Bill Savedoff wrote to me following my post last week on “Are caesarean section rates in developing countries too high?”. I thought his comments were too insightful to bury them at the bottom of the post in the comment section, so I am including them here:

Ever since I became aware of the high rates of Cesarean rates in the US (in 1986 when expecting my first child), I have seen it as an indication of how doctors have medicalized birth – seeking greater prestige, less emotionally demanding interaction with patients, and possibly higher fees. Whenever people tell me that doctors do cesareans because women prefer them, I find it laughable. The power relations in the consulting room and the way doctors characterize options has an enormous influence over what patients do or do not want.

In the 1990s, I oversaw a research project in which one of the studies took c-section rates as an indication of corruption – when a private hospital had rates over 70% they claimed it was appropriate given the risks, but the rates were less than half as high in the public hospital with much higher risk population. We suspected that fees and convenience were driving a large part of those high rates.

My view, however, has mellowed considerably since reading an essay by Gawande in the New Yorker. While other procedures may be safer than cesareans in the hands of a skilled midwife or obstetrician, he points out that it is easier to train competent and skilled practitioners in one procedure (c-section) that can be used in many circumstances than to do so for dozens of procedures that apply to different situations (turning a breech birth, forceps delivery, etc.). So while I still believe that cesarean rates are higher than they need to be, I’m aware that in a well-functioning health system, they are not likely to be the last resort emergency procedure that I thought they should be.

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