By Dr. Leila El-Alti

The need for capping, controlling, and reducing “rising” caesarean rates worldwide is an omnipresent topic of discussion in birth circles, reviews, original research, opinion articles, media, and campaigns. Vehement criticism of this “epidemic” of high cesarean rates rests on the premise that a significant percentage of these births are unnecessary and must therefore be prevented.

But who exactly is defining the criteria of necessity? What makes a cesarean unnecessary?

Well, it’s a woman’s need that dictates when a cesarean birth is necessary, one might think. But this only invites further questions. What is a need? How is it defined? Whose perspective ascertains the absence of need and lack of necessity for a cesarean birth? Which authority has the power to dictate the constituents of a woman’s need?

It would be strange, to say the least, if the person giving birth is not that authority. After all, birth necessarily happens through a woman’s body. The birthing woman is the only person who will subjectively experience the birth and the only person who will live with the body, mind, and life forever altered by the birth. And if permanent change is inescapable, taking risks is unavoidable, and experiences are unpredictable, then it makes little sense that the birthing woman is not the ultimate decision-maker in birth. Yet not only are birthing women rarely viewed as an authority on birth in general, the individual woman giving birth is also not recognized as an authority over her own birth.

“Scrutinize the disdain and cruelty reserved for women who decide on a cesarean birth without medical reasons”

I realize that some readers might be skeptical about the accuracy of the preceding claims concerning women’s lack of authority. Truth be told, skepticism is a good sign. It means that unquestioned assumptions are being challenged for the first time. But if in doubt, all one has to do is simply observe the condemnation directed at women who make decisions independently of another authority, especially when said decisions fail to comply with accepted birth norms.

Take note, for instance, of the moral reckoning that ensues when women decide to give birth without any professional present. Consider how moral judgment of women choosing or refusing pain relief during labor shapeshifts to blame, praise, or a ‘told-you-so’ depending entirely on the judge. Most urgently, scrutinize the disdain and cruelty reserved for women who decide on a cesarean birth without medical reasons a.k.a. the unnecessary cesarean.

The necessity, or lack thereof, of a caesarean birth is defined and prescribed exclusively through the biomedical lens, leaving no room for birthing women to author or dictate any part of that definition. The evidence for that is abundantly clear and overwhelmingly ubiquitous. There exists countless variations of the widely supported claim that cesareans save lives when medically necessary but cause severe harm when unnecessary. These variations are accepted and used with little scrutiny or critique, not only by the proponents of the biomedical perspective on birth, but also by its staunch opponents. Yes, the very opponents who claim to center women’s empowerment in everything they do.

Birth is natural. Medicalization of birth strips women of power and autonomy.

Medically necessary cesareans are ok.

But elective cesareans? Only because women want them? These should be banned.

To determine the necessity and acceptability of a cesarean birth, natural birth advocates assign more power and authority to the biomedical perspective than to the birthing woman. They also argue that they honor a woman’s bodily autonomy through fighting the biomedical perspective which paternalistically controls her and restricts her autonomous choices. But they also promote the restriction of a woman’s autonomous choices by denying her access to a birth mode made possible by their ideological enemy. Why? Because that enemy simply deemed it unnecessary that she gives birth that way. It’s gaslighting galore with extra cognitive dissonance.

The dichotomy between the physiological and the biomedical, concerning women’s empowerment in birth, is simply nonsensical. Claims that medicalization of birth is the root cause of women’s disempowerment cannot be taken seriously when it is a woman’s own desire for a medical birth that’s under question.

“Women who reject what is expected of them and accepted for them need to be intentionally alienated; out of concern that their disobedience reveals the façade of power and protection compliant women assume they have”

Medical indications seem to always meet the widely accepted threshold of justifiability for a cesarean birth. This is not due to some secret wisdom only attainable through medical practice, but because the threshold itself has been medically established. In comparison, a woman’s reasons for wanting a cesarean are assessed, challenged, and inspected for validity by others. Only then can it be decided whether her reasons amount to justifiability.

It is irrelevant whether the reasons are ultimately judged to be good enough, convincing enough, valid enough, or reasonable enough. Non-medically-indicated cesarean births, whether merely desired or actually achieved, are assumed to be the result of women’s entitlement, ignorance, fear, mental illness, weakness, or otherness. Even when her reason is validated, a woman’s authority is invalidated by default.

Is it permissible for physicians to approve women’s requests for cesareans?

Do women really have the right to ask for a cesarean?

Why do some women not want to birth naturally?

Is women’s fear of natural birth driving cesarean rates up?

Are cesareans negatively affecting human evolution?

It is by design that moral doubt perpetually surrounds the authenticity and validity of women’s reasons for cesarean birth. This is why “too posh to push” has never fallen out of favor, and why elective cesareans are portrayed as morally contentious. Women who reject what is expected of them and accepted for them need to be intentionally alienated; out of concern that their disobedience reveals the façade of power and protection compliant women assume they have.

“If support and empowerment are bestowed exclusively on women whose birth choices align with certain ideals but withheld from those who reject the ideals, then neither group of women had power to choose in the first place”

Despite what appears to be a general shift towards a holistic understanding of birth and support for women’s choices, in reality it is merely women’s powerlessness being cloaked.

Women who defy the authority of medicine by rejecting the biomedical definition of their needs and any subsequently recommended birth interventions, are said to be selfish, foolish, and irresponsible risk-takers who deserve every tragedy that befalls them. Don’t they realize that birth is dangerous and professionals know best?

Women who defy the authority of nature by refusing the teleological view on their birthing bodies and the suffering imposed by it, are said to be entitled, irrational, and scared comfort-seekers who do not deserve to be mothers. Don’t they realize that birth is safe and nature knows best?

When purported supporters of women’s empowerment and informed birth choices accuse other women, who choose cesareans without medical reasons, of being uninformed, then support, knowledge, choice, and power are illusions. If support and empowerment are bestowed exclusively on women whose birth choices align with certain ideals but withheld from those who reject the ideals, then neither group of women had power to choose in the first place.

A woman is not merely a vessel of birth but an authority, an autonomous subject, a moral agent, the sole owner of her body, and the final decision-maker over all matters pertaining to her body and birth experience. Either this holds true for all women or for none. There is no middle ground. There are no shades of grey. Bodily autonomy cannot be acknowledged and respected selectively based on whether a woman’s decisions serve to strengthen a specific ideology.

But I don’t believe people are yet willing to face what lurks beneath birth ideologies.

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Note: The featured image in this post is AI-generated.