When I have strong feelings about an issue but find that many others feel differently, I often wonder, is it just me? Why don't others see what I see? Am I somehow off base, or are my beliefs correct? Can there be multiple "right" answers, or is this a moral issue for which only one answer is possible? Lately I've been struggling with this feeling about the rising cesarean birth rates. It seems so fundamentally wrong to me that over 30% of women now give birth by surgical intervention that I can't even imagine how all this came to be and why anyone would believe it's okay. When did the whole "natural childbirth" movement that I grew up in as a nurse give way to maximum intervention childbirth? Of course there's no answer to this question, and a cultural shift such as this takes decades to take hold, but somehow the general public now seems to think that it is acceptable-and even necessary-for one third of women to be cut open to birth their babies. I know that society's beliefs about childbirth in general have changed; women want analgesia and other such interventions in labor, and I believe we should meet women's needs when we're sure they understand the consequences of their choices. But now childbirth is controlled by the interventionists, and that seems to be perfectly fine with a majority of women. This is Alice-Through-the-Looking-Glass, upside-down thinking to me. Many factors have contributed to this, as the literature describes. Was analgesia the slippery slope leading us to where we are? Was it the epidural? Was it the women's movement itself, which might make it seem acceptable to consider childbirth just another scheduled appointment in women's busy lives? Was it the growth of maternal/fetal medicine as a subspecialty of OB/Gyn, fueling the impression that every pregnancy is filled with dangers waiting to happen? Was it the introduction of electronic fetal monitoring? Perhaps it was just the perfect storm of these and other cultural and medical events, but there is no doubt now; despite the best efforts of the vocal midwifery community, the nursing community, and some few public health advocates, childbirth is now a medical/surgical event, and everyone is anticipating a dangerous occurrence that will necessitate the operating room.

Young nurses starting out in maternal-child health may not even understand that only a few short decades ago (in 1970) the cesarean birth rate was 5% (Bettegowda et al., 2008). By 1980, it had risen to 25% and now stands at 30.3%. What has happened in those few decades? Could it be that 30.3% of women have become incapable of giving birth vaginally? There are major consequences to this incredibly high rate of cesarean births-consequences for the mothers, the babies, and society. Because many of the cesareans are done before 39 weeks (despite ACOG's recommended GA for elective cesarean), often for convenience, too many babies are being born between 36 and 39 weeks ("late preterm"). We used to think these babies would be fine, but now we know that they have much higher risk for many health problems (see the article by Riesser Shaw in this issue of MCN). Alarming statistics (Bettegowda et al., 2008) have shown that the rising preterm birth rate in the United States (now 12.7%) is heavily influenced by cesarean birth and that 92% of the increase in singleton preterm birth is due to birth by cesarean. These babies are "almost exclusively late preterm births" (Bettegowda et al., 2008, p. 310). This figure-92%-is astounding.

Is it just me? I think not. I believe that the escalating cesarean birth rate is dangerous. It's not okay to put so many women at danger for the health risks of surgery, and it's not acceptable to endanger so many newborns by allowing them to be born before term. We can't assign blame; there's blame enough for everyone. What we need to do now is advocate for change. Cesarean birth before 39 weeks must be reserved for women who have grave medical indications or for infants who simply must be born due to true medical complications. The Bettegowda paper is a wake-up call. I urge you all to read it.

It's not just me.

Margaret Comerford Freda, EdD, RN, CHES, FAAN EDITOR

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