But a doctor says you need a cesarean. Doesn’t that mean it’s necessary?
Nearly one third of women give birth by cesarean in the United States, a rate that has risen for eleven straight years. Most agree that the reason for the rise in cesareans is multifactorial with a strong leaning toward attributing the majority of the blame to obstetricians’ spoken or unspoken fears of being sued. In spite of this, many still hold onto magical thinking and belief in the infallibility of doctors, leaving pregnant women to blame for being increasingly defective and risky. One commonly used example is the following:
The cesarean rate is higher because there are more obese women.
At face value, the statement looks at two rising rates—cesareans and obesity—and claims that one is, in part, causing the other. This WebMD article quoted Dr. Frederic Frigoletto Jr., a professor of obstetrics and gynecology at Harvard Medical School making this claim.
More obese women —> Higher cesarean rate
There are more obese women. More cesareans are being performed. Therefore, more cesareans are being performed because there are more obese women.
However, cesareans do not occur spontaneously. An obstetrician performs them.
More obese women —> Obstetricians perform more cesareans —> Higher cesarean rate
So what is it about being obese and pregnant that is different from being non-obese and pregnant? Is it that obese women are more likely to experience obesity-related health risks during pregnancy and these obesity related health risks during pregnancy will cause more emergency cesareans to be performed on them? Perhaps.
The statement “obstetricians perform more cesareans” needs to be unpacked and analyzed. Many discussions about childbirth become deadlocked because of a flawed assumption: If an obstetrician performed a cesarean, it was because a cesarean was medically necessary. Similarly, if an obstetrician recommends a cesarean, it is because the cesarean is medically necessary.
While this is sometimes true, it is not always true. The argumentum ad necesarean is both an appeal to authority and an appeal to common practice.
Banning or refusing to attend VBACs in spite of ample evidence to support the safety of VBAC, a skyrocketing number of prophylactic primary cesareans performed for suspected macrosomia based on inaccurate late-term ultrasound estimates of fetal weight which yield a baby that is not macrosomic and a documented correlation between cesareans and fear of litigation all add up to unnecessary cesareans performed as standard practice.
Several Huffington Post commenters relied on the argumentum ad necesarean in discussing the case of V.M., a New Jersey woman who refused a cesarean and had her competence evaluated during labor by two psychologists, the first of whom found her competent to make her own medical decisions. During her second psych consult for refusing a cesarean, her baby was born healthy and without incident. Angry commenter lcrown noted “[t]hat the baby was born naturally without incident was a miracle” and zachrg pointed out that “[t]here’s a notable difference between “I won’t engage in an unnecessary C-section for a doctor’s convenience” and “I refused a C-section AGAINST MEDICAL ADVICE but by sheer, dumb luck, everything turned out okay.”
In the minds of lcrown and zachrg, a doctor recommended a cesarean; therefore, the cesarean was medically necessary. The birth of a healthy baby was merely the result of luck, which is the typical conclusion of this type of fallacious argument. Incidentally, lcrown took it one step further in pointing out that she “can completely understand their judgement to try and deliver this baby in the safest and least chaotic way.” This would actually have nothing to do with the medical benefit of a cesarean to the baby and everything to do with putting an end to what commenter GBGB called “the mother’s hysterics…caused by a long history of psychological problems.” Either way, a medically unnecessary cesarean was inappropriately recommended and the real luck was actually getting out of St. Barnabas Medical Center without unnecessary surgery, as St. Barnabas sections half of its pregnant patients.
An OB-GYN at Good Samaritan Medical Center in Brockton, Massachusetts told a reporter that there is no “magical number” for c-sections—that “whatever that C-section number turns out to be, is the right number” as long as mothers and babies are healthy. Dr. Lisa Masterson from the television show, The Doctors, emphatically argues the same, but the supposedly “ever cautious” modus operandi of obstetricians she touts is resulting in astronomical percentages of primary and repeat cesareans performed with no medical indication. Truly cautious doctors would not knowingly make a low-risk patient a high-risk one by recommending they submit to unnecessary major surgery.
Furthermore, patients and potential patients are justified in demanding that their doctor hold themselves and their peers accountable for the number of cesareans that they perform rather than accepting their fallacious reasoning that everything they do is correct and necessary, cesareans being no exception. While it can be emotionally difficult to come to terms with the fact that many doctors are now habitually and often unapologetically placing their self-interest before best evidence and the health of their patients in performing unnecessary cesareans on the women who trust them, it is important to point out or become self-aware of this fallacious thinking.
Ironically, when doctors rely on the argumentum ad necesarean to assert their own authority and defend their high cesarean rate to themselves and others, they are setting themselves up for that which they are trying to avoid by performing an unnecesarean in the first place: litigation. The argumentum ad necesarean, rooted in the assumption that doctors do not make mistakes when it comes to cesareans, leads patients and the public to believe that doctors have more control over birth outcomes than they actually do. This leaves them more vulnerable to being blamed for a negative outcome.