University of Arizona sociologist Louise Roth wonders why women, at least according to news reports, are increasingly opting to give birth by cesarean section, rather than via natural delivery. Stories have focused on better-educated and more well-to-do women having the surgical procedure, a phenomenon dubbed "too posh to push."
Roth, an associate professor of sociology who is interested in the effects of malpractice and, more generally, on the impact of the organizational environment on maternity care, looked at the data surrounding the issue and found herself totally stumped.
"I'd been reading a lot in the news about how women were choosing to have cesareans, and what I discovered was that women you would expect would have more cesareans – if that story were true – were not the women who were more likely to have them," Roth said.
"In fact, the women who were most likely to have cesareans were low-education, Black and Hispanic women, which was not what I expected based on the ‘too-posh-to-push' story. That was the impetus of this paper. I started playing with the data and found this finding that seemed counter-intuitive to me, and so I decided to investigate further."
The results of her study will be published in the May issue of the sociology journal Social Problems, published by the Society for the Study of Social Problems.
Roth said the disparities in the rates of cesareans are an important issue because the procedure is tied to maternal deaths and the cost of health care. One key issue is understanding the "pervasive racial-ethnic and socioeconomic disparities in maternity care (and) health care more generally, yet there has been little scrutiny of how overuse of cesarean deliveries might be linked to these disparities."
Roth poured through a year's worth of data, approximately 4 million recorded births in 2006, the most recent year available. Black, Native American, Hispanic and women from lower socio-economic backgrounds were less likely to have needed cesareans or more likely to have medically unnecessary cesareans.
Either scenario has potentially negative outcomes for both the mother and child. While maternal deaths are statistically low, they still are a concern to public health officials – and deaths from c-sections are four times higher than from vaginal births. Likewise, infants born earlier than 36 weeks, whether naturally or via c-section, are at higher risk for respiratory ailments.
What then is driving the increase in surgeries? Roth asked several researchers, including one who studies cesareans, if this trend was because women want them.
"I think the answer is ‘no.' Women can have different preferences, but those who have the most ability to exercise those preferences seem to exercise them in the direction of avoiding cesareans rather than choosing them," she said.
What's more, lack of prenatal care does not seem to be a factor, and Roth noted that women who get more prenatal care are more likely to have cesareans.
There are other confounding issues. Some studies suggest women in a higher socio-economic status are more likely to get cesareans because they are getting more care than would otherwise be warranted. Other literature report that minority women are more likely to get cesareans.
"I have a statistical model where I account for all of those clinical indications. And when we look at the cases where the clinical indications don't appear to be there, who is more likely to end up with a cesarean delivery?"
"One thing I find is that if you just look at education alone, with rising education, there are more cesareans, which would suggest that it is the more affluent women who are being overtreated," Roth said.
"But that is because they are older and maternal age is correlated with cesarean delivery. Once you take that into account, you see that education is actually associated with a much lower probability of having a cesarean."
A woman who is the same age but has less education is actually more likely to have a cesarean delivery, she said.
"There is that confounding effect that if you look at education alone, without accounting for all those other factors, you might think the ‘too-posh-to-push' story might be correct. But once you look at everything together, you see that it is not. In fact, it's the opposite. The ‘posh' women are more likely to avoid the cesarean."
From a public policy standpoint, Roth said the rising number of cesarean deliveries significantly contributes to the high cost of health care, as well as increasing the risks for women in subsequent pregnancies. Insurance companies and Medicaid plans pay more for cesarean deliveries. Hospitals are able to charge more for them.
One goal of her research is dispelling the myth that cesarean deliveries have increased are because women are choosing to have them.
"The most recent data, the last two years suggest that the increase is close to a third, so it is very high, and higher than would be clinically recommended. There also are things that suggest that practice patterns are the cause of this, not the choices that women make," Roth said.
"In a larger way, there hasn't been that much attention paid on the beginning of life and the unnecessary costs that are incurred at the beginning of life through these practice patterns.
"There is some discussion of end-of-life care, but not that much on maternity care and how the maternity care system could be made more cost-effective and lead to public health improvements. These things have implications, especially in subsequent pregnancies."