from medical procedures unless medically necessary. Informed and shared decision-making with patients and families are also essential components of midwifery care (ACNM, 2012). The evidence base as well as ACOG (2016) recognize that certain supportive measures such as continuous support during labor are necessary because they reduce complications and cesarean sections. These practices that support normal physiologic birth and reduce cesarean sections and are traditionally practiced by midwives.


While there are numerous risk factors associated with cesarean section, the most common reason for primary cesarean is labor dystocia, when labor does not progress quickly enough or when progress is deemed inadequate.  Yet current evidence shows that women and normal physiologic labor progress at a rate much slower than once believed. For decades, many labors and women were considered abnormal and too slow.  As a result, cesareans were often performed, and unnecessarily.  Today, new definitions of normal labor progress will help decrease these unnecessary cesareans, and these new definitions -- which are based on normal physiologic processes -- are again, those promoted by midwifery care.


I am reminded of the women and their unmedicated labors and births at the Texas birth center. I have often thought back to my time there as one of profound education and experience of what women can do when cared for by those who know and honor the physiologic birth process. The women had continuous support during their labors, along with patience and good care and management from the midwives and the nurses.  These basic tenets of care are the very skills that will help reduce our exorbitant cesarean section rate.  The good news is that we know the vast majority of healthy women have a very good chance of having a normal vaginal delivery. Their physiology remains capable.  The challenging news is that our system still needs the education and structure to support this.  We must continue to learn how to support this basic normal physiologic process, and have systems that support it as well. Nurse-midwifery education and care is a significant and essential part of the solution.




ACNM Core Competencies for Basic Midwifery Practice. (December 2012).


American College of Obstetricians and Gynecologists (Reaffirmed 2016). Safe prevention of the primary cesarean delivery. Obstetrics & Gynecology,123, 693–711.


Declercq,E.R., Sakala,C., Corry,M.P., Applebaum,S., & Herrlich, A. (May 2013).


Martin, J.A., Hamilton, B.E., Osterman,M., Driscoll, A.K., & Mathews,T.J. (Jan 5, 2017). Births: Final data for 2015. National Vital Statistics Reports, 66(1).


WHO Statement on Caesarean Section (2015). Executive summary.

Thank you for this article. As a woman who has not had any children (yet), pregnancy and the birthing process terrifies me. It is a beautiful process but has so many things that can go wrong. It is truly amazing how the majority of pregnancies and births are flawless. The process is beautiful and I wish more birthing centers would allow the woman to progress naturally and not rush the process. Our bodies are made for this, let it happen at it's own pace! You should not rush a miracle.