Stephanie Dulli knew she needed a cesarean section shortly after learning that her unborn son was in a "jackknifed" position under her ribs, with his feet up over his head. Even though it deviated from her birth plan, she made peace with the idea in a hurry after her husband asked the obstetrician what would have happened in "pioneer days" before c-sections were an option.
"The OB said they would have died in childbirth," said Dulli, a mother of three in Washington, D.C. "I'm pretty grateful C-sections exist."
Cesarean sections save lives, but the World Health Organization says they shouldn't be performed unless they're medically necessary. They're necessary when the baby is in distress or in an abnormal position, or when the mother's labor has become prolonged, the organization said, adding that c-sections should generally only happen in about 10 or 15 percent of births.
When c-sections are performed in about 10 percent of births, maternal and newborn deaths decrease, according to WHO. But when they occur in more than 10 percent of births, there's no change in the mortality rates. Yet, C-section rates continue to rise in wealthy countries, WHO said. In the United States, 32.7 percent of births are c-sections, according to the Centers for Disease Control and Prevention.
"Due to their increased cost, high rates of unnecessary cesarean sections can pull resources away from other services in overloaded and weak health systems," WHO said in a news release Friday.
Dr. Marjorie Greenfield, chief of general obstetrics and gynecology at UH Case Medical Center in Cleveland, said there are many factors that contribute to deciding to perform a c-section.
"A lot of people in the United States view labor as a minefield of disaster waiting to happen," she said, adding that not everyone feels this way, but it includes patients and their doctors.
"Over the decades, cesareans have gotten safer. It's safer now than it was in the 1940s," thanks to better anesthesia, techniques, antibiotics and blood banking, she said. "That's part of why I think we see it as a benign thing."
She said some women fear complications from vaginal child birth such as incontinence and stretched organs, and believes moms are more likely to ask for c-sections on the East Coast than they do where she is in Ohio.
Greenfield said the health complications are about even between c-sections and vaginal births -- if you only have one child. The risks increase with each sequential c-section because of scar tissue and other potential issues that can arise. But the risks decrease with each sequential vaginal birth, she said.
Sometimes, doctors will opt to do a c-section because patients often sue if they think a c-section hasn't been done soon enough, but patients will rarely sue over an unnecessary c-section.
"If you were only looking at malpractice liability, you're always better off having a lower threshold," Greenfield. said.
Private practice obstetricians also do perform c-sections before they're absolutely necessary labor is lasting longer than they expect, in part because of compassion, but also because they have other patients or need to go home to dinner and don't have someone else available to step in.
Denise Schipani, a mother of two, said that she's not sure she needed her c-section and wishes the doctors had let her wait to deliver vaginally. She labored for two days and felt too overwhelmed to make her own decision.
"I feel like after the first one, after my first son, I felt like I missed out on something powerful and personal," Schipani said. "I felt like I was kind of lost in this long, painful hell of a day and a half then had surgery."
She said if she could do it again, she would have asked for a midwife or a doula to stay with her and advocate on her behalf.
No matter what, Greenfield said people shouldn't shame each other for choosing not to deliver vaginally.
"My feeling about it is women have the right to make decisions about their bodies," Greenfield said. "Life is short, and everyone is just struggling to do their best."