what is cesarean section essay

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Cesarean Section

What is a cesarean section.

Cesarean section, C-section, or cesarean birth is the surgical delivery of a baby through a cut (incision) made in the birth parent's abdomen and uterus. Healthcare providers use it when they believe it's safer for the birth parent, the baby, or both.

The incision made in the skin may be:

Up-and-down (vertical).  This incision extends from the belly button to the pubic hairline.

Across from side-to-side (horizontal).  This incision extends across the pubic hairline. It's used most often, because it heals well and there is less bleeding. 

The type of incision used depends on the health of the mother and the fetus. The incision in the uterus may also be either vertical or horizontal.

Why might I need a C-section?

If you can't deliver vaginally, C-section allows the fetus to be delivered surgically. You may be able to plan and schedule your cesarean. Or, you may have it done because of problems during labor.

Several conditions make a cesarean delivery more likely. These include:

Abnormal fetal heart rate.  The fetal heart rate during labor is a good sign of how well the fetus is doing. Your healthcare provider will keep track of the fetal heart rate during labor. The normal rate varies between 120 to 160 beats per minute. If the fetal heart rate shows there may be a problem, your provider will take immediate action. This may be giving the mother oxygen, increasing fluids, and changing the mother's position. If the heart rate doesn’t improve, they may do a cesarean delivery.

Abnormal position of the fetus during birth.  The normal position for the fetus during birth is head-down, facing the mother's back. Sometimes a fetus is not in the right position. This makes delivery more difficult through the birth canal.

Problems with labor.  Labor that fails to progress or doesn't progress the way it should.

Size of the fetus.  The baby is too large for your provider to deliver vaginally.

Placenta problems.  This includes placenta previa, in which the placenta blocks the cervix. (Premature detachment from the fetus is known as abruption.)

Certain conditions in the mother, such as diabetes, high blood pressure, or HIV infection

Active herpes sores in the mother’s vagina or cervix

Twins or other multiples

Previous C-section

What are the risks of a C-section?

Some possible complications of a C-section may include:

Reactions to the medicines used during surgery

Abnormal separation of the placenta, especially in women with previous cesarean delivery

Injury to the bladder or bowel

Infection in the uterus

Wound infection

Trouble urinating or urinary tract infection

Delayed return of bowel function

Blood clots

After a C-section, a person may not be able to have a vaginal birth in a future pregnancy. It will depend on the type of uterine incision used. Vertical scars of the uterus are not strong enough to hold together during labor contractions, so a repeat C-section is necessary.

You may have other risks that are unique to you. Be sure to discuss any concerns with your healthcare provider before the procedure, if possible.

How do I get ready for a C-section?

Your healthcare provider will explain the procedure to you and you can ask question.

You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is unclear.

You will be asked when you last had anything to eat or drink. If your C-section is planned and needs general, spinal, or epidural anesthesia, you will be asked to not eat or drink anything for 8 hours before the procedure.

Tell your healthcare provider if you are sensitive to or are allergic to any medicine, latex, iodine, tape, or anesthesia.

Tell your healthcare provider of all medicine (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.

Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning medicines (anticoagulants), aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.

You may be given medicine to decrease the acid in your stomach. These also help dry the secretions in your mouth and breathing passages.

Plan to have someone stay with you after a C-section. You may have pain in the first few days and will need help with the baby.

Follow any other instructions your provider gives you to get ready.

What happens during a C-section?

A C-section will be done in an operating room or a special delivery room. Procedures may vary depending on your condition and your healthcare provider's practices.

In most cases, you will be awake for a C-section. Only in rare cases will a birth parent need medicine that puts them into a deep sleep (general anesthesia). Most C-sections are done with a regional anesthesia such as an epidural or spinal. With these, you will have no feeling from your waist down, but you will be awake and able to hear and see your baby as soon as they are born.

Generally, a C-section follows this process:

You will be asked to undress and put on a hospital gown.

You will be positioned on an operating or exam table.

A urinary catheter may be put in if it was not done before coming to the operating room.

An IV ( intravenous) line will be started in your arm or hand.

For safety reasons, straps will be placed over your legs to hold you on the table.

Hair around the surgical site may be shaved. The skin will be cleaned with an antiseptic solution.

Your belly (abdomen) will be draped with sterile material. A drape will also be placed above your chest to screen the surgical site.

The anesthesiologist or nurse anesthetist will continuously watch your heart rate, blood pressure, breathing, and blood oxygen level during the procedure.

Once the anesthesia has taken effect, your provider will make an incision above the pubic bone, either transverse or vertical. You may hear the sounds of an electrocautery machine that seals off bleeding.

Your provider will make deeper incisions through the tissues and separate the muscles until the uterine wall is reached. They will make a final incision in the uterus. This incision is also either horizontal or vertical.

Your provider will open the amniotic sac, and deliver the baby through the opening. You may feel some pressure or a pulling sensation.

They will cut the umbilical cord.

You will get medicine in your IV to help the uterus contract and expel the placenta.

Your provider will remove your placenta and examine the uterus for tears or pieces of placenta.

They will use stitches to close the incision in the uterine muscle and reposition the uterus in the pelvic cavity.

Your provider will close the muscle and tissue layers with sutures. They will close the skin incision with stitches or surgical staples.

Finally, your provider will apply a sterile bandage.

What happens after a C-section?

In the hospital.

In the recovery room, nurses will watch your blood pressure, breathing, pulse, bleeding, and the firmness of your uterus.

Usually, you can be with your baby while you are in the recovery area. In some cases, babies born by cesarean will first need to be watched in the nursery for a short time. Breastfeeding can start in the recovery area, just as with a vaginal delivery.

After 1 or 2 hours in the recovery area, you will be moved to your room for the rest of your hospital stay.

As the anesthesia wears off, you may get pain medicine as needed. This can be either from the nurse or through a device connected to your IV (intravenous) line called a PCA (patient controlled analgesia) pump. In some cases, pain medicine may be given through the epidural catheter until it is removed.

You may have gas pains as the intestinal tract starts working again after surgery. You will be encouraged to get out of bed. Moving around and walking helps ease gas pains. Your healthcare provider may also give you medicine for this. You may feel some uterine contractions called after-pains for a few days. The uterus continues to contract and get smaller over several weeks.

The urinary catheter is usually removed the day after surgery.

You may be given liquids to drink a few hours after surgery. You can gradually add more solid foods as you can handle them.

You may be given antibiotics in your IV while in the hospital and a prescription to keep taking the antibiotics at home.

You will need to wear a sanitary pad for bleeding. It's normal to have cramps and vaginal bleeding for several days after birth. You may have discharge that changes from dark red or brown to a lighter color over several weeks.

Don't douche, use tampons, or have sex until your healthcare provider tells you it’s OK. You may also have other limits on your activity, including no strenuous activity, driving, or heavy lifting.

Take a pain reliever as recommended by your healthcare provider. Aspirin or certain other pain medicines may increase bleeding. So, be sure to take only recommended medicines.

Arrange for a follow-up visit with your healthcare provider. This is usually 2 to 3 weeks after the surgery.

Call your healthcare provider right away if any of these occur:

Heavy vaginal bleeding

Foul-smelling drainage from your vagina

Fever or chills

Severe belly (abdominal) pain

Increased pain, redness, swelling, or bleeding or other drainage from the incision

Trouble breathing, chest pain, or heart palpitations

Your healthcare provider may give you other instructions, depending on your situation.

Before you agree to the test or procedure make sure you know:

The name of the test or procedure

The reason you are having the test or procedure

What results to expect and what they mean

The risks and benefits of the test or procedure

What the possible side effects or complications are

When and where you are to have the test or procedure

Who will do the test or procedure and what that person’s qualifications are

What would happen if you did not have the test or procedure

Any alternative tests or procedures to think about

When and how you will get the results

Who to call after the test or procedure if you have questions or problems

How much you will have to pay for the test or procedure

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Cesarean section: More than a maternal health issue

* E-mail: [email protected]

Affiliation Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya

• Marleen Temmerman, 
• Abdu Mohiddin

Published: October 12, 2021

• https://doi.org/10.1371/journal.pmed.1003792
• Reader Comments

A cesarean section (CS) can be a lifesaving intervention when medically indicated, but it may also lead to adverse short- and long-term health effects for women and children.

Citation: Temmerman M, Mohiddin A (2021) Cesarean section: More than a maternal health issue. PLoS Med 18(10): e1003792. https://doi.org/10.1371/journal.pmed.1003792

Copyright: © 2021 Temmerman, Mohiddin. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: CS, cesarean section; FIGO, International Federation of Gynaecology and Obstetrics; OR, odds ratio

Therefore, the accompanying research study by Paixao and colleagues published in PLOS Medicine , looking at CS and associated child mortality in Brazil, provides further valuable evidence on the balance of benefits and risks [ 1 ].

CS rates are rising worldwide: Boerma and colleagues, on the basis of data from 169 countries including 98.4% of the world’s births, estimated that 29.7 million (21.1%) births occurred by CS in 2015, almost double the number of CS births in 2000 (16.0 million, 12.1%) [ 2 ]. In a further study investigating CS rates in specific obstetric populations using the Robson system, which classifies all deliveries into one of 10 groups on the basis of 5 parameters: obstetric history, onset of labour, foetal lie, number of neonates, and gestational age, there was an increase of CS across most Robson groups, especially after induction of labour in multiparous women [ 3 ].

WHO guidance is clear that CS is essential for those who need it, specifying a recommended rate of 10% to 15% to improve maternal and perinatal outcomes and prevent maternal and neonatal mortality and morbidity [ 4 ]. Yet, given the increasing use of CS, particularly without medical indication, a more complete understanding of its health effects on women and children has become crucial. The maternal sequelae of CS are well described, while long-term consequences for child health require more research. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures and that these exposures can subtly alter neonatal physiology. Short-term risks (within 3 years) of CS can include altered immune development; an increased likelihood of allergy, atopy, and asthma; and reduced intestinal gut microbiome diversity [ 5 ]. In a systematic review, CS was found to be a risk factor for respiratory tract infections (pooled odds ratio (OR) = 1.30 for asthma) as well as for obesity (pooled OR = 1.35) in children [ 6 ]. In a further study including 327,272 neonates born by vaginal delivery and 55,246 by elective CS investigating neonatal respiratory morbidity in relation to mode of delivery, there was a 95% higher risk in neonates delivered by elective CS than in neonates born by spontaneous vaginal delivery [ 7 ]. Further, Alterman and colleagues described a moderately elevated risk of severe lower respiratory tract infections during infancy in infants born by planned CS, as compared to those born vaginally [ 8 ]. Infants born by planned or emergency CS may also be at a small increased risk of severe upper respiratory tract infections, with a stronger estimated effect if including the indirect effect arising from planning the cesarean birth for an earlier point in gestation than would have occurred spontaneously [ 8 ].

However, the extent to which CS, in particular nonmedically indicated CS, benefits or reduces child survival remains unclear. Therefore, Paixao and colleagues conducted a population-based cohort study in Brazil by linking routine data on live births from 2012 to 2018 and assessing mortality up to 5 years of age [ 1 ]. Women with a live birth were classified into a Robson group based on pregnancy and delivery characteristics. The analysis of 17,838,115 live births showed that live births to women with low expected frequencies of CS (Robson groups 1 to 4) had a higher death rate up to age 5 years compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). This means that CS was associated with a 25% increase in child mortality in infants born via CS in Robson groups with low expected frequencies of CS (i.e., low-risk mothers). In groups with high expected frequencies of CS (i.e., high-risk mothers), mortality rates were lower among infants born via CS, supporting the benefits of clinically indicated CS.

This large study shows how important it is to optimise the use of CS, which is increasingly overused leading to global concern. Underuse of CS leads to maternal and perinatal mortality and morbidity, and yet, conversely, overuse of CS has not shown benefits and can create harm. As the frequency of CS continues to increase, interventions to reduce unnecessary CS are urgently needed. As described by Betrán and colleagues, many factors can affect rates of CS, and these may be associated with women, families, health professionals, and healthcare organisations and systems, being influenced by behavioural, psychosocial, health system, and financial factors [ 9 ]. These authors concluded that interventions to reduce overuse of CS must be multicomponent and locally tailored, addressing women’s and health professionals’ concerns, as well as reflecting health system and financial factors [ 9 ].

Paixao and colleagues’ study provides evidence that either overuse or underuse of CS is associated with child survival, and the findings will help pregnant women and their providers to make informed decisions as to whether CS is appropriate for them. The authors should be commended for carrying out this big data record linkage study, which paves the way for further analyses to study risk profiles using other available population-level data. At a health policy level, the paper shows the significant challenge to child population health that the sequelae of low-risk CS pose, especially in countries with high CS rates such as Brazil at 56% [ 10 ]. This represents an avoidable threat to some of the gains to child mortality and morbidity seen over the past few decades and to the achievement of the UN’s Sustainable Development Goal 3 to ensure health and well-being at all ages [ 11 ]. Policymakers and civil society groups should take note and act by implementing the recommendations of the 2018 International Federation of Gynaecology and Obstetrics (FIGO) position paper, calling for “joint actions with health professionals, governmental bodies, women’s groups and the healthcare insurance industry to stop unnecessary caesarean sections” [ 12 ].

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• 4. WHO statement on caesarean section rates. [cited 2021 Jun 28]. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/ .
• 11. The UN’s Sustainable Development Goals. [cited 2021 Jun 28]. Available from: https://sdgs.un.org/goals .

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Article Contents

Introduction, evolution and birth, reasons for cesarean section related to human evolution, non-medical (and non-evolutionary) reasons for cesarean section, risks and benefits associated with mode of delivery, fear of childbirth and request for cesarean section, public health implications of an evolutionary perspective on cesarean section, acknowledgements, evolutionary perspectives on cesarean section.

• Article contents
• Figures & tables
• Supplementary Data

Karen R Rosenberg, Wenda R Trevathan, Evolutionary perspectives on cesarean section, Evolution, Medicine, and Public Health , Volume 2018, Issue 1, 2018, Pages 67–81, https://doi.org/10.1093/emph/eoy006

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Cesarean section (surgical removal of a neonate through the maternal abdominal and uterine walls) can be a life-saving medical intervention for both mothers and their newborns when vaginal delivery through the birth canal is impossible or dangerous. In recent years however, the rates of cesarean sections have increased in many countries far beyond the level of 10–15% recommended as optimal by the World Health Organization. These ‘excess’ cesarean sections carry a number of risks to both mothers and infants including complication from surgery for the mother and respiratory and immunological problems later in life for the infants. We argue that an evolutionary perspective on human childbirth suggests that many of these ‘unnecessary’ cesarean sections could be avoided if we considered the emotionally supportive social context in which childbirth has taken place for hundreds of thousands or perhaps even millions of years of human evolution. The insight that human childbirth is usually a cooperative, even social event in which women are attended by familiar, supportive family and friends suggests that the harsh clinical environment in which women often give birth in the developed world is not the best setting for dealing with the strong emotional forces that usually accompany labor and delivery. We argue that providing a secure, supportive environment for laboring mothers can reduce the rate of ‘unnecessary’ surgical deliveries.

Throughout human history, the childbearing years have represented a time of increased risk of mortality for women with a significant portion of that risk associated with childbirth [ 1–3 ]. Pregnancy and birth are times in the human life cycle when natural selection operates intensely on the biology of both the mother and her infant. Cultural adaptations to these risks take the form of attendants of many sorts, including untrained friends and relatives, experienced midwives and obstetricians, all of whom provide a range of services from emotional support to surgical delivery.

In many countries today, especially wealthy ones, surgical deliveries (cesarean sections) represent a significant proportion of all births; in 2014, rates in some countries (e.g. Brazil and Cyprus) exceeded 50%; and in 26 nations the rates exceed 30% [ 4 , 5 ] (see Fig. 1 ). There is also substantial variation in rates within nations, as illustrated by the United States with state rates ranging from 23% in New Mexico to almost 40% in Kentucky; hospital rates in the United States vary from a low of 7.1% to a high of 69.9% [ 6 ]. The availability of cesarean sections has helped millions of mothers and infants around the world to survive childbirth, but it is important to note that in many parts of the world this often life-saving procedure is inaccessible. Thus, low rates such as those seen in Cambodia, Afghanistan and Haiti occur in nations that lack access to medically necessary surgeries, whereas the high rates seen in Brazil, Iran and the Dominican Republic arguably represent a high proportion of non-medically necessary surgical deliveries [ 7 ]. Some of the high rates may be due to co-occurring factors such as obesity [ 8 ] and maternal age [ 9 ]; given the link between cesarean section and obesity in offspring who may then go on to need cesarean section when they give birth, the combined effects of obesity and surgical delivery may well be transgenerational [ 10 ]. Furthermore, surgical delivery is not risk free and has substantial costs both in terms of financial resources and maternal and infant morbidity.

Histogram showing percentage of births (vertical axis) that are cesarean section for a range of countries. Data from Betrán et al. [ 4 ]

In 1985, WHO set a target cesarean section rate of 10–15% as theoretically optimal for balancing among health outcomes and resource use [ 11 ]; this rate has recently been supported [ 12 ] in a study of 19 countries with low rates of maternal and infant mortality that concluded ‘our findings corroborate the statement that a population-level cesarean section rate above 10–15% is hardly justified from the medical perspective’ (p. 237). Cesarean section rates over 10% do not appear to have negative or positive effects on maternal or infant mortality rates in resource-rich populations [ 13 ] but maternal and infant morbidity does rise with increasing use of cesarean sections. In fact, a recent study reports that while health outcomes improve with rising Cesarean section rate when it is below 15%, they actually decline with a rising rate above 15% [ 11 ]. Indeed, Althabe and Belizán [ 14 ] note that in parts of Latin America at least, ‘paradoxically, and only for caesarean section rates, poorer women receive health care of better quality than those of higher income’.

In addition to having questionable health benefits in many cases, cesarean sections are also expensive financially. If the cost associated with excess use of cesarean section in the countries with high rates could be applied to needed cesarean sections in countries with low rates there would be health benefits to women on both sides of the 10–15% target rate recommended by WHO [ 15 ]. In other words, redistribution of resources (in the form of access to cesarean sections) worldwide would clearly benefit women in poor countries, with inadequate health care, but it should also improve the health outcomes of women in rich countries who are overusing cesarean section. This is analogous to the situation with global food availability in which some areas of the world suffer from starvation and undernutrition while more affluent countries have high rates of obesity, diabetes and heart disease, much of which is due to excessive food intake.

Based on an understanding of the costs and benefits in terms of both monetary and health outcomes, and a concern that health care professionals were too focused on the target rate [ 16 ] rather than the welfare of individual women, the most recent WHO recommendation (2015) is that cesarean section should be done only when ‘medically necessary’ but that ‘every effort should be made to provide caesarean sections to women in need rather than striving to achieve a specific rate’ [ 17 ]. In this paper, we will consider ways in which an evolutionary perspective can enhance understanding of why cesarean deliveries are necessary in some cases, and offer suggestions of ways in which excessive rates can be reduced in others.

When they founded the field of ‘Darwinian Medicine’, Williams and Nesse [ 18 ] argued that understanding the evolutionary explanation for vulnerability to disease often has practical benefits in medical treatment. Evolution involves tinkering with a preexisting biological system rather than a de novo design and often results in compromises that carry significant costs in the form of disease susceptibility or other apparent ‘flaws in design’. Reconstructing the evolutionary basis of difficulty and risk during childbirth may provide a useful context for understanding warranted obstetrical intervention. Additionally, and perhaps more importantly, an evolutionary perspective on the successful process by which birth occurs under most conditions can raise awareness of ways in which unwarranted intervention can increase risks and difficulties of childbirth.

Box 1. Skeletal changes associated with the evolution of bipedalism [ 155 , 156 ].

The evolution of upright walking in our ancestors from an ape-like quadrupedal form involved a major restructuring of the muscles involved in locomotion and the bones associated with each muscle. Specifically, the human pelvis differs from the pelvis of other apes by having (i) a shorter ilium, (ii) a broader sacrum, (iii) iliac blades which are oriented more sagitally, (iv) a sacrum close to the acetabulum, (v) a short ischium and a long ischial spine and (vi) a deep sciatic notch ( Fig. 3 ). These anatomical changes for locomotion also led to significant restructuring of the bony birth canal, which lies within the pelvic girdle. The birth canal in other apes is elongated (like the overall pelvis) in the anterior posterior plane and maintains this shape and orientation from the inlet to the outlet. It is also shallow throughout. In contrast, the birth canal in humans changes shape from the inlet to the outlet: like the overall bipedal pelvis, the canal is wide transversely at the inlet, most spacious in the anterior-posterior direction at the outlet and most constrained at the midplane with bony protuberances (such as the sacral promontory and the ischial spines) that provide resistance to the infant as it passes through the canal. These morphological changes were associated initially with locomotor changes; subsequent brain size increase much later in human evolution meant further changes in the mechanism of birth. The result is that the neonates of modern humans have a birth mechanism quite different from that of their ape ancestors as they must typically rotate their heads and bodies as they pass through the birth canal from inlet to outlet. Furthermore, the large head of the infant best articulates with the anterior portion of the pelvis so that birth usually occurs with the infant facing toward the mother’s back. These changes, we argue, placed a selective premium on seeking assistance at delivery for the instances in which the passage and emergence of the infant are hindered.

The passage of the human neonate through the maternal birth canal. Each panel is a sagittal section through the body of a mother squatting during labor. The maternal pelvic skeletal elements (pubic bone, sacrum and vertebrae) are shown in black (other parts of the bony skeleton are not visible in this midline view). In the lower right corner of each panel is a ‘midwife’s-eye’ view of the neonatal head as it rotates within and emerges from the birth canal. Athough this mechanism of labor is not the only way that human neonates emerge through the birth canal it is by far the most common and is associated with the lowest risks to both mothers and their babies

The pelvis in a modern chimpanzee (top) and a modern human (bottom), illustrating the differences discussed

Today virtually all women in all societies seek assistance during delivery from relatives, midwives or obstetricians [ 20 , 21 ]. The most likely reason for seeking companionship at birth is for emotional support at a time when the normally gregarious female feels vulnerable. In evolutionary terms, the proximate reason for seeking assistance is for emotional support. Birth usually takes place without any form of intervention as the infant negotiates the series of rotations with the force of uterine contractions in a manner referred to by some as the ‘fetal ejection reflex’ [ 22 ]. But occasionally a mother and infant can benefit from assistance, for example, when the umbilical cord is wrapped tightly around the neck, when the shoulders get stuck or when the infant begins breathing when the head first emerges, risking inhalation of birth fluids. Over the course of human evolution, seeking another person for companionship during labor would probably have improved birth outcome, providing the ultimate explanation that selection favored assistance by reducing morbidity and mortality for both mothers and infants.

Box 2. Opinion: can women really choose how to give birth?

How much control does a 21st century woman have over labor and delivery? Our proposal that a woman who is informed about the process of labor and delivery and is provided continuous care from the prenatal period through birth to establishment of breastfeeding is less likely to approach birth with excessive fear neglects the question of how much control an individual woman has over her body and decisions about reproduction. Several decades ago, birth began to be regarded as a medical event that required highly skilled clinical personnel and the facilities available in a hospital. Many have argued that the transfer of birth from home to hospital meant that women had less control over labor, delivery and the immediate postpartum period, factors that led to greater anxiety and fear of birth [ 157 ]. The ethnographic evidence that birth is a woman-centered event in most traditional cultures (see [ 20 ] for review) (and female-centered in some nonhuman primate groups), has led us to conclude that most births in the evolutionary past occurred in the presence of female relatives and friends and that men were rarely present. Returning to this familiar support network may not be an option available to all women today.

We have suggested that women request cesarean section even when there is not a clear medical indication that it is necessary for a variety of reasons. In many cases, however, a woman may acquiesce to cesarean section when a clinician suggests it, even though continuing to labor may have resulted in a healthy, vaginally delivered infant. The word ‘acquiesce’ speaks to issues of power, autonomy and consent, all of which may be absent in a high-tech hospital setting. Furthermore, many women lack the confidence to challenge or question their attendants. In fact, low self-esteem has been shown to be one of the strongest psychological predictors for elective cesarean section [ 158 ]. Women with low self-esteem often develop doubts about their ability to give birth and request surgical delivery to relieve those doubts [ 42 ]. Consider some of the phrases that are used to describe challenges to the birth process: ‘failure to progress’, ‘incompetent cervix’, ‘inefficient contractions’, ‘uterine dysfunction’, (see Martin [ 159 ] for other examples). Is it any wonder that a woman who has been in labor for a long time and hears some of these phrases decides to acquiesce when surgery is suggested?

These discussions lead to consideration of cultural and sociological notions of risk, blame, power, control, norms and inequality, all of which are deserving of far more attention that we can give in this paper on evolutionary medicine and cesarean section. They are too important and too salient to disregard, however, and should be added to any examination of factors influencing rates of elective cesarean section. Focusing on educating individual women about the positives and negatives of surgical delivery when not medically required will not go very far in changing the culture of birth technology and may even add to feelings of guilt when ability to control choices is not possible. Adding evolved strategies for dealing with birth will require structural changes in the medical system that too often ignores them.

The most frequently cited reasons for medically necessary surgical delivery in the United States are labor arrest (34%), problems with fetal heart rate (23%), fetal malposition (17%), multiple gestation (7%) and suspected fetal macrosomia (4%) [ 24 ]. Notably, the clinical diagnoses of many of these are highly variable, sometimes arbitrary and often subjective. For example, the definition of abnormally long labor varies by clinical settings and has changed historically. Variation in cesarean section rates across health care systems is at least partly a result of variation in risk assessment and cultural expectations about birth, suggesting opportunities for reduction of cesarean section rates.

Nonhuman primates cannot, of course, tell us when labor begins because they lack language, so that comparisons of length of labor with humans are difficult. Nevertheless, based on observations of postural and other behavioral changes in nonhuman primates, labor appears to be longer in humans than other animals including other primates (see [ 20 ] for review). But, given the tight fit between the mother’s pelvis and the neonate’s head, it may take more time and more uterine contractions for the neonatal head to engage and stimulate cervical dilation. Furthermore there is great variation in labor length within human populations. Thus, it is not surprising that, given all of the ways in which women and neonates may vary, the lengths of both the first (uterine contractions and dilation of the cervix) and second (pushing the infant out) stages of labor are also highly variable. Maternal parity, age and body weight all influence labor length in humans so that an arbitrary cut-off point (e.g. 12 h for primiparas and 7 for multiparas) for recommendation of surgical delivery is difficult to support [ 25 , 26 ]. In a recent study in which the time limit for the second (pushing) stage of labor was extended by a third beyond what is defined as ‘prolonged second stage of labor’ (from 3 to 4 h) the incidence of cesarean delivery was reduced by slightly more than one half without any change in neonatal or maternal morbidity [ 27 ]. Perhaps due to changing standards of practice, changing measurement methods or changing maternal characteristics (e.g. greater age and higher BMI), labor appears to be longer today than it was in the mid-twentieth century when standards of labor length were first established [ 6 , 28 , 29 ]. Just as sleeping patterns, mealtimes and various other aspects of our biological lives are culturally constructed into norms of behavior, expectations about length of labor are shaped differently by cultural ideals. Labor management may be an appropriate context in which to adopt the evolutionary medicine recommendation of watchful waiting before stimulating labor with oxytocin or rupture of the membranes or moving on to surgical delivery.

When labor is excessively long (however that may be defined), the fetus or mother may be at risk for compromised health or life. But many of the factors that account for long labors can be dealt with through other means before resorting to surgery. For example, maternal anxiety is a common reason for arrested or ineffective labor contractions and thus longer labors [ 30 ]. Adequate preparation for childbirth and emotional support during labor have been shown in numerous studies to reduce stress in labor and thus reduce the length of labor and increase uterine function [ 23 , 31 ]. Walking during labor not only decreases its length, but it may also decrease discomfort and increase willingness to delay a request for surgical delivery on the part of the parturient or attendant [ 32 ]. Evolutionary medicine-based recommendations of emotional support and walking in labor may help to decrease the rate of requests by laboring women for surgical deliveries. In addition, any other environmental factors that may enhance women’s comfort during labor and delivery likely have a positive effect on birth outcome [ 33 , 34 ]. Attempts to approximate the ancestral environments of birth (e.g. in a familiar setting and with familiar people) without compromising health can have positive impacts on the birth process in addition to reducing rates of surgical deliveries. In evolutionary medicine terms, the hospital environment for normal birth is often mismatched with the environment most conducive for healthy birth outcomes. Consider that a typical delivery suite usually has bright fluorescent lights, noisy beeping machines and unfamiliar faces, a description quite unlike a typical home birth with low lights, soothing music and familiar people. One of the major differences between standard hospital suite deliveries and those that occur in a more home-like environment is continuity of care. In a standard hospital delivery a woman is seen by one group of professionals for prenatal care, another group of (usually unfamiliar) professionals attends her at delivery, and a third group helps with postpartum and early infant care. When continuity-of-care models are adopted, cesarean section rates decrease [ 35 ].

Another aspect of obstructed labor is failure of the infant to progress through the birth canal despite sufficient uterine contractions. In this situation the health and lives of the infant and the mother are potentially compromised. Risks for the mother include uterine rupture, sepsis, trauma to the bladder and rectum, and the especially problematic risk of an obstetric fistula, wherein the area between the vagina and rectum is compromised, leading in the extreme to lifetime disability [ 36 ]. Risks to the infant include brain and nerve damage or death from asphyxia. The risk of death and disability are especially high in parts of the world where safe surgical delivery is rarely available reminding us that in some parts of the world, there is a need to increase the cesarean section rate [ 37 ].

Cephalo-pelvic disproportion (CPD) is another reason for obstructed labor [ 36 ]. Although far from the most common reason for surgical delivery, CPD is the obstetric challenge most directly related to the evolution of bipedalism as described above and in the box ( Box 1 ). Large-headed and large-bodied human neonates must pass through the tight and twisting length of the birth canal and there are cases in which the pelvis is so restricted or the infant head so large that birth cannot occur without surgical intervention. The most common examples are associated with histories of rickets, broken pelvis, diabetes, postmaturity of the infant and anomalous pelvic shapes. In addition, women of short stature are at greater risk for CPD [ 38 ]. Stature is highly correlated with nutrition, suggesting a link between poverty and obstructed labor due to CPD. Dietary changes in the past several thousand years have probably contributed to larger neonatal size and thus more challenges to delivery [ 39 ], suggesting that the incidence of CPD may have been less common in the human species before the origin of agriculture (about 10 000 years ago).

Although the passage of the neonatal head through the birth canal usually receives the most attention in discussions of the compromise between neonatal size and pelvic size, humans have broad rigid shoulders [ 40 , 41 ] that create the potential for shoulder dystocia, a relatively frequent cause of birth injury in humans today [ 42 ]. Because shoulder dystocia occurs far enough along in the delivery process that cesarean section is rarely used to alleviate it, it is not known to be one of the risk factors for surgical delivery. We mention it here because if unresolved, shoulder dystocia can lead to perineal trauma and postpartum hemorrhage for the mother and neuromusculoskeletal injuries to the neonate [ 43 ]. Frequency of occurrence, although relatively low (<1% of deliveries), has quadrupled in the US in the last 4 decades [ 44 ]. Risk is greater with large babies and obese or diabetic mothers, all factors that have themselves increased in recent decades, suggesting that shoulder dystocia may largely be associated with contemporary lifestyles and medical practices and may be regarded as a reason for recommending cesarean section in women known to have large babies, contributing to rising rates.

Another common reason for cesarean section is abnormal fetal heart rate, usually indicated today by electronic fetal monitors. Contractions of labor have variable effects on fetal heart rates and usually result in short-term decelerations and accelerations. Up to a point, this variation is normal and expected. Extreme variation in heart rates and prolonged (>2 min) decelerations are often interpreted as signs of fetal distress at which point intervention is usually recommended [ 6 ]. In some cases immediate delivery is seen as a high priority, although heart rate variation may just reflect an incorrect interpretation of electronic fetal monitors and even if correct, may not be an accurate indicator of distress [ 45 ]. Although there are many explanations for fetal heart rate abnormalities that may benefit from medical intervention, one consideration is that maternal anxiety results in stress hormone production that affects fetal heart rate [ 46 ]. Continuous labor support helps to reduce maternal anxiety, which also reduces fetal stress, and may, in turn, reduce unnecessary interventions including surgical delivery [ 23 ].

As noted above, malposition of the fetus accounts for 17% of cesarean sections in the United States [ 24 ]. The overwhelming majority (88–90% [ 47 ]) of human infants are born in the occiput anterior (OA) position because the back of the infant head fits better against the front of the mother’s pelvis. In fact, so many infants are born this way that OA is described as the ‘normal’ presentation and those that are not OA are described as ‘malpositions’ and include breech, transverse lies and occiput posterior (OP) presentations [ 28 ]. Transverse lie and breech presentations, although likely present in small numbers throughout history and across cultures, have better health outcomes when delivered by cesarean section [ 48 ]. OP presentations, however, are another matter and most can be delivered vaginally, albeit often with longer labors [ 49 ]. It is important to note that for some pelvic shapes, the best fit for the infant is the OP position, so the concept of ‘normal’ should be defined by the pelvic shape itself rather than on the basis of frequency [ 50 , 51 ]. For example, women with narrow subpubic arches are more likely to deliver their infants in the OP positions, suggesting that a narrow pelvis directs the fetal head to turn forward so that the back of the head is pressing against the sacrum [ 52 ]. Attention to variability in pelvic shapes and birth mechanisms that have positive outcomes (and a more inclusive definition of what is ‘normal’) may decrease unnecessary interventions including surgical deliveries.

Nevertheless, persistent posterior presentations (those that are OP at delivery and account for about 5–8% of all deliveries [ 47 ]) are associated with longer labors, more interventions (e.g. epidurals, episiotomies, instrumental delivery and cesarean section), and greater stress for the mother and infant than OA presentations [ 49 ]. Many of these challenges can be alleviated by practices such as walking during labor, massaging the lower back to alleviate pain, manually turning the fetal head [ 47 , 53 ], and emotional support and encouragement, all of which likely have deep roots in human evolutionary history.

Problems with placental implantation (e.g. covering the cervical opening) and premature separation can lead to a number of negative sequellae such as postpartum hemorrhage and, when diagnosed in advance, may indicate a need for a cesarean section. Although complications with implantation and separation may have characterized much of human history, their frequency has increased due to surgical scarring of the uterus (e.g. from previous cesarean sections and some types of abortions [ 6 ]) so that many of the challenges associated with the placenta can be seen as ‘diseases (or complications) of civilization’.

Preeclampsia and eclampsia, disorders that appear to be unique to humans [ 54 ] (and perhaps the great apes, [ 55 ]) are linked to another phenomenon of human evolutionary history, our large and energetically expensive brains. Humans have highly invasive placentas with fetal nutrient and oxygen needs met by direct contact with the maternal vascular system [ 56 ]. In the third month following initial implantation, the human placenta undergoes a secondary invasion, or burrowing in, when brain development takes off and nutrient and oxygen needs increase significantly. Sometimes this secondary invasion is incomplete, limiting nutrient and oxygen delivery later in pregnancy and occasionally resulting in preeclampsia. The resulting cost is often a compromised pregnancy or even maternal and/or fetal death. The only cure for preeclampsia is delivery of the infant, which is usually achieved today by induction or by surgical delivery [ 57 ].

There are a number of non-medical reasons for cesarean section, although distinguishing medical necessity from non-necessity is far from simple. In many cases there are misjudgments about the medical need for cesarean sections [ 58 ] as illustrated by such factors as arbitrarily defined standards for labor length, discussed above. Cesarean sections have increased along with increases in labor induction, augmentation and epidural usage, practices that have themselves been subjected to scrutiny about medical necessity [ 59–61 ]. Unalleviated fear or anxiety about birth may lead women to choose (or acquiesce to) cesarean section over vaginal delivery. Other reasons include a range of socio-economic, cultural, political, legal and personal motivations that include concern about litigation (in countries where medical malpractice suits are common) [ 62 ], financial incentives for physicians or hospitals [ 63 , 64 ] (e.g. in Brazil, 31% of public patients but 72% of private ones receive cesarean section [ 65 ]), physician’s preference or convenience [ 66 ], and with increasing frequency, maternal request in many parts of the world (e.g. the United States [ 67 , 68 ], Brazil [ 69 ] and China [ 70 ]). Women may choose to have a cesarean section [ 71 ] because of concerns about pain and loss of control, urinary or rectal damage, and trauma and tissue damage that might make them less sexually desirable to their partners. Desires to have a baby on an auspicious day [ 72 ] or not on an unlucky day (e.g. Friday the 13 or 29 February, or in the United States, before the end of the tax year) have been cited as reasons for cesarean section. While these reasons may be important to women, their physicians or health care systems, such elective cesarean sections do not usually provide a direct health benefit to mothers or their babies that might balance the health risks that they are both subjected to as a result of the surgery.

Despite public confidence in modern surgery, cesarean section has never been without risks. As is true for any major surgery and associated drugs, cesarean section certainly poses risks to mothers and infants but many clinicians and parents believe that birth outcomes are equal to or better for cesarean-delivered infants than vaginally delivered ones [ 73 ]. A review of birth outcomes in cesarean and vaginal deliveries by the US National Institutes of Health (NIH) in 2006 concluded that ‘There is insufficient evidence to evaluate fully the benefits and risks of cesarean delivery on maternal request as compared to planned vaginal delivery, and more research is needed’ [ 74 ]. At the time, their only recommendations, which were repeated in an American College of Obstetricians and Gynecologists (ACOG) report in 2013 [ 75 ], were that elective cesarean sections should not be done (i) before 39 weeks gestation, or (ii) because effective pain management is not available or (iii) for women desiring a lot of children. In other words, they found few serious risks of elective cesarean delivery, leaving open the idea that the medical community could support a woman’s choice of delivery methods.

Recently, cesarean section on request has become part of the movement to provide women more choice in reproductive decisions [ 71 , 76–78 ]. An often-cited statistic suggests a higher approval of elective cesarean section among female compared to male obstetricians in the UK [ 79 ]. In this study, 31% of women obstetricians reported they would choose surgical over vaginal delivery for themselves, whereas only 8% of male obstetricians would recommend that to their wives. In contrast, Bettes et al. [ 67 ] found in a sample of American obstetricians and gynecologists that female physicians had more negative attitudes towards cesarean section on maternal request and performed them somewhat less frequently than males.

At one extreme is an evaluation of risks and benefits of cesarean section in comparison to vaginal delivery that concludes that the risks of cesarean section are lower for both mother and baby and should be recommended for all women. In a 2003 publication, Morrison and McKenzie envisioned a day when ‘Those preferring to labor and deliver vaginally may be required to sign a consent form that acknowledges the increased risks to mother and baby compared to those associated with cesarean section’ [ 73 ]. The view that cesarean section is better for babies than vaginal delivery did not survive closer scrutiny, however. By 2014, concern about the rising rate of surgical delivery led ACOG and the Society for Maternal-Fetal Medicine to issue a joint statement suggesting ways of preventing unnecessary cesarean section. Among their recommendations were expansion of the length of time for labor to progress, closer examination of fetal heart rates to more accurately determine abnormality, and provision of continuous labor support [ 6 ], all of which are consistent with recommendations from evolutionary medicine.

Obviously, if the risk of dying or disability for mother and/or infant is high with a vaginal delivery, the risks associated with surgical deliveries are worth assuming. Furthermore, the most dangerous way of giving birth is by emergency cesarean section. For example, of 100 000 deliveries in the UK in the mid-1990s, the maternal mortality rate for planned cesarean section was 5.9 compared with 18.2 for emergency cesarean section and 2.1 for vaginal birth [ 80 ]. There are significant risks associated with surgical delivery, especially in an emergency situation and there are almost no health benefits to elective cesarean section that would outweigh those risks. Only a few health benefit claims have been made and they include avoidance of damage to the pelvic floor and perineum [ 81 ], pelvic organ prolapse [ 82 , 83 ] and urinary incontinence [ 84 , 85 ]. These are certainly serious medical concerns but the decision to do a cesarean section to avoid these potential risks needs to be weighed against the risks associated with that surgery [ 86 ]. Finally, the burden of the decision about cesarean delivery differs for mothers and their physicians: the risks of choosing a cesarean are assumed by the mother and infant, whereas the risks of not performing a cesarean rest on the physician especially in the form of possible litigation [ 24 ].

Despite previous arguments that there are few risks to the mother associated with planned cesarean section, a Canadian study of all women who gave birth from 1991 to 2005, reported the risk of severe negative consequences of planned cesarean section for the mother included hemorrhage requiring hysterectomy or transfusion, uterine rupture, complications from anesthesia, shock, cardiac arrest, renal failure, thromboembolism and major infection, rates of which were three times those of planned vaginal deliveries [ 87 ]. Some studies have found a link between postpartum depression and cesarean section [ 88 , 89 ]. Long-term effects from previous surgical deliveries and the resulting scars include placenta problems and uterine rupture in future pregnancies. An Austrian study of low-risk obstetric patients found significantly higher rates of puerperal febrile morbidity, wound infections and high blood loss in those who had elective cesarean sections compared with those who had vaginal deliveries [ 90 ]. Looking at long-term effects of an elective cesarean section without a trial of labor for a first delivery (see below), Miller and colleagues [ 91 ] found that the cumulative risk of a major adverse maternal outcome was 10% by the fourth pregnancy. Future childbearing may be compromised following cesarean section as indicated by slight increases in stillbirths and ectopic pregnancies [ 92 ].

In the past, discussions about the risk of cesarean section have focused on the mother, but another risk is surgically delivering an infant prematurely. It is difficult to determine the precise age of the fetus and many ‘due dates’ are based on rough estimates from mothers or physicians (e.g. time from last monthly menstrual cycle). Recent assessments find that ‘normal’ gestation lengths, measured directly from conception, range by as many as 37 days, with a mean of 268 days [ 93 ]. In a Brazilian study, as the rate of cesarean section rose from 28 to 43%, the rate for preterm births rose from 6 to 16%, despite improvements in economic and nutritional conditions over the same time period [ 94 ]. These data are interpreted to suggest that increased use of cesarean section and labor induction contributed to the rise in premature births [ 93 ].

In a 2000 commentary in The Lancet , Wagner stated unequivocally ‘There is no scientific evidence to suggest any benefits to the baby’ of elective cesarean delivery [ 77 ]. Indeed, awareness of the risks to the infant has increased dramatically in recent years [ 95 ]. Negative short-term effects of cesarean section on the infant include impaired lung function, reduced thermogenic response, altered metabolism and blood pressure [ 96 ] and altered sleep patterns [ 97 ]. Long-term risks to the infant associated with cesarean delivery include increase in type 1 diabetes [ 98 , 99 ], allergies, asthma [ 100 ], cancers, celiac disease [ 101 ], inflammatory bowel disease and obesity [ 10 , 102 ]. Many of these can be linked to inadequate colonization of the infant gut at the time of delivery.

Mode of delivery and immune function

A meta-analysis of 23 studies that compared the relationship of asthma in children born by cesarean section with those born vaginally found a 20% increase associated with the surgery [ 103 ]. Likewise, risk of asthma for children 5–9 years of age in nine European countries (sample size >69 000) was found to be higher in children born by elective cesarean section [104]. Rates of allergic rhinitis and atopy are also elevated in children who were delivered by cesarean section [ 105 ]. Similarly, based on 20 studies, Cardwell and colleagues [ 97 ] found a significant increase (as much as 23% higher) in Type 1 diabetes in children born by cesarean section compared to those born vaginally. Food allergies were higher in the first three years of life for children who were delivered by cesarean section, especially in those who had a parent with similar allergies [ 106 ].

Cho and her colleagues [ 104 ] identified three pathways by which mode of delivery could potentially affect immune function: (i) inadequate or inappropriate colonization of the infant gut; (ii) incomplete or failed activation due to lack of stress response and (iii) altered epigenetic regulation of gene expression. The long-term effects of cesarean delivery on infant and child health may be associated with immune-activating and epigenetic effects of labor on the infant immune system [ 101 ], effects that are missing in surgical deliveries. Indeed, one group of scholars has gone so far as to ask the question ‘Is society being reshaped on a microbiological and epigenetic level by the way women give birth?’ [ 107 ].

Most of the bacteria in the infant gut come from maternal bacteria via the vagina and skin in vaginal deliveries, whereas in surgical deliveries the infant gut is colonized primarily by bacteria on the skin, reflecting environmental (hospital) microbiota [ 108–110 ]. In recognition of the importance of the microbiota, which is transmitted from mothers to babies during vaginal delivery (and which is missed by babies born by cesarean section), some birth professionals have advocated ‘vaginal seeding’ a procedure in which a swab taken from the mother’s vagina is wiped on the baby’s mouth, eyes, face and skin shortly after it is removed surgically from her body. The intent is that this contact with maternal bacteria would boost the infant’s gut bacteria and reduce the risks of allergies, obesity and other problems that exist later in life in higher frequency in individuals born by cesarean section than in those born vaginally. At the moment, there is inconclusive evidence linking vaginal seeding to lower rates of these problems [ 111 ] (but see [ 112 ]) but this serves as a good example of the potential of applying an evolutionary understanding to the birth process in order to mitigate the health impacts of cesarean section.

Benefits of labor contractions and vaginal delivery

We have argued that there are no apparent benefits of elective cesarean section to infants, but another question to consider is whether there are direct benefits of experiencing the contractions of labor [ 113–116 ]. Ashley Montagu proposed >50 years ago that there were positive effects of labor on neonates and argued that there is a benefit to being pressed by uterine contractions, having to navigate the tight quarters of the birth canal and occasionally being deprived of oxygen [ 117 ], and that the cutaneous stimulation during labor influences organ development and proper functioning of the nervous system [ 116 ]. Some of the well-known respiratory and digestive problems associated with cesarean delivery may be due to the lack of experiencing labor contractions [ 113 ].

Another reason that labor might be good for infants is that the stress hormones that both the mother and fetus produce during labor trigger the production of corticosteroids (e.g. cortisol) and catecholamines (e.g. adrenalin/epinephrine and dopamine) in the infant that help it cope with life outside the womb [ 103 ]. Specifically, these ‘stress hormones’ increase production of surfactants that speed up maturation of the lungs and enable the lungs to expand to keep amniotic and other fluids from filling them up. They also serve to increase fetal blood flow, especially to the brain; increase availability of calories/energy to the baby; and increase white blood cells for immune protection [ 103 ]. Further, corticosteroids and catecholamines help the fetus withstand hypoxia during delivery [ 118 ]. They appear to be important for promoting breathing immediately after birth and infants born by elective cesarean section without labor (and thus not producing the high levels of corticosteroids and catecholamines) often have breathing problems. Blood sugar levels are low in babies delivered by elective cesarean section, reinforcing the significance of these compounds for mobilizing energy [ 106 ].

The birth process also appears to initiate an acute phase response in the infant, which serves as the infant’s first line of defense against infectious agents encountered in the new environment [ 119 ]). Part of the response is an increase in body temperature, which is extremely important for neonates who are unable to effectively regulate their body temperatures. In the ancestral past, this ability to increase temperature may have enhanced survival. Infants delivered by cesarean section produce much lower levels of the immune agents that are part of the acute phase response.

One of the most important hormones involved in labor and delivery (and, indeed, in the entire reproductive process) is oxytocin. Although not fully understood, oxytocin is believed to play a role in the initiation of labor, as well as maintaining contractions once labor has begun [ 46 ]. It is especially important in mother-infant bonding and lactation, being responsible for the let-down reflex that enables milk to flow when the infant suckles. When cesarean section occurs in the absence of labor, many of the effects of oxytocin are compromised and mothers may find it more challenging to establish successful breastfeeding (see below [ 120 ]).

Breastfeeding and bonding and mode of delivery

The hormones of labor, most especially oxytocin, also play a positive role in mother-infant bonding [ 103 ]. Infants who are born after unmedicated births are often very alert for the first few hours after birth, perhaps due to cortisol and to catecholamines such as norepinephrine, which surge in labor. This alertness and ability to respond to stimuli are important in initiation of mother-infant interaction. Infants delivered by cesarean section, however, do not show this level of alertness nor do they have high levels of norepinephrine in their blood [ 103 , 121 ].

Norepinephrine facilitates development of the neonatal olfactory system, so one of the pathways through which bonding might work is olfaction: babies who were born after normal labor and delivery showed enhanced learning of odors to which they were exposed immediately after birth compared with infants born by cesarean section [110]. Babies who experienced labor contractions before surgical delivery showed better olfactory learning than those who were delivered before labor began. This suggests that infants can more readily recognize their mothers’ odors if they have been through the contractions of labor, which may contribute to maturation of the olfactory system. The catecholamine surge during delivery also dilates the pupils and increases alertness, both of which contribute to bonding [ 106 ].

Unless there are legitimate mitigating circumstances, the evolutionary medicine perspective urges keeping the mother and infant together in the immediate postpartum period as a way of improving maternal and infant health, increasing breastfeeding success, and improving maternal self-esteem and confidence in her abilities to care for her infant [ 122 ]. Skin-to-skin contact [ 123 ] is especially valuable in helping the infant adapt to the extrauterine environment and it may help stabilize heartbeats [ 124 ] and thermoregulation; it is also associated with improved breastfeeding rates and experience [ 125 ]. Interaction in this period may even have epigenetic effects in ways we are just beginning to appreciate [ 126 ]. Both planned and emergency cesarean sections have a negative effect on breastfeeding initiation and maintenance, even when the women plan to breastfeed their infants [ 127–129 ]. One reason for this is that surgical deliveries are usually associated with mother-infant separation in the immediate postpartum period and fewer opportunities to be in skin-to-skin contact [ 112 ]. It should be noted that many women who elect to have cesarean sections when not medically necessary, also choose not to breastfeed their infants [ 116 ].

In spite of the many benefits of vaginal delivery reviewed above and the risks associated with cesarean section, there are still high numbers of cesarean sections performed in the absence of medical indication. The great variation in cesarean section rates around the world and among different clinical settings indicates that there are cultural factors beyond medical concerns that influence decisions about childbirth. A recent review by O’Donovan and O’Donovan [ 130 ] cited three primary reasons for requesting cesarean section based on a meta-analysis of 16 detailed studies conducted between 2006 and 2016. Themes identified included social norms, emotional experiences and personal experiences [ 130 ]. One frequently cited reason for maternal request of a cesarean section is fear of or extremely negative attitudes toward childbirth [ 131 ]. Although measures used have been variable, estimates of the frequency of fear of childbirth range widely: 10% of pregnant women in Sweden [ 132 ]; 25% of 650 pregnant women in Canada [ 133 ]; 10% of 2662 in Finland [ 134 ]; 5% of 8000 in Switzerland [ 135 ]; 26% in Australia [ 136 ] and >8% of 25 297 in Denmark [ 137 ]. Fear of childbirth was found to be particularly high in Norwegian women who had poor mental health and low levels of social support and, most especially, a previous negative birth experience [ 138 ]. Among the reasons cited for fearing childbirth are worry about the infant, fear of pain, previous or co-existing psychological and emotional problems, sexual abuse and other sexual problems, problems with previous pregnancies or births, lack of social support and lack of knowledge about birth. In most studies, fear is inversely correlated with economic and educational status [ 125 ].

In-depth studies of childbirth fear based on qualitative interviewing rather than questionnaires have revealed more about the nature of childbirth fear. Among the findings are expressions of fear of their bodies failing to perform as necessary, of not being able to push adequately, of becoming exhausted during labor and fear of powerlessness [ 139 , 140 ]. Many of these fears could be ameliorated in most cases by having intensive childbirth education and continuous social support during labor and delivery [ 141 ]. Does fear of childbirth lead to cesarean section? Fear was cited as a reason for elective cesarean section in 7–22% of cases in Finland, Sweden and the United Kingdom [ 142 ]. A longitudinal cohort study in six European countries found that fear of childbirth is associated with an approximately tripled rate of cesarean sections in primaparous women and an almost doubled rate in multiparous women [ 143 ]. Fear and anxiety about birth are often associated with sleep deprivation during late pregnancy [ 144 ], which, in turn, is related to risk of cesarean section [121]. The odds of an emergency cesarean section are increased significantly for women who express fear of birth [ 125 ]. On the other hand, denying a woman an elective cesarean section when she strongly desires one has been shown to increase postpartum depression in some cases [ 145 ].

Given both the health risks to mothers and infants and the resources (in money and time) involved in cesarean section, it seems prudent to minimize the numbers of unnecessary procedures performed. As noted above, one major reason why we see high numbers of unnecessary cesarean sections is fear and anxiety on the part of mothers who either elect a planned cesarean section early in pregnancy or who can be easily convinced of the value of a surgical delivery when they are in pain and distress during labor. Our evolutionary perspective on this surgical procedure provides some ways of addressing these issues that would both improve outcomes for mothers and infants and require fewer resources.

Efforts to provide interventions to reduce cesarean section requests based on fear have had mixed results. Sweden is one of the few nations that has taken fear of childbirth seriously enough to establish methods for helping women deal with their fears [ 130 ]. In one study, intervention with education and counseling did not reduce requests for surgical delivery but did reduce the length of labor for vaginal deliveries [ 146 ]. Hodnett et al. [ 23 ] reviewed 23 studies and showed that women with continuous social support, such as the presence of a doula are significantly more likely to have a spontaneous vaginal delivery and significantly less likely to have intrapartum or regional analgesia or to report dissatisfaction with their experience. They had shorter labors, fewer instrumental interventions or cesarean sections and fewer babies with low 5-min Apgar scores. The last 50 years have witnessed great changes in how obstetrics is practiced in clinical settings in the United States and other developed countries in response to the demands of women to create more comfortable, familiar settings (or indeed, to leave clinical settings entirely). Our evolutionary perspective suggests that this demand is more than just personal preference, fashion or fad, but is a rational way to address the desire of women for emotional and social support, which we understand as a legacy of our evolutionary history. Expanding the use of doulas or providing other forms of support and making women feel comfortable makes good evolutionary sense.

This paper does not address severe and pathological fear of childbirth that has come to be called tokophobia , a disorder [ 147 ] that may apply to about 6–10% of pregnant women [ 138 ]. In the language of evolutionary medicine, low levels of fear and anxiety can be seen as healthful responses to impending childbirth, defenses rather than defects [ 18 ]. In fact, with regard to birth, mild anxiety can be advantageous when it enables a woman to focus cognitively, emotionally and physically (and leads to seeking assistance during labor). When this fear and anxiety become disabling even to the point of avoidance of pregnancy, it moves into the realm of a defect, requiring more serious medical and psychological intervention. For example, tokophobia is associated with post-traumatic stress disorder, postnatal depression, compromised mother-infant relationships, termination of the pregnancy and suicide [ 148 ]. A health challenge that leads women to avoid reproducing or to significantly compromise childrearing is challenging to understand from the view of evolutionary medicine.

We would like to think that education about risks of cesarean section in the absence of medical necessity may motivate women and their care providers to pursue alternatives when they are available. However, even when based on solid scientific evidence, many public health educational campaigns fail. Two major successes have been seat-belt use, which has increased and smoking, which has decreased, as a result in part of intensive public health education [ 149 ]. As with anti-smoking campaigns, a public health message that focuses on possible negative outcomes of unnecessary cesarean sections may be able to overcome a woman’s fear of vaginal birth [ 150 ].

In general, women are more receptive to public health campaigns than men and they respond better to messages about health of those for whom they care [ 151 ]. For example, smoking during pregnancy has been shown to have myriad negative effects on birth outcomes and long-term infant health, including epigenetic effects [ 152 ]; public health campaigns to reduce smoking in pregnancy have been more successful than those aimed at reducing smoking among adults in general [ 153 ]. Furthermore, women are more likely to quit smoking on their own during pregnancy than they are at other times in their lives, suggesting high motivation to create an optimal environment for the fetus [ 154 ]. From an evolutionary perspective, because of their great investment in their infants, it makes sense that mothers may be especially receptive to health messages that emphasize the welfare of their offspring. For this reason, a public health campaign emphasizing the risks of unnecessary cesarean section to their infants may be best targeted toward women during pregnancy and may be more effective than one that focuses on the health of women themselves. We now have significant evidence that the risks of cesarean section to the infants are greater than we realized as recently as 10 years ago. We suggest this public health approach while recognizing that in many contemporary clinical settings, women do not have the power or agency to make decisions on their own despite information that may be provided (see Box 2 ).

In this review, we have considered the evolutionary factors that have made human birth complex, including bipedalism and large brained babies. Many of these complexities are dealt with through cultural adaptations ranging from minimal cooperative assistance and support during birth to highly technical intervention, which may include surgical delivery. Although medical intervention is welcome and necessary in some cases, cesarean section has reached levels that cause concern in many parts of the world. In support of the concern, we have presented evidence of both the risks to mother and infant of unnecessary surgical delivery and benefits to both the mother and infant of vaginal delivery. One factor that contributes to the high rates of elective cesarean section may be maternal attitudes towards birth that include both a misperception of the safety of surgical delivery as well as the extreme fear of vaginal delivery. We have argued that anxiety about birth is a legacy of human evolutionary history in which social support at delivery, a key aspect of our adaptation, is too often lacking in hospital settings today. We have proposed that providing social and emotional support during labor and delivery may help alleviate fear of childbirth and decrease requests for cesarean section, benefitting the health of mothers and infants throughout the world.

We are indebted to the careful reading of three knowledgeable anonymous reviewers whose thoughtful comments significantly improved the manuscript.

Conflict of interest: None declared.

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Cesarean Delivery

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Patient handouts, what is a cesarean delivery.

A cesarean delivery, also called a cesarean section or c-section, is surgery to deliver a baby. The baby is taken out through your abdomen (belly). In the United States, almost one in three babies are born this way. Some cesarean deliveries are planned. Others are emergency cesarean deliveries, which are done when unexpected problems happen during delivery.

When is a cesarean delivery needed?

You may need a cesarean delivery because:

• You have health problems , including infection
• You are carrying more than one baby
• Your baby is too big
• Your baby is in the wrong position
• Your baby's health is in danger
• Labor is not moving along as it should
• There are problems with your placenta (the organ that brings oxygen and nutrients to your baby)

Not everyone who has had a cesarean delivery before will need another one next time. You may be able to have a vaginal birth after cesarean (VBAC). Talk to your health care provider about what is right for you.

How is a cesarean delivery done?

Before the surgery, you will be given pain medicine. Depending on your circumstances, you might get:

• An epidural block, which numbs the lower part of the body through an injection in the spine.
• A spinal block, which numbs the lower part of the body through an injection directly into the spinal fluid.
• General anesthesia, which makes you unconscious during the surgery. This is often used during emergency cesarean deliveries.

During the surgery, the surgeon will:

• Make a cut in your abdomen and uterus. The cut is usually horizontal, but in some cases it may be vertical.
• Open the amniotic sac and take out your baby.
• Cut the umbilical cord and the placenta.
• Close the uterus and abdomen with stitches that will later dissolve.

What are the risks of a cesarean delivery?

A cesarean delivery is relatively safe for you and your baby. But it is still a major surgery, and it carries risks. They may include:

• Blood clots in the legs, pelvic organs, or lungs
• Injury to surrounding structures, such as the bowel or bladder
• A reaction to the medicines or anesthesia used

Some of these risks do also apply to a vaginal birth. But it does take longer to recover from a cesarean delivery than from a vaginal birth. And having a cesarean delivery can raise the risk of having difficulties with future pregnancies. The more cesarean deliveries you have, the more the risk goes up.

NIH: National Institute of Child Health and Human Development

• Cesarean Sections (C-Sections) (Nemours Foundation) Also in Spanish
• Delivery by Cesarean Section (American Academy of Pediatrics) Also in Spanish
• Having a C-Section (March of Dimes Foundation)
• Labor and Delivery, Postpartum Care (Cesarean Delivery) (Mayo Foundation for Medical Education and Research) Also in Spanish

• Breastfeeding after Cesarean Delivery (American Academy of Pediatrics) Also in Spanish
• Repeat C-Sections: Is There a Limit? (Mayo Foundation for Medical Education and Research) Also in Spanish
• VBAC: Know the Pros and Cons (Mayo Foundation for Medical Education and Research)
• Medical Reasons for a C-Section (March of Dimes Foundation) Also in Spanish
• C-section - series (Medical Encyclopedia) Also in Spanish
• FastStats: Births - Method of Delivery (National Center for Health Statistics)
• PeriStats: Perinatal Statistics (March of Dimes Foundation)

Journal Articles References and abstracts from MEDLINE/PubMed (National Library of Medicine)

• Article: A Perioperative Quality Improvement Program for Cesarean Delivery in Ethiopia: A...
• Article: Maternal antibiotic prophylaxis during cesarean section has a limited impact on...
• Article: Evaluation of oxygen administration in cesarean section under spinal anesthesia via...
• Cesarean Delivery -- see more articles
• How to Find Find an Ob-Gyn (American College of Obstetricians and Gynecologists)
• March of Dimes Foundation Also in Spanish
• After a C-section - in the hospital (Medical Encyclopedia) Also in Spanish
• C-section (Medical Encyclopedia) Also in Spanish
• Going home after a C-section (Medical Encyclopedia) Also in Spanish
• Vaginal birth after C-section (Medical Encyclopedia) Also in Spanish

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Introduction to the cesarean section articles

Cesarean section is the most frequently done operation on women. Therefore, it was decided to dedicate this special issue to different aspects of this operation, where obstetricians and researchers from different countries share their experience and knowledge.

In the 1930s, the rate of cesarean section in Europe was about 2–3%, [ 1 ]. These days the cesarean numbers are rising constantly all over the world. The rate of cesarean section in the Dominican Republic reached 58.1% and is the highest in the world. In Brazil the rate is 55.8% [ 2 ], in Egypt 54% [ 3 ], and the range among the different American states is 22–38.5% [ 4 ].

In 47.2% of the countries, the cesarean rate is over 15%; in Latin America, the Caribbean, Europe, North America, and Oceania we find the highest values [ 5 ].

There are various reasons for these extremely high numbers, and certainly for the variations between countries and among hospitals in the same country, and sometimes even in the same cities. These are, among others, the fear of the obstetricians of possible lawsuits, and the requests for cesareans on demand. One of the outcomes of the high rate of cesareans are abnormal placentation during the next pregnancies, and as a result excessive bleeding, coagulation problems where even hysterectomies might result. Therefore, it is of utmost importance to reduce as much as possible unnecessary operations without risking the mothers and newborns.

Very often women who had an emergency cesarean section, or were operated for different reasons such as abnormal presentation, toxemia or bleeding, are expecting again, where it seems that normal birth is not an option. It is suggested not to plan the operation before fetal maturation. This will prevent respiratory problems in the newborn. The outcome of cesarean sections done earlier can be associated with non-favorable outcomes, early ones, such as the need for oxygen support due to respiratory distress syndrome, including the need to use the intensive care unit and late outcomes such as retinopathy of prematurity [ 6 ] or cerebral palsy [ 7 ].

And indeed, Jis Thomas et al. from Doha, Qatar, who evaluated the outcome of newborns delivered by cesareans before the 39th week, showed that respiratory distress syndrome, the need for respiration, and the use of intensive care units were significantly higher in these newborns as compared to those who were delivered after the 39th week [ 8 ]. The authors followed the Society for Maternal-Fetal Medicine which does not advocate the routine administration of steroids before early-term cesareans. This issue lately became controversial [ 9 ]. There are various arguments for not using steroids, such as possible hypoglycemia in the newborn, which might affect the child’s development [ 10 ].

As the administration of steroids to women before a premature delivery is still the routine in many medical centers, this question should be further explored.

In Germany, nearly 50% of trials of labor are done after previous cesareans. Dr. Anastasia Lazarou and colleagues from the Charite University Hospital in Berlin, Germany, discussed this practice in a well-designed study, done in order to predict the chance of a successful vaginal birth after a previous cesarean [ 11 ]. The study was done by using, next to Grobman’s parameters, a binary-logistic regression analysis as well as additional variables. Among 348 women who met the inclusion criteria for a trial of labor, 51.7% had a successful birth, 18.4% had a vacuum delivery, and only 29.9% were operated.

Certainly, the prerequisites for the trial of labor need to be followed carefully, such as examining the previous post-operative history, the ultrasound evaluation of the uterine scar, the estimated birth weight, and the availability of an operation room.

Additional ways should be evaluated in order to predict possible risks and successes of post-cesarean deliveries, and to compare them to the models of Grobman and Fagerberg. Lately, the machine learning model was introduced, which seems to predict with high sensitivity the chance of successful delivery [ 12 ].

Many factors should be taken into account when trying to predict the chance of normal birth, such as the influence of obesity on labor induction: a systematic review and meta-analysis showed that the rate of cesarean deliveries following induction of labor is more common among obese women compared with those of normal weight [ 13 ].

Motivation and participation of the women is needed when vaginal birth after cesarean section is considered. Dorothea M. Koppes et al. from the Netherlands in a multicenter study presents an original approach by offering the use of a Decision Aid Questionnaire in order to assist women in their decision to try a vaginal birth [ 14 ]. The decision aid includes information about the women’s previous experience, provides information about risks and benefits of a trial of labor, as well as the knowledge of all existing options, and the women’s individual birthing plan. The decision aid is available in four languages; and therefore, it is accessible to different populations in the country. The study included 30 hospitals. When the decision aid was used, a statistically significant difference among hospitals was shown concerning the probability of a successful vaginal birth, and its use improved the probability of a successful vaginal birth. It is not improbable that if the Decision Aid Questionnaire will be used in countries where the rate of vaginal delivery following cesarean is low, it will encourage more women to avoid a repeated operation.

In a study where women with class III obesity underwent induction of labor, the cesarean rate was about 50%. Nulliparity, height, and low cervical score were significant factors for performing the operation [ 15 ].

Therefore, the study of Eberle et al. from McGill University in Montreal. Canada, is of interest, as it is a large cohort sized report which retrospectively evaluated 2,147,014 singleton vertex deliveries between 39 and 43 pregnancy weeks in women with a BMI of 30 or more, and with no previous cesarean [ 16 ]. Among these 375,928 women were induced at the 39th week and 1,771,086 were not.

The Cesarean section rate in the induced group was 20.5% compared to 24.68% in the non-induced.

There are different methods to induce labor, but the evidence on methods of induction of labor after previous Cesarean section is inadequate [ 17 ]. However, with no doubt, induced labor could prevent a repeated operation and should always be considered in obese women.

There are different ways to induce labor in post-cesarean section women. Josefine Koenigbauer et al. from different German centers compared a mechanical labor stimulation method by using the osmotic dilator (Dilapan) to the use of prostaglandins (Dinoprostone, Minprostin) [ 18 ]. The time to the onset of labor was longer in the Dilapan group, and parturients in this group required significantly more frequent additional oxytocin labor augmentation (76% as compared to 43.1%).

Several studies already compared the different ways of induction after previous cesarean section [ 19 ]. The use of labor stimulation by mechanical means such as the Atad catheter is already well established [ 20 ].

However, this study shows that the osmotic dilator is as effective and safe as the usage of prostaglandins and should considered as a valid option for labor induction in women who had a previous cesarean.

Cesarean sections are done in different ways even at the same departments, and therefore it is difficult to compare the outcomes as long as the surgical technique in use is not standardized. The Misgav Ladach (Stark Cesarean) method which is presented here is an evidence-based operation [ 21 ]. This method has been subjected to scores of studies comparing it to the traditional time-honored methods. With no exception its superiority has been shown in regard to the operation time, blood loss, need for analgesics, febrile morbidity, and costs. In this operation, the modified Joel-Cohen abdominal incision is used, in which just two instruments are needed, a scalpel and scissors. The uterine incision is done below the bladder plica and the uterus is sutured with only one continuous layer. Both peritoneal layers are left open and the abdomen is closed just with a continuous suturing of the fascia and a few Donati skin sutures. This method is suggested as a standardized method for universal use.

However, the suggested single layer closure of the uterus is questioned in an online survey presented by Celine Kaps et al. from the Charite University Hospital in Berlin, Germany [ 22 ]. Obstetrical departments in 160 hospitals responded to a questionnaire about their method of suturing the uterus in cesarean section. The survey reveals that the methods in use were single layer continuous sutures (in hospitals with a high birth rate, maternal care level IV and III). Single layer locked technique (in hospitals with low birth rates), double-layer continuous sutures (used in five hospitals with high median birth rates), and interrupted sutures (which was only done in six hospitals).

Except in the presented Misgav Ladach cesarean method, there are no definite recommendations by the different associations for a unified way of the uterine closure, and the most commonly used ways are continuous or locked single layer, as well as the interrupted sutures. The outcomes of the different studies seem to be controversial, because some claim that the result of double-layer closure is a thicker uterine wall whereas others cannot find any differences concerning the thickness of the uterine wall in ultrasound controls.

The confusing factor is the lack of standardization in the different presented studies. Meta-analyses cannot be reliable if no standardized and unified methods are used in the examined groups [ 23 ]. Some obstetricians open the uterus above the bladder plica where the thickness of the uterine wall is larger than in the lower segment, claiming short operating time and incision-delivery interval, reduced blood loss, and need for analgesics [ 24 ] while others believe that the uterine incision should be done as low as possible [ 25 ], with the justification of a lower percentage of muscle fibers in the lower segment [ 26 ].

Standardization applies also to the suture material in use, and even to the size of the needle in use, because the bigger the needle, the less suture material is left behind. This might have a role in the healing process, because the less suture material left behind, the less foreign body reaction. Involution of the uterus starts immediately after the operation, and the sutures will anyhow loosen in time, so probably there are no benefits to suturing more than needed for immediate hemostasis, and the less suture material left behind, which is the case when one layer with a big needle is done, less reaction to the suture material left behind occurs, which might weaken the scar [ 27 ]

Christina Pulvermacher et al. from the universities of Bonn and Cologne in Germany analyzed the rate of the cesarean sections using the Robson’s 10 group classification in hospitals with different levels of care [ 28 ]. As expected, variations among the different hospitals were shown, probably due to different populations and the different clinical routines. The use of the Robson classification could contribute to the reduction of the cesarean section rate in case each indication is discussed before a final decision. This classification was proposed by the WHO as a global standard for assessing, monitoring, and comparing the rate of cesarean sections among different hospitals [ 29 ]. The Robson classification enables objective comparison of the indications for cesarean sections in different institutions, as was shown in this study.

It is highly suggested that the Robson classification should be used for internal audits in each hospital. It enables defining and controlling the accuracy of the surgical indications, certainly in a planned first cesarean section. It is important to perform a cesarean section only for justified indication, and each non-emergency case should be discussed and controlled, for example, by a required documented second opinion.

Michel Odent’s article: “Three kinds of cesarean sections: the fetal/neonatal perspective” concludes this issue [ 30 ]. Michel Odent is well known all over the world for his original, philosophical and constructive ideas and methods, such as the introduction of the water deliveries and his original insight into the modification of the parturient psychological mode. He presents here three kinds of cesarean sections, the pre-labor, the in-labor emergency cesarean, and the in-labor non-emergency cesarean which is not included in the Robson classification. This article gives insight into the influence of each one of these cesareans on the newborn’s maturity, and the ability to adjust to his new environment.

No doubt the introduction of the cesarean sections in the 19th century saved the lives of many women and babies. However, it seems that the rising numbers during recent years are not justified and are causing complications and problems. There are certainly good reasons to perform this operation in case the parturient or the newborn is at risk. Many unjustified cesareans are the reason for several unnecessary risks, and therefore it is our duty to limit this operation only for justified reasons. This can be done when each operation, except the obvious emergency ones, should be discussed, preferably during the daily staff meeting, and the decision should be explained and documented.

Research funding : None declared.

Author contributions : Single author article.

Competing interests : Author states no conflict of interest.

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Journal and Issue

Articles in the same issue.

REVIEW article

Cesarean section or natural childbirth cesarean birth may damage your health.

• 1 School of Psychology, Nanjing Normal University, Nanjing, China
• 2 School of Psychology, Xinxiang Medical University, Xinxiang, China
• 3 School of Education Science, Nanjing Normal University, Nanjing, China

The increasing popularity of Cesarean birth has become a social concern in many countries. This paper reviews the literature on the effects of Cesarean section on children’s psychological health. The results show that Cesarean birth may have adverse effects on children’s sensory perception, sensory integration ability, neuropsychiatric development, and the infant-mother relationship. However, there remain deficiencies in extant research methods, research content, subject groupings, and interpretation of research results. Future research should improve research methods, broaden the research content, and refine the grouping of children born by Cesarean section. The exploration of neural mechanisms is also needed, as well as research directed toward suggesting effective interventions to reduce unnecessary Cesarean sections.

Introduction

Human reproduction guarantees the continuation and evolution of the human species; thus, births are significant events, which many view as sacred. In general, human birth can be divided into four categories: natural delivery, assisted delivery, Cesarean section due to medical factors, and Cesarean section due to social factors. It is well known that Cesarean section has an irreplaceable role in the rapid resolution of parturition under certain medical conditions, such as dystocia, intrauterine distress, fetal position, and so on. Therefore, Cesarean section due to medical indications is a necessary operation. However, in the last two decades, Cesarean section due to social factors has become an increasingly popular choice ( Muula, 2007 ; Bu, 2008 ; Khadem and Khadivzadeh, 2009 ; Khalaf et al., 2015 ; Curran et al., 2016 ).

Cesarean section was originally a surgical solution to solve the problems associated with difficult labor, but now there are no controls over its use. This increasing popularity has led to a rapid growth in the number of Cesarean section operations worldwide. The percentage of births delivered by Cesarean section has increased in the United Kingdom from 18% in 1997 to 25% in 2010, and in the United States, the percentage has increased from 27% in 1997 to 31.8% in 2011 ( Curran et al., 2016 ). A survey by the World Health Organization showed that the average percentage of deliveries by Cesarean section in developed countries has reached 25%, which is considerably greater than the 15% recommended by the World Health Organization ( Curran et al., 2016 ). In Asia, the ratio is even higher. In Iran, the proportion of Cesarean section operations is close to 40%, and in some areas the proportion is as high as 52.8% ( Khadem and Khadivzadeh, 2009 ). In China, the percentage has reached 34.9% ( Tian, 2017 ), however, in some rural areas, this proportion is even higher.

Natural childbirth is the inevitable physiological process of human reproduction and it has many positive effects. For example, in spontaneous labor, the first contact between mother and child is timely, which is very important for establishing mother-child coordination and the child’s psychological development ( Huang et al., 2004 ). However, Cesarean section is an unnatural mode of delivery. After Cesarean section, first contact time is delayed due to anesthesia, pain of surgical incision, emotional tension, and other factors, which affects the psychological development of newborns. In recent years, researchers have investigated the impact of Cesarean section on children’s psychological health. This paper reviews the extant research to provide points of reference for standardizing the occupational behaviors of obstetricians and promoting the physical and mental health of children.

Criteria for Inclusion of Studies in This Review

In this review, we focus on the effects of Cesarean section on children’s psychological health, such as sensory perception, sensory integration ability, neuropsychiatric development, and infant-mother relationship. We present a selective review of articles addressing the effects of Cesarean section on children’s psychological health. Thus, studies on the effects of Cesarean section on children’s physiological aspects were excluded, for example, on children’s obesity, asthma, allergy, autoimmune disorder, gastro-intestinal disorders, and so on.

The primary criterion for inclusion in this review was that publications were original research published in a peer-reviewed scientific journal. Medline, PubMed, EBSCO, and Psychlit were used for article searches. Search terms were as follows: “Cesarean section,” “natural childbirth,” and “children.” However, since our focus was on the effects of Cesarean section on children, comparisons with natural and assisted delivery groups were excluded. Additionally, as we focused on the effects of Cesarean section on children’s psychological health, studies of the effects of Cesarean section on the puerperas’ psychological health were excluded. The second criterion for inclusion was that the study must have a sample size of at least 10 subjects (per group).

Effect of Cesarean Section on Children’s Psychological Health

Effect of cesarean section on children’s sensory perception.

Sensory perception refers to the processing by the human brain of objective sensory inputs that have been transduced by the sensory organs. Such perception is the basis for all the advanced psychological processes, which are of great significance for individual development. Research has indicated that, compared with natural childbirth, Cesarean section has negative impacts on children’s senses of smell, touch, and visual ability.

Varendi et al. (2002) studied the impact of Cesarean section on infants’ olfactory performance among 31 individuals who received Cesarean section, 15 of whom underwent uterine contraction before Cesarean section and 16 of whom did not experience uterine contraction. The two groups of newborn babies were exposed to a certain odor for 30 min after birth. They were then exposed to familiar and novel smells on both sides of their faces 80 h later. The experimental materials used were two odorant-saturated gauzes. Infants’ responses to the odorants were videotaped. Neonates who had experienced contractions showed a preference for familiar scents, while newborns who did not experience contractions did not have this preference; that is, the latter could not recognize the familiar scent. This suggests that contractions may promote the newborn child’s olfactory learning ability. However, in this study, a non-Cesarean section group was not assessed. Therefore, there were limitations regarding the sampling.

Through two decades of clinical observations, Mao and Jing (2005) found that newborns delivered via Cesarean section did not like to be touched or hugged as compared with newborns delivered via natural childbirth. The neonates expressed stress regarding physical contact with their mothers. Furthermore, emergency Cesarean section operations had a greater impact on neonates’ sense of touch compared to those born by planned Cesarean section. Children born through emergency Cesarean section were prone to tactile resistance due to the experience of birth trauma.

Approximately 80% of sensory information that humans process is visual in nature, and visuospatial perception is of great importance for the development of children’s learning abilities. Huang et al. (2005) adopted the Benton Visual Retention Test to assess the visuospatial perception of children in the third and fourth grades of school who had been born by Cesarean section due to social factors or born by vaginal delivery. The two groups were balanced in terms of school, age, gender, family, and other factors. The results showed that these children were less able to reproduce figures compared to a group of children born by vaginal delivery; that is, the visual memory and visuospatial perception abilities of the former group were poorer than those of the latter group. Additionally, among the various types of errors made on the Benton Visual Retention Test, the average number of errors made by the Cesarean section group was significantly higher than that of the control group. This indicates that the visuospatial perception ability of children in the Cesarean section group was poorer than that of the control group.

Effect of Cesarean Section on Children’s Sensory Integration

Sensory integration refers to the ability of individuals to utilize sensory information from different parts of the body and to respond to these sensory inputs appropriately. Sensory integration plays a crucial role in children’s learning ability and social adaptability. Studies have found that the sensory integration ability of children born by Cesarean section is worse than that of children born by natural childbirth ( Bu et al., 2008 ; Kong et al., 2009 ; Tian, 2009 ; Yuan et al., 2009 ). Tian (2009) also found that children born by Cesarean section due to medical factors and Cesarean section due to medical factors both showed poorer sensory integration ability than children born by natural childbirth.

Overall, the results indicate that Cesarean section has negative impacts on children’s senses of smell, touch, and vision and on sensory integration abilities. However, few studies have considered the effects of Cesarean section on children’s perceptual abilities; research on this topic needs to be further strengthened.

Cesarean Section and Neuropsychiatric Disorders in Children

Cesarean section and children’s attention deficit/hyperactivity disorder.

Attention deficit/hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning ( American Psychiatric Association [APA], 2013 ). Children with ADHD may experience deficits in cognitive abilities, issues with social and adaptive functioning, as well as disturbances in motivation and emotion. Research has shown that Cesarean delivery may increase the risk of ADHD in children.

Song et al. (2008) found the proportion of children with ADHD in a natural delivery group, assisted delivery group, and Cesarean section group were 6.25, 4.76, and 11.6%, respectively, differences among groups were statistically significant. Additionally, a Swedish study assessed a population cohort of 722,548 newborns registered by the Swedish National Bureau of Statistics during 1990–2008 ( Curran et al., 2016 ). It was found that the hazard ratio (HR) of the association between elective Cesarean section compared with natural delivery regarding ADHD was 1.15. The HR of the association between emergency Cesarean section and ADHD was 1.16. However, among siblings the association only remained for emergency Cesarean section. This indicates that the relationship between ADHD and Cesarean delivery mode may be related to medical indications that necessitate emergency Cesarean section. Therefore, the relationship between Cesarean delivery mode and ADHD needs to be further explored.

Cesarean Section and Autism Spectrum Disorder in Children

Autism spectrum disorder (ASD) is characterized by impaired social interactions and communication, with the presence of restricted interests and repetitive behaviors ( American Psychiatric Association [APA], 2013 ). Studies have found that there may be a link between Cesarean section and ASD ( Dodds et al., 2011 ; Yip et al., 2016 ).

A Canadian study found that children born by Cesarean section were 1.23 times more likely to experience ASD than children born by natural childbirth ( Dodds et al., 2011 ). An epidemiological study in 2016 used a cohort design to investigate ASD among 5 million children in Norway, Sweden, Denmark, Finland, and Australia ( Yip et al., 2016 ). Compared with vaginal delivery, the overall adjusted OR for ASD following Cesarean section was 1.26. Across the five countries, emergency or planned Cesarean section was consistently associated with a modestly increased risk of ASD from gestational weeks 36–42 when compared with vaginal delivery ( Yip et al., 2016 ). However, Curran et al. (2015b) found that compared with children in a spontaneous delivery group, children born by Cesarean section were approximately 20% more likely to be diagnosed as having ASD. However, the association did not persist when using sibling controls, implying that this association may be due to familial confounding of genetic and/or environmental factors. Therefore, the relationship between Cesarean delivery and ASD needs to be further explored.

Overall, among the studies of the impact of Cesarean section on children’s neuropsychiatric development, population cohort designs have predominated. Such studies typically used the risk ratio as an indicator of the existence of relationships between Cesarean delivery patterns and ADHD and ASD. Recently, researchers have used sibling-control designs. There are differences in the results obtained by the two methods. Thus, the relationship between Cesarean section and children’s neuropsychiatric development needs to be further explored.

Cesarean Section and Schizophrenia in Children

Schizophrenia is a serious and disruptive mental disorder that has a substantial effect on public health ( Collins et al., 2011 ). Schizophrenia and Cesarean birth are associated ( Verdoux et al., 1997 ; Boksa and Ei-Khodor, 2003 ; Fond et al., 2016 ). For instance, Verdoux et al. (1997) found that the incidence of early onset schizophrenia in a group of Cesarean births was 10 times higher than the incidence of late onset schizophrenia, which suggests that Cesarean birth is associated with the early onset of schizophrenia. The natural childbirth group did not exhibit this characteristic.

The Effect of Cesarean Section on the Mother-Infant Relationship

The emotional relationship between infant and mother is intense. A healthy maternal-infant relationship plays an important role in the successful socialization of children and the robust development of their personality. Cesarean delivery is not conducive to the establishment of a healthy relationship between mother and infant.

Numerous studies have found that mothers with children born by Cesarean section have far poorer mother-infant relationships than mothers who experienced spontaneous delivery ( Green et al., 1991 ; Hillan, 1991 ; Simons et al., 1992 ). Studies have found that Cesarean section has a negative effect on establishing a safe pattern of parent-child attachment ( Dimatteo et al., 1996 ; Lobel and Deluca, 2007 ; Herguner et al., 2012 ). Mothers with children born by Cesarean section have more negative evaluations of their children ( Dimatteo et al., 1996 ). Mothers in a Cesarean section group had significantly lower scores on a mother-child attachment scale than mothers in a natural birth group ( Herguner et al., 2012 ). Mothers in a natural birth group have also been shown to be more motivated to take care of newborns and felt less tired than mothers in a Cesarean section group, who were more likely to fail in their efforts to care for their newborns ( Wiklund et al., 2009 ).

Questionnaires and clinical observations have been the most popular research tools for investigating the impact of Cesarean section on the mother-infant relationship. Studies have investigated the scores of puerpera on mother-child attachment scales after delivery, and observed the interaction between puerpera and newborns after delivery. The results indicated that Cesarean section has negative impacts on the mother-infant relationship.

The Mechanism of Negative Impacts of Cesarean Birth on Child Development

The mechanism of negative impacts of cesarean birth on children’s sensory perception and sensory integration.

The newborn child’s olfactory learning ability may be promoted by contractions. The fetus experiences the mother’s contractions during natural delivery, whereas most children delivered via Cesarean section lack this experience. From this perspective, natural childbirth may help to promote the newborn child’s olfactory learning ability. Researchers have noted that labor contractions also stimulate noradrenergic neurons in the locus coeruleus and thereby increase brain arousal. This activation may account for the state of alertness that is typical of human neonates within the first 1–2 h of birth, as well as their heightened responsiveness to stimulus input (and possibly increased learning efficiency) within that brief time window ( Svensson, 1987 ; Lagercrantz, 1996 ).

Regarding the child’s sense of touch, newborns delivered by Cesarean section do not experience compression within the birth canal. The first touch they receive is that of the operation-related medical staff. This is not the gentle touch required by newborns, and such inappropriate physical contact engenders pain in the neonate.

Concerning the child’s visuospatial ability, researchers have noted that unbalanced development of visuospatial ability in infants following Cesarean may be closely related to the absence of sensory learning associated with natural delivery. Similarly, the lack of tactile learning associated with Cesarean section may be one reason for sensory integration disorders in children ( Guo et al., 2000 ; Wang, 2000 ). Cesarean section is an interventional delivery, during which neonates are delivered passively in a short period of time. As such, infants delivered by Cesarean section do not experience early tactile pressure and the associated learning; consequently, some such infants show no sense of proprioception and may develop other sensory integration disorders. Due to the extrusion of the birth canal, children born by natural childbirth experience cohesion, descent, flexion, internal rotation, and extension over a short time period; thus, they undergo marked tactile, proprioceptive, and vestibular learning.

In conclusion, a possible reason for the negative impact of Cesarean section on children’s sensory perception and sensory integration ability is the lack of sensory learning associated with natural delivery. However, the mechanisms underlying the adverse effects of Cesarean section on children’s sensation have not been fully explored; further study is needed.

The Mechanisms of Negative Impact of Cesarean Birth on Children’s Neuropsychiatric Disorders

Concerning the relationship between Cesarean delivery mode and ADHD, animal experiments have been used to determine why Cesarean section increases the risk of ADHD in children. Juárez et al. (2010) considered 120 randomly-chosen newborn rat pups that had been delivered by vaginal birth (VAG), Cesarean section only (C-only), or Cesarean section accompanied by an absence of oxygen (C+Anoxia). Neurons were extracted from living pups from both sides of the medial prefrontal cortex (PFC), nucleus accumbens (NAcc), and hippocampal CA1 regions at different postnatal ages over time. Subsequently, the rats were sacrificed and brain PFC, NAcc, and hippocampal CA1 regions sliced and each section examined by microscopy. Dendritic tree length and density were compared at each postnatal age at which samples were collected and after the brain was removed. Cesarean section, regardless of anoxia, affected prepubertal development of PFC and hippocampal CA1 neurons, as well as the NAcc medium spiny neurons. The dopamine levels in the NAcc were increased in the rats born by Cesarean section, with or without anoxia. The results of this study indicate that neural changes can affect dopamine function in the PFC and NAcc, which may be associated with dopamine-related disorders such as schizophrenia, ADHD, and drug addiction.

Many neuroanatomical networks, including the prefrontal cortex and anterior basal ganglia, are rich in dopamine ( Purper-Ouakil et al., 2005 ). Dopamine, which is very sensitive to perinatal factors, is involved in the regulation of attention and task-execution. Cesarean delivery can alter the amount of neurotransmitters and the mechanisms by which neurotransmitters are released after birth, thus increasing the risk of attention deficit disorder ( Ei-khodor and Boksa, 2002 ).

Studies have sought evidence for a relationship between Cesarean delivery mode and ASD. The incidence of ASD following Cesarean births may primarily relate to two factors. First, anesthesia during childbirth is an important factor. Taiwanese studies have assessed the effect of general anesthesia in Cesarean births and local anesthesia on autism in children ( Chien et al., 2015 ). Children who underwent general anesthesia for Cesarean section had a higher risk of autism compared to a control group. However, the incidence of autism in the Cesarean group who underwent local anesthesia was not significantly different from that in the spontaneous labor group. Additionally, the researchers also noted that, compared with the natural birth group, girls in the Cesarean group who had experienced general anesthesia were twice as likely as boys to experience autism, suggesting that girls may be more sensitive to the long-term effects of general anesthesia than boys. This also highlights that neurotoxicity of general anesthetic agents affects children’s future neurological development. Rice and Barone (2000) found that damage to the brain in the early stages of infancy can affect the development of synapses in certain brain regions, and subsequently delay or influence the future development of those regions.

Second, postpartum anesthesia and surgical trauma delay the time of first contact between mother and child and of breastfeeding. The delayed parent-child interaction affects child-attachment, which can greatly harm the psychological development of children born by Cesarean section and cause behavioral problems in children ( Di, 2009 ).

The influence of Cesarean section on schizophrenia may be the result of many factors. First, those born by Cesarean section are not exposed to the mother’s vaginal microbiota at birth; hence, their intestinal microbiota differ from that of natural births ( Makino et al., 2013 ). The difference in microbiota continues into adolescence and early adulthood ( Mueller et al., 2015 ). Microbiota play an important role in the development of the brain and in the occurrence of major neurological disorders ( Collins et al., 2012 ); thus, the lack of microbiota caused by Cesarean section may play a role in the onset of schizophrenia. Second, dopamine receptors have been implicated in the pathogenesis of schizophrenia ( El-khodor and Boksa, 2001 ; Boksa et al., 2002 ; Novak et al., 2011 ; Fond et al., 2015 ). Long-term changes in dopamine receptors caused by Cesarean section may also account for schizophrenia. Additionally, perinatal brain injuries caused by emergency Cesarean section, particularly intrauterine fetal hypoxia, also constitute an etiological risk factor for schizophrenia ( Boksa and Ei-Khodor, 2003 ).

The Mechanisms of the Negative Impact of Cesarean Section on the Mother-Infant Relationship

Functional magnetic resonance imaging studies have also investigated mother-infant attachment patterns ( Swain et al., 2008 ). After 2 weeks of delivery, mothers in the spontaneous delivery group were more sensitive to their children’s cries and responded more positively compared to mothers in the Cesarean section group. In addition, the former group showed more activity in brain regions such as the frontal gyrus, middle fusiform gyrus, anterior superior lobe, caudate nucleus, thalamus, hypothalamus, amygdala, and pons. The study also showed that some infant behaviors activated the mother’s neuronal circuits related to mood, motivation, attention, and empathy. Among the key factors affecting the neuronal circuit of the mother’s brain, and ultimately the maternal-infant relationship, the mode of birth delivery plays an important role ( Swain et al., 2007 ; Swain and Lorberbaum, 2008 ). In the course of spontaneous labor, the contraction of the uterus and the movement of the vagina and cervix stimulate the mother’s pulsed release of hormones from the posterior pituitary gland ( Leckman and Herman, 2002 ). Animal experiments have shown that the posterior pituitary hormone is an important intermediary in maternal behavior ( Kendrick et al., 1992 ; Morgan et al., 1992 ; Porter et al., 2002 ; Poindron, 2005 ). The mode of Cesarean delivery deprives the vagina and cervix of the movements involved in spontaneous labor, thus affecting the release of hormones from the pituitary gland. This will affect the response of the mother’s brain to infant behavior in the early postpartum period.

Overall, the mechanism underlying the negative impact of Cesarean section on child development needs to be further elucidated; indeed, the mechanisms underlying certain aspects remain at the stage of speculation. Additionally, some underlying mechanisms of the effect on Cesarean section on the infant have not been explored in depth. Therefore, future research could combine animal experiments, brain imaging, electroencephalography, and additional methods to further explore the neural mechanisms.

Deficiencies of Existing Research and Prospects for Future Research

Previous studies have assessed the adverse effects of Cesarean birth through experimental designs, population cohort designs, clinical observations, and questionnaire investigations. Such studied attempted to reveal the mechanisms underlying the effect of Cesarean section through animal experiments and functional magnetic resonance imaging (fMRI). However, our review reveals deficiencies in the extant literature. Based on our review, we propose the following topics for future research.

In terms of methodology, most previous findings utilized cross-sectional designs, such as prospective cohort studies and crowd cohort studies, but few were based on longitudinal tracking studies. The influence of Cesarean delivery on children’s psychology is not static but may be different at different stages of development and periods of growth. Therefore, conclusions based on cross-sectional research lack continuity and generality. It would be appropriate to trace development to the primary school stage, to detect whether a dynamic process of change occurs, and over what time-scale and thereby obtain more robust conclusions. Additionally, researchers have recently proposed a more effective research method, named the sibling-control design, which compares Cesarean birth and spontaneous birth from the same parent. This design can largely balance the influence of the genetic and family environment, and thus improve the reliability of the research ( Curran et al., 2015a ). However, the drawback of this design is that the available sample is very limited.

Extant research topics are limited in scope and have not addressed some aspects of children’s psychology. The fetus delivered via the birth canal experiences a series of extrusions, efforts, and movements (flexion, internal rotation, extension, and so on), which continue through various planes of the birth canal until the delivery is complete. This early external pressure and the serial efforts of the fetus in the birth canal may have an impact on the child’s later persistence and willpower. A child who was delivered by Cesarean section did not experience this process, and its persistence and willpower may be negatively affected. Therefore, future research should explore whether Cesarean delivery indeed diminishes children’s persistence and willpower.

In terms of research participants, several previous studies compared two groups of subjects only: a Cesarean section group and a natural delivery group. However, a Cesarean birth may be due to medical or social factors, which may have different effects on the child’s psychology. If Cesarean births are not divided into these two groups, any conclusion is suspect. In addition, Cesarean births due to social factors can be classified as full-term Cesarean s section or premature Cesarean sections, which may also have different effects on the child. Therefore, future research should refine the choice of subjects.

Previous findings indicate the importance of the effects of general anesthesia in Cesarean births. General anesthesia increases the risk of autism in children, and girls born by Cesarean section are twice as likely to develop autism as boys ( Chien et al., 2015 ). Therefore, future studies are needed to explore the effects of general anesthesia and its mechanisms on infants’ early development, and to further identify the intrinsic mechanisms underlying autism in men and women.

Vitale et al. (2016) noted that some studies report an increased risk of delayed motor and neurological development, generalized cognitive deficits, and learning difficulties in children born from mothers with psychosis. Therefore, it is necessary to comprehensively consider diverse factors when studying the relationship between Cesarean section and children’s neuropsychiatric development.

In terms of general orientation, attention should be paid to cross-cultural research. Previous studies have shown that different cultures have different attitudes toward Cesarean section ( Savage, 1986 ). In some Asian cultures, Cesarean section is regarded as highly negative thing ( Savage, 1986 ). However, in Brazil, Cesarean section is regarded as a symbol of modernization and is seen as positive and valuable ( Nuttall, 2000 ). Therefore, it is necessary to consider cultural factors and role models when studying the influence of Cesarean section on children’s psychology. Researchers should compare births among different cultural groups to avoid drawing erroneous conclusions.

In terms of the clinical application of research, it is necessary to develop research into countermeasures. Accordingly, medical, psychological, and sociological researchers should form multidisciplinary research teams to enhance interdisciplinary cooperation, and thereby present effective measures to avoid unnecessary Cesarean sections.

To conclude, Cesarean section may have adverse effects on children’s perceptual and sensory integration abilities and on the mother-child relationship, while the effects of Cesarean section on ADHD and ASD in children need to be further explored. However, the negative effects of Cesarean section have attracted insufficient attention in society at large. It is therefore important to improve the quality of information on these effects and disseminate it as widely as possible to improve children’s health.

Author Contributions

HC gathered and analyzed the literature, and wrote and revised the manuscript. DT put forward the research topic and revised the manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Wiklund, I., Edman, G., Larsson, C., and Andolf, E. (2009). First-time mothers and changes in personality in relation to mode of delivery. J. Adv. Nurs. 65:1636. doi: 10.1111/j.1365-2648.2009.05018.x

Yip, B. H., Leonard, H., Stock, S., Stoltenberg, C., Francis, R. W., Gisser, M. G., et al. (2016). Caesarean section and risk of autism across gestational age: a multi-national cohort study of 5 million births. Int. J. Epidemiol. 46, 429–439. doi: 10.1093/ije/dyw336

Yuan, H. M., Wei, Y. F., and Yu, X. H. (2009). Impact of delivery mode on children’s sensory integration ability. ZheJiang J. Prev. Capacity 21, 12–13. doi: 10.3969/j.issn.1007-0931.2009.06.005

Keywords : Cesarean section, children, natural childbirth, psychological aspects, neural mechanisms

Citation: Chen H and Tan D (2019) Cesarean Section or Natural Childbirth? Cesarean Birth May Damage Your Health. Front. Psychol. 10:351. doi: 10.3389/fpsyg.2019.00351

Received: 10 October 2018; Accepted: 04 February 2019; Published: 21 February 2019.

Reviewed by:

Copyright © 2019 Chen and Tan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Dingliang Tan, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Second Opinion

Cesarean Section

What is a Cesarean section?

Cesarean section, C-section, or Cesarean birth is the surgical delivery of a baby through a cut (incision) made in the mother's abdomen and uterus. Healthcare providers use it when they believe it's safer for the mother, the baby, or both.

The incision made in the skin may be:

Up-and-down (vertical). This incision extends from the belly button to the pubic hairline.

Across from side-to-side (horizontal). This incision extends across the pubic hairline. It's used most often, because it heals well and there is less bleeding. 

The type of incision used depends on the health of the mother and the fetus. The incision in the uterus may also be either vertical or horizontal.

Why might I need a C-section?

If you can't deliver vaginally, C-section allows the fetus to be delivered surgically. You may be able to plan and schedule your Cesarean. Or, you may have it done because of problems during labor.

Several conditions make a Cesarean delivery more likely. These include:

Abnormal fetal heart rate. The fetal heart rate during labor is a good sign of how well the fetus is doing. Your provider will monitor the fetal heart rate during labor. The normal rate varies between 120 to 160 beats per minute. If the fetal heart rate shows there may be a problem, your provider will take immediate action. This may be giving the mother oxygen, increasing fluids, and changing the mother's position. If the heart rate doesn’t improve, he or she may do a Cesarean delivery.

Abnormal position of the fetus during birth. The normal position for the fetus during birth is head-down, facing the mother's back. Sometimes a fetus is not in the right position. This makes delivery more difficult through the birth canal.

Problems with labor. Labor that fails to progress or doesn't progress the way it should.

Size of the fetus. The baby is too large for your provider to deliver vaginally.

Placenta problems. This includes placenta previa, in which the placenta blocks the cervix. (Premature detachment from the fetus is known as abruption.)

Certain conditions in the mother, such as diabetes, high blood pressure, or HIV infection

Active herpes sores in the mother’s vagina or cervix

Twins or other multiples

Previous C-section

Your healthcare provider may have other reasons to recommend a Cesarean delivery.

What are the risks of a C-section?

Some possible complications of a C-section may include:

Reactions to the medicines used during surgery

Abnormal separation of the placenta, especially in women with previous Cesarean delivery

Injury to the bladder or bowel

Infection in the uterus

Wound infection

Trouble urinating or urinary tract infection

Delayed return of bowel function

Blood clots

After a C-section, a woman may not be able to have a vaginal birth in a future pregnancy. It will depend on the type of uterine incision used. Vertical scars of the uterus are not strong enough to hold together during labor contractions, so a repeat C-section is necessary.

You may have other risks that are unique to you. Be sure to discuss any concerns with your healthcare provider before the procedure, if possible.

How do I get ready for a C-section?

Your healthcare provider will explain the procedure to you and you can ask question.

You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is unclear.

You will be asked when you last had anything to eat or drink. If your C-section is planned and requires general, spinal, or epidural anesthesia, you will be asked to not eat or drink anything for 8 hours before the procedure.

Tell your healthcare provider if you are sensitive to or are allergic to any medicine, latex, iodine, tape, or anesthesia.

Tell your healthcare provider of all medicine (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.

Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning medicines (anticoagulants), aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.

You may be given medicine to decrease the acid in your stomach. These also help dry the secretions in your mouth and breathing passages.

Plan to have someone stay with you after a C-section. You may have pain in the first few days and will need help with the baby.

Follow any other instructions your provider gives you to get ready.

What happens during a C-section?

A C-section will be done in an operating room or a special delivery room. Procedures may vary depending on your condition and your healthcare provider's practices.

In most cases, you will be awake for a C-section. Only in rare cases will a mother need medicine that puts her into a deep sleep (general anesthesia). Most C-sections are done with a regional anesthesia such as an epidural or spinal. With these, you will have no feeling from your waist down, but you will be awake and able to hear and see your baby as soon as he or she is born.

Generally, a C-section follows this process:

You will be asked to undress and put on a hospital gown.

You will be positioned on an operating or exam table.

A urinary catheter may be put in if it was not done before coming to the operating room.

An intravenous (IV) line will be started in your arm or hand.

For safety reasons, straps will be placed over your legs to hold you on the table.

Hair around the surgical site may be shaved. The skin will be cleaned with an antiseptic solution.

Your abdomen (belly) will be draped with sterile material. A drape will also be placed above your chest to screen the surgical site.

The anesthesiologist or nurse anesthetist will continuously watch your heart rate, blood pressure, breathing, and blood oxygen level during the procedure.

Once the anesthesia has taken effect, your provider will make an incision above the pubic bone, either transverse or vertical. You may hear the sounds of an electrocautery machine that seals off bleeding.

Your provider will make deeper incisions through the tissues and separate the muscles until the uterine wall is reached. He or she will make a final incision in the uterus. This incision is also either horizontal or vertical.

Your provider will open the amniotic sac, and deliver the baby through the opening. You may feel some pressure or a pulling sensation.

He or she will cut the umbilical cord.

You will get medicine in your IV to help the uterus contract and expel the placenta.

Your provider will remove your placenta and examine the uterus for tears or pieces of placenta.

He or she will use stitches to close the incision in the uterine muscle and reposition the uterus in the pelvic cavity.

Your provider will close the muscle and tissue layers with sutures. He or she will close the skin incision with sutures or surgical staples.

Finally, your provider will apply a sterile bandage.

What happens after a C-section?

In the hospital.

In the recovery room, nurses will watch your blood pressure, breathing, pulse, bleeding, and the firmness of your uterus.

Usually, you can be with your baby while you are in the recovery area. In some cases, babies born by Cesarean will first need to be monitored in the nursery for a short time. Breastfeeding can start in the recovery area, just as with a vaginal delivery.

After an hour or 2 in the recovery area, you will be moved to your room for the rest of your hospital stay.

As the anesthesia wears off, you may get pain medicine as needed. This can be either from the nurse or through a device connected to your IV (intravenous) line called a PCA (patient controlled analgesia) pump. In some cases, pain medicine may be given through the epidural catheter until it is removed.

You may have gas pains as the intestinal tract starts working again after surgery. You will be encouraged to get out of bed. Moving around and walking helps ease gas pains. Your healthcare provider may also give you medicine for this. You may feel some uterine contractions called after-pains for a few days. The uterus continues to contract and get smaller over several weeks.

The urinary catheter is usually removed the day after surgery.

You may be given liquids to drink a few hours after surgery. You can gradually add more solid foods as you can handle them.

You may be given antibiotics in your IV while in the hospital and a prescription to keep taking the antibiotics at home.

You will need to wear a sanitary pad for bleeding. It's normal to have cramps and vaginal bleeding for several days after birth. You may have discharge that changes from dark red or brown to a lighter color over several weeks.

Don't douche, use tampons, or have sex until your healthcare provider tells you it’s OK. You may also have other limits on your activity, including no strenuous activity, driving, or heavy lifting.

Take a pain reliever as recommended by your healthcare provider. Aspirin or certain other pain medicines may increase bleeding. So, be sure to take only recommended medicines.

Arrange for a follow-up visit with your healthcare provider. This is usually 2 to 3 weeks after the surgery.

Call your healthcare provider right away if any of these occur:

Heavy vaginal bleeding

Foul-smelling drainage from your vagina

Fever or chills

Severe belly (abdominal) pain

Increased pain, redness, swelling, or bleeding or other drainage from the incision

Trouble breathing, chest pain, or heart palpitations

Your healthcare provider may give you other instructions, depending on your situation.

Before you agree to the test or the procedure make sure you know:

The name of the test or procedure

The reason you are having the test or procedure

What results to expect and what they mean

The risks and benefits of the test or procedure

What the possible side effects or complications are

When and where you are to have the test or procedure

Who will do the test or procedure and what that person’s qualifications are

What would  happen if you did not have the test or procedure

Any alternative tests or procedures to think about

When and how you will get the results

Who to call after the test or procedure if you have questions or problems

How much you will have to pay for the test or procedure

Related Links

• Johnson Center for Pregnancy and Newborn Services
• Fetal and Pregnancy Health
• Postpartum Hemorrhage
• Baby's Care After a Cesarean Delivery
• Breastfeeding and Delayed Milk Production

Related Topics

Baby's Care After a Cesarean Delivery

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Elective Cesarean Sections

• Download PDF Copy

A Cesarean section (C-section) is a surgery performed to deliver a baby via an incision made in the abdomen.

This mode of delivery may be performed as an emergency procedure when normal delivery is not possible or may be planned in cases where a natural delivery is not recommended due to the mother having a health condition such as high blood pressure, for example.

In the case of a planned C-section, when the procedure is scheduled for a particular date, the term “elective C-section” is used.

Reasons for emergency C-section

Some of the reasons an emergency C-section may be required include:

Fetal distress ─ If the baby is not receiving enough oxygen or the heart rate is increasing.

Non-progress of labour ─ Prolonged labour is the most common reason for a C-section being performed. The labour may be prolonged because the cervix is not dilating sufficiently despite contractions or because the baby’s head is simply too big to pass through the birth canal.

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Infection ─ A C-section may also be recommended in cases where the mother is known to have an infection they could pass onto their baby during delivery, such as HIV.

Abnormal position of the baby ─ In a vaginal birth, the baby is usually positioned head-down in the womb and the head comes out before the rest of the baby’s body. If the buttocks have moved into the birth canal first (breech position) or the baby is positioned on its side (transverse position), then a C-section may be advised.

Reasons for elective C-section

An elective C- section is performed in the absence of any of these indications. Patients may opt for a C-section if they have a health condition such as high blood pressure or if a previous Cesarean means a future vaginal birth is associated with a degree of risk. However, women also elect to have a C-section, simply to schedule the birth for a convenient date or for other non-clinical reasons.

In cases where there is no medical basis for a C-section being performed, health authorities often advise against the procedure for a range of reasons including the prevention of unnecessary harm to both mother and child.

• http://www.nhs.uk/conditions/Caesarean-section/Pages/Introduction.aspx
• https://www.nice.org.uk/
• https://wsnm.org/
• https://www.who.int/
• kebijakankesehatanindonesia.net/.../...%20for%20Cesarean%20section.pdf
• http://www.nlm.nih.gov/medlineplus/cesareansection.html

Further Reading

• All Cesarean Section Content
• Cesarean - What is a Cesarean Section?
• Cesarean Section History
• Cesarean Section Types
• Cesarean Section Anaesthesia

Last Updated: Jun 17, 2023

Dr. Ananya Mandal

Dr. Ananya Mandal is a doctor by profession, lecturer by vocation and a medical writer by passion. She specialized in Clinical Pharmacology after her bachelor's (MBBS). For her, health communication is not just writing complicated reviews for professionals but making medical knowledge understandable and available to the general public as well.

Please use one of the following formats to cite this article in your essay, paper or report:

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Cesarean section or normal vaginal delivery: A cross-sectional study of attitude of medical students

Tanisha sudhir saraf.

MIMER Medical College and Dr. BSTR Hospital,Talegaon Dabhade, Pune, Maharashtra, India

Rupali Verma Bagga

1 Gian Sagar Medical College and Hospital, Ramnagar, Patiala, Punjab, India

INTRODUCTION:

Childbirth is regarded as an important life event for women, and growing numbers of them are making the choice to give birth by cesarean delivery. Increasing rate of births by cesarean section is an issue of concern in many countries. In order to reduce the rates of unnecessary cesarean sections, it is essential to acquire information of the reasons that motivate physicians to carry out cesarean sections rather than vaginal deliveries. The objective of present study is to evaluate whether the education process for undergraduate medical students affects their decision-making.

MATERIALS AND METHODS:

The present study was cross-sectional and questionnaire based. A total of 292 students participated in the study. Out of which, 150 were first-year students and 142 were doing internship in Maharashtra Institute of Medical Education and Research (MIMER), Talegaon Dabhade, Maharashtra, India. The study was conducted in the months of June and July 2019. Data was collected with the help of person to person interview of all the participants who satisfied the inclusion criteria after obtaining their informed consent. The data was entered by using Microsoft Excel 2007 and was analyzed using Epi Info version 3.3.2. The data was tabulated and analyzed according to responses which were given by the respondents.

A total of 292 students answered the questionnaire. Age of participants varied between 19 and 23 years. 130 males and 162 females were the subjects, out of which 40 students declared fear of labor. Most of the students preferred vaginal delivery over cesarean sections in all the four scenarios. The difference of opinion was significant in case of an uneventful pregnancy and normal pregnancy under their care. For general population as healthcare manager this difference of opinion was not significant. In case of one's own or partner's delivery, internship students preferred cesarean section but this difference was statistically non-significant.

CONCLUSION:

Most of the students would recommend vaginal delivery because this form of delivery has fewer risks as compared to cesarean section. Majority of students chose vaginal delivery for the birth of their own child; however, a higher number of interns as compared to first year students preferred cesarean section. Pain associated with vaginal delivery was the most common reason given for choosing cesarean section. The student's preference for childbirth changed in due course of graduation toward cesarean section. This indicates a probable effect of medical education on permissive culture of cesarean section as a mode of delivery.

Introduction

The pain that you have been feeling could not compare to the joy that is coming. Such words are said to women who are pregnant, who are about to bring another soul into this world. With all this love and affection a mother tries to choose what is best for her baby and in such moments of fear and doubt, we let assumptions such as, cesarean sections are safer for the child and has higher success rate or natural births help to keep the child healthier and avoids any infections, etc., into our minds. These are all just conclusions made based upon various cases or situations that have occurred earlier. Historically, the natural process of Vaginal Birth (VB) has been viewed as the unquestioned mode of birth, whereas Cesarean Delivery (CD), which involves an operative incision, has been perceived as a risky procedure designed for women with medical indications.[ 1 ]

Cesarean section is only recommended when life of mother or fetus is at risk. However, this method has currently become a way of escaping from labor pain. People have a common belief that CD is less painful, safer, and healthier than VD.[ 2 ] The childbirth is regarded as an important life event for women, and growing numbers of them are making the choice to give birth by CD.[ 3 ] With advances in reproductive technology, an increase in the number of CDs has been observed in recent years.[ 4 ] An increasing rate of births by cesarean section is an issue of concern in many countries. In developed countries, women often opt for CD because of their improved understanding of its role and safety and increasing importance given to the right to self decision-making, regarding mode of delivery. However in developing countries like India, women are reluctant to accept CD because of their traditional beliefs and sociocultural norms, hence they even try to avoid hospital delivery and engage in the services of untrained and unskilled care providers. These women usually report to hospital with life threatening complications and in such situations most of the cesareans are performed as an emergency procedure under suboptimal circumstances.[ 5 ]

Despite the recommendations by World Health Organization (WHO), that no region in the world is justified to have a Cesarean section (C-section) rate greater than 10-15%, it is the most common obstetrical operation worldwide.[ 6 ] It is a challenge to achieve adequate C-section rates as it entails a balance between performing appropriately indicated C-sections while avoiding unnecessary interventions that do not provide better health outcomes and can cause complications to the mother and the infant.[ 7 ] The overall rate of cesarean section delivery (CSD) in 2015–2016 is around 17.2% in India, increased from 8.5% in 2005–2006.[ 8 ] However, WHO recently suggested that they do not recommend a specific rate at either a country-level or a hospital-level.

The cause of increased cesarean section rate is multi-factorial and decision to deliver by cesarean section depends on a variety of factors including previous cesarean section, multiple gestation, malpresentation, fetal distress, failure of progress during labor, and maternal medical conditions.[ 9 , 10 , 11 , 12 , 13 , 14 ] while considering the rapidly increasing cesarean rates, non-clinical factors have emerged as equally important as clinical factors.[ 15 ] Studies have reported that pregnant women, even those with no pathology, prefer surgical childbirth. Fear of the pain associated with VD, uncertainty with respect to her sexual life following delivery and the belief that this route of delivery is more unpredictable and therefore more risky for the infant are factors that are said to contribute to women's preference for a cesarean section.[ 16 , 17 , 18 , 19 ]

Further it should be kept in mind that neither women preferences nor clinical indications can justify such increasing cesarean section rates. The physician's role should be taken into consideration. Whatever experience and skills medical students gain from their practical training will be reflected in their professional conduct. There is a direct link between knowledge and attitude of medical students with future practice. Today, where awareness toward natural birth frequently finds a voice and it is been increasingly questioned, views of young medical students on VD is of utmost importance. In view of the need to reduce, the rates of unnecessary cesarean sections (cesarean sections with no indication or clinical justification), it is essential to acquire information on the reasons that motivate physicians to carry out cesarean sections rather than vaginal deliveries. Therefore, the objective of this present study was to evaluate whether the education process for undergraduate medical students affects their decision-making. There are no studies available regarding the attitude of medical students toward the choice of mode of delivery in India. So, this study was planned in this perspective.

Material and Methods

Study design and setting.

The present study was cross-sectional in nature and was conducted in Maharashtra Institute of Medical Education and Research (MIMER), Talegaon Dabhade, Maharashtra, India. The study was undertaken in months of June 2019 and July 2019 (two months) and analysis and writing report stretched till October 2019.

Study participants and sampling

The study participants were the medical students enrolled in first year and those doing Internship. There are no studies available regarding the attitude of medical students toward the choice of mode of delivery in India. All the medical students present in first-year MBBS (150) and all those who are doing Internship (150) in Maharashtra Institute of Medical Education and Research (MIMER), Talegaon Dabhade were included as study population. Hence, the sample size should have been 300 but 8 interns did not participate in the study. These interns could not be contacted after repeated efforts. So, final sample size was 292.

Data collection tool and technique

Data was collected with the help of person to person interview of all the participants who satisfied the inclusion criteria after obtaining their informed consent.

• Inclusion criteria: Students who were willing to participate.
• Exclusion Criteria: Students who were not willing to participate were excluded.

A pre-designed, pre-tested, self-administered questionnaire in English was devised to collect data. It was validated after a pilot study. Questionnaire was explained to participants for their understanding. Administration of questionnaire forms was done for all the study participants after briefing them the purpose of the study.

The Proforma had two sections:

• Section-1 was regarding the sociodemographic data of the participant like age, gender, parent's education, monthly family income, how the student was born (cesarean/vaginal), etc.
• Under an uneventful pregnancy
• Mode of delivery for a pregnant woman under their care
• Best choice as a healthcare manager
• Choosing the birth of their own child.

For each circumstance, there was an open question to explain their choice.

Ethical consideration

Ethical clearance of Institutional Ethics Committee (IEC) was taken before conducting research. Informed consent was obtained from each of the study participant before administration of questionnaire. We took all possible precautions to maintain anonymity of each study participant. Confidentiality was assured in collection of personal data. The study was conducted abiding by all principles of the Declaration of Helsinki.

Statistical analysis

The data was entered by using Microsoft Excel 2007 and was analyzed using Epi Info version 3.3.2. The data was tabulated and analyzed according to responses given by the respondents. Results were tabulated in percentages and proportions. To calculate the differences between the groups, appropriate statistical tests including chi square test was applied. Significance was checked at P = 0.05. Yates correction was applied whenever it was required.

The sociodemographic characteristics of the study subjects are shown in Table 1 . A total of 292 college students finished the questionnaire, 150 students in the first year and 142 doing internship in medical college. Eight internship students did not take part in the study. Out of 292 students, there were 130 (44.5%) males and 162 (55.5%) females. But the distinction among first year and interns with respect to gender was found to be statistically non-significant ( P = 0.320). There were 71 (47.3%) males and 79 (52.7%) females in first year and there were only 59 (41.5%) males and 83 (58.5%) females in internship. In addition, there has been a significant four years difference in age between the groups. All the study subjects were unmarried.

Sociodemographic characteristics of the study population

Based at the distribution of the control variables [ Table 1 ], statistically significant differences was found between the two age groups with respect to monthly family income ( P = 0.00002). The monthly family income of the subjects ranged from Rs 10000 to Rs 300000. It became determined that 86 (57.3%) of first-year college students and 115 (81.0%) of internship students had their monthly family income less than Rs 50000.

Table 2 shows the students' responses to their birth history and their knowledge of the modes of delivery, with a statistically significant difference found in the area of birth, previous experience of seeing delivery, and knowledge of the type of delivery causing more complications.

Birth history and knowledge regarding modes of delivery among study subjects

Of the birth history, 62 (41.3%) of first-year college students and 73 (51.4%) internship students were born in metropolitan city which represents the majority, while only 31 (20.7%) of first-year college students and 14 (9.8%) internship students were born in village area. Statistically, the difference was significant ( P = 0.0281).

When looking at the type of hospital they were born in, a high number of around 117 (78.0%) of first-year students and 112 (78.9%) interns admitted being born in private hospital. When asked regarding the mode of delivery by which they were born, a maximum 102 (68.0%) of first year and 107 (75.4%) of final-year students were born by VD whereas a very few of 48 (32.0%) of first-year students and 35 (24.6%)of internship students were born by CD, which had a greater influence on decision making.

An expected rate of 100% interns had seen a delivery so far, compared to a limited 25 (16.7%) of first-year students. Statistically, the difference turned out to be significant ( P = 0.000). The last question on this table was the type of delivery with the most complications, with a maximum of 131 (92.3%) internship students and 91 (60.7%) of first-year students who said that cesarean section were at higher risk and complications, which was thought to be the greatest influencing factor, on their preferred delivery mode when making personal and professional decisions, the difference was statistically significant ( p = 0.000).

Table 3 shows the students response to each one of the four scenarios, consisting of the preferred mode of delivery preferred in the event of an uneventful pregnancy, normal pregnant women under their care, in general population as a healthcare manager and in their pregnancy or of their partner.

Preferred mode of delivery by study subjects in different scenarios

According to the analysis carried out, it was found out that in the first scenario: preferred mode of delivery under an uneventful pregnancy where no pathology was present, most students in the first year, that is, 104 (69.3%) and 114 (80.3%) internship students preferred VD, while only 46 (30.7%) first-year students and 28 (19.7%) internship students preferred a cesarean section. Statistically, the difference was significant ( P = 0.032).

Undergraduate students who preferred VD rated child's health as their prime concern, followed by emergency situations and time needs. Technology was the least rated. Whereas students preferring cesarean section, also ranked emergency situations on their top priority, giving technology and cost the least rank. While in the case of interns, those who prefer VD and a cesarean section, greater importance was attached to child health and emergency situations while technology was given zero importance.

In the second scenario: normal pregnant women in their care, it was observed that 136 (90.7%) of the first-year students and 142 (98.6%) of the interns preferred VD, while a level below 14 (9.3%) and 2 (1.4%) of first-year and internship students preferred a cesarean section, respectively. The difference was statistically significant ( P = 0.003).

Where, among first-year students opting for a cesarean section, child health was their top priority while time, technology, and patients opinion were less of a priority and for VD, child health was the top priority and least importance was given to technology and cost.

On the other hand, among interns who preferred VD, child health was the most important while 0% gave priority to technology and for cesarean section interns preferred time and emergency situations over other options (0%).

In the third scenario, preferred delivery modality as a healthcare manager, in which the healthcare executive ensures that the organization grows with financial strength and medical quality, it was witnessed that 139 (92.7%) and 135 (95.1%) of first-year and internship students, respectively, preferred VD for their patients. Statistically, the difference was found to be non-significant ( P = 0.393).

Among first-year students who preferred VD rated health of the child as their prime concern, followed by emergency situations and cost required. Technology was the least rated. Whereas students preferring cesarean section also ranked health of child on their top priority, giving technology and patient's opinion zero priority. Interns who preferred VD, gave health of child followed by emergency situations, cost and patients opinion the most important while technology was given least importance.

In the last scenario, 131 (87.3%) of the first-year students expressed a higher proportion of the preference for VD for the birth of their own child in their own pregnancy or their partner compared to internship students 121 (85.2%), cesarean section was preferred by 21 (14.8%) of internship students as compared to 19 (12.7%) of first-year students for the mode of self or partner birth and the difference is statistically non-significant ( P = 0.598).

Among first-year students who preferred cesarean section, pre-operative pains was their topmost reason while post-operative pain was given zero priority and in VD, the greatest importance was given, as it is a natural process of birth and least importance was given to relying on technology development and post-operative pains. Among interns, those preferring VD, natural process of birth was the given the most importance while least priority was given to preoperative and post-operative pains. And in cesarean section, pre-operative pains were prioritized while natural process of VB was given 0% priority.

When the results in case of their own pregnancy or that of their partner were compared with their options in the different scenarios, it was found that if the student preferred VD for himself/herself, he/she invariably chose the same mode of delivery in the other scenarios.

The analysis of the open question as to why the student opted for this particular form of delivery revealed that the following reasons were given when choosing a VD “lesser morbidity and mortality for the mother and foetus”, “natural and physiological process”, “quicker recovery”, and “shorter hospital stay” both in the case of the first year students and interns. When cesarean section was chosen for the birth of one's own child, the most common reason given was “less pain and less suffering”. Another reason given was the possibility of being able to “schedule the delivery”, and this was mentioned both by first-year and by interns. Three students (two in their internship and one in their first year) preferred a cesarean section because it offered “Lesser risk to the mother and less traumatic for baby”.

Pregnancy is a very special and beautiful experience for the parents. It is a physiological phenomenon, and its end is associated with pain, fear, anxiety, and even fear of death for mothers. Child delivery is a multi-dimensional process with physical, emotional, social, physiological, cultural, and psychological dimensions. Childbirth can be a critical and sometimes painful experience for women.[ 20 ] Sharing different kind of experiences of the women with others also involve the pain related to childbirth. It constitutes a false image about labor. Labor pain is a very important factor that affects individuals' preference toward the mode of delivery preferred. It also involves the physician or the medical student who are in their clinical practice.

Personal preferences of medical students toward the mode of delivery are an important aspect to study as its effects the population in a great way. The choice of mode of delivery is a very important decision for the health of baby and mother. Many studies have been done in pregnant women,[ 21 ] university graduates,[ 22 ] and nursing students[ 23 ] but we were not able to find any similar studies involving medical students except, a cross-sectional study conducted among medical students in Santa Catarina, Brazil.[ 24 ] There were total of 189 students (101 males and 88 females) in the above mentioned study.

In the Brazilian study,[ 24 ] the statistics state that 45.4% were born by VD whereas the remaining 54.6% were born by cesarean in the first-year students. In the present study, the analysis states that 68% of the participants were born by VD and 32% were born by cesarean in the first year.

According to the analysis of the Brazilian study[ 24 ] for the internship year students, 45.1% were born by VD whereas the remaining 54.9% were born by cesarean. In the present study, the analysis states that 75.35% of the interns were born by VD and 24.64% were born by cesarean section.

When the mode of delivery preferred in an uneventful pregnancy or as a healthcare manager, it was observed that in our study 84.25% of students preferred VD whereas in Brazilian study,[ 24 ] around 95% students preferred VD for their patients. It is indeed very pleasing to know that today, although the cesarean section rate is on the rise, new generation sides itself with normal birth.

Whereas around 30% of the medical students who participated in Brazilian study[ 24 ] stated that they would prefer a cesarean section for the birth of their own child, with a significantly greater proportion of sixth-year students opting for this mode of delivery compared to the first-year students. Whereas, in our study around 15% students preferred cesarean section for the birth of their own child or of their partner, with the difference being non-significant. But it was found that majority of the students who would choose a CD for themselves or for their partner would recommend VD for their patients when no pathologies are present. In the Iran study conducted by Hantoushzadeh S et al .,[ 22 ] it was reported that 28.3% of the professionals who stated having recommended VD for their patients would choose a cesarean section for themselves.

A web survey was applied to over 3,600 university students on their preference for type of childbirth. No comparison was made between age-groups; however, slightly less than 9% indicated a preference for a cesarean section which is lesser as compared to our study (15%).[ 25 ] In another meta-analysis, conducted in a population of more than 600 nulliparous, only 10.2% would opt for a cesarean section.[ 26 ] which is lesser as compared to our study.

Although either of the studies has come to their own conclusion, this study covers only a small fragment or part of a very wide population. The preferences are just based on their own personal experiences with their parents or people surrounding them and also based on what knowledge they gain through their academics or what they may have experienced with other patients during their internship year.

Limitations and recommendations

The study had certain limitations, the cross-sectional study design that does not allow causal relationships to be determined. The study was conducted in a limited time period (two months) and qualitative evaluation of open-ended questions could not be performed. In the present study, the difference in age between the two groups was predictable. It constituted as a confounding factor, since there was a difference of four years in age between the groups. It should be taken into consideration that the internship students have more experience and greater maturity with regard to their sexuality and may be closer to planning their own pregnancies. These differences between the groups have affected the students' answers irrespective of the effect of their medical training.

There are many other limitations like cultural differences, sense of maturity, opportunity of watching or studying a patient closely during a delivery, etc., that do not for sure help us to come to any such conclusions that any one mode of delivery is a 100% perfect decision of the women today irrespective of where they are located around the globe. This is because the factors based on which these decisions are made, may keep changing with time hence the preferences may also keep changing with time.

Nowadays, due to increased rate of cesarean section and invasive delivery preferences there is an urgent need to reduce the rates of unnecessary cesarean sections in our country. It is essential to gather information on the reasons that motivate doctors to prefer cesarean section rather than VD. More number of studies particularly longitudinal and qualitative should be conducted in different groups like doctors and women of reproductive age groups in different parts of the country. Raising awareness on natural birth among young generation is of great importance. Comprehensive information about adverse effects of cesarean section is often not available to pregnant women and their families. So, we feel the need to emphasize the importance of educative and informative programs for people.

Conclusions

Majority of medical students preferred VD because the delivery has lesser risks and it is a natural phenomenon having greater benefits. Most of the internship students preferred VD in case of uneventful delivery and normal pregnant women under their care, as compared to first-year students and statistically, the difference in both scenarios was found to be significant. Their attitude suggests that they would practice this in near future and would recommend the same as a healthcare manager for general population. Majority of the medical students would prefer VD for the birth of their own child or their partners. In this case, greater number of internship students preferred cesarean section as compared to first-year students. It is thought provoking that almost all the students think that labor is a normal physiological phenomenon; still when it comes to their own situation almost 15% prefer cesarean section. The main reason for choosing cesarean section by interns was preoperative (labor) pains. Although this difference was not statistically significant, this indicates a probable effect of medical education on escalating rates of cesarean sections as an option of child birth. As physicians personal choice is always reflected in his/her profession, reasons for preference of cesarean section for oneself or partner need to be explored in detail.

Financial support and sponsorship

Indian Council of Medical Research – Short-Term Studentship (ICMR-STS) 2019.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

The authors would like to thank students who enthusiastically participated in the study. The authors also acknowledge faculty members for their motivation and support.

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First-Ever North American Porcupine C-Section Birth Successfully Performed by San Diego Zoo Wildlife Alliance

Veterinary Teams Played a Crucial Role in the Procedure, S howcasing Their Dedication to Wildlife Conservation and Animal Well-Being

SAN DIEGO (Sept. 17, 2024) – San Diego Zoo Wildlife Alliance’s veterinarians successfully performed the first-ever cesarean section (C-section) birth for a North American porcupine, marking a pioneering achievement in veterinary science. This procedure was instrumental in saving both the mother, Maizey, and her male porcupette (baby porcupine), illustrating the essential contributions of veterinary teams to wildlife conservation and their commitment to safeguarding animal health and vitality.  

“This landmark procedure highlights the critical role that our veterinary teams play in species conservation, not just in emergencies, but as part of a legacy of leadership in wildlife care,” said Greg Vicino, vice president of wildlife care with San Diego Zoo Wildlife Alliance. “The success of Maizey’s C-section is another example of our veterinarians’ unwavering commitment to preserving the health and longevity of wildlife.”  

The Denny Sanford Wildlife Explorers Basecamp wildlife care specialists meticulously prepared for Maizey's pregnancy, working closely with her and allowing for voluntary radiographs and veterinary examinations. When Maizey went into labor, wildlife care specialists provided around-the-clock monitoring and consulting with the veterinary team. Once it became evident that Maizey required further assistance with her pregnancy, the team decided to proceed with a C-section. Due to the complex medical procedure, the wildlife care specialists decided to hand-rear the youngster. This decision also allowed Maizey time to properly heal from the operation.  

“This groundbreaking surgery emphasizes the integral role of expert veterinary medical care in zoological facilities and highlights the advantages of innovative approaches to save species in need of conservation,” said Dr. Michele Goodman, director of animal care with Elmwood Park Zoo and veterinary advisor for the North American porcupine Species Survival Plan (SSP). “For the North American porcupine, this procedure represents a significant step forward to improve long-term survival rates and contributes to broader conservation efforts aimed at securing its future in the wild.”  

Multiple teams across the organization—from the Wildlife Explorers Basecamp wildlife care specialists with their extensive expertise in natural history and husbandry of Maizey, to the veterinary technicians and hospital care specialists who kept Maizey and baby safe during their surgery, to the neonatal assisted care unit specialists who attended to the porcupette in the critical period after birth—were fundamental to the success and well-being of both individuals.  

“It can take a village to raise a child, and sometimes this is true even if they have quills,” said Dr. Garrett Fraess , clinical veterinarian with San Diego Zoo Wildlife Alliance. “Seeing both Maizey and her baby healthy and thriving is a testament to the exceptional care and teamwork at San Diego Zoo Wildlife Alliance.”  

Today both Maizey and her porcupette are doing well. Maizey is back to her normal self, nicely healed from the C-section. Her easygoing nature makes her an excellent wildlife ambassador, having educated guests for many years. The porcupette is also healthy and getting bigger every day. He is very playful, often spinning quickly in circles and flaring up his quills, which simultaneously serves as practice for defending against predators.  

Wildlife ambassadors such as Maizey play an important role by connecting guests with wildlife, showcasing natural behaviors and adaptations up close and personal. Maizey also helps guests understand the ecological role wild porcupines play and inspires people of all ages to appreciate the wonder of nature.

About San Diego Zoo Wildlife Alliance   San Diego Zoo Wildlife Alliance, a nonprofit conservation leader, inspires passion for nature and collaboration for a healthier world. The Alliance supports innovative conservation science through global partnerships. Through wildlife care, science expertise and collaboration, more than 44 endangered species have been reintroduced to native habitats. Annually, the Alliance reaches over 1 billion people, in person at the San Diego Zoo and San Diego Zoo Safari Park, and virtually in 150 countries through media channels, including San Diego Zoo Wildlife Explorers television programming in children’s hospitals in 14 countries. Wildlife Allies—members, donors and guests—make success possible.

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Maizey’s Miracle

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San Diego Zoo vets perform first-ever porcupine C-section

Sept. 17 (UPI) -- San Diego Zoo Wildlife Alliance announced its veterinarians have performed the first-ever cesarean section birth for a North American porcupine.

The wildlife alliance said Maizey, a female North American porcupine living at the San Diego Zoo, suffered complications during labor that necessitated a C-section procedure to protect her life and that of her male baby. Advertisement

"This landmark procedure highlights the critical role that our veterinary teams play in species conservation, not just in emergencies, but as part of a legacy of leadership in wildlife care," Greg Vicino, vice president of wildlife care with San Diego Zoo Wildlife Alliance, said in a news release. "The success of Maizey's C-section is another example of our veterinarians' unwavering commitment to preserving the health and longevity of wildlife."

The male porcupette, who has not yet been named, is being hand-reared by zookeepers to allow Maizey to recover from the C-section.

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