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Scheduling the Stork: Media Portrayals of Women’s and Physicians’ Reasons for Elective Cesarean Delivery Lisa Campo-Engelstein, PhD, Lauren E. Howland, MPH, Wendy M. Parker, PhD, and Paul Burcher, MD, PhD ABSTRACT: Background: Media interest in cesarean delivery has grown in recent years
driven both by rising cesarean delivery rates and the decision by the American College of Obstetrics and Gynecology (ACOG) to permit elective cesarean (EC) delivery. Methods: A content analysis of United States newspaper and magazine articles from 2000 to 2013 (n = 131 articles) was completed to understand how the news media portrays ECs. Results: The majority of articles (71.8%) emphasized reasons to support women having an EC, while 38.2 percent of the articles exhibited themes of physician support for ECs. Relatively few articles mentioned reasons against ECs either from the women’s perspective (11.5%) or the practitioners’ (3.8%). The most common themes given for women choosing ECs were convenience/scheduling (48.9%), avoidance of pain or fear of labor (29.8%), and physical harm to women from vaginal birth (17.6%). Doctors’ perspectives were less prevalent in the media than women’s perspectives, but when mentioned they were almost exclusively in support of ECs for reasons including avoiding malpractice (28.2%), avoiding physical harm to the woman or baby (16.8%), and timing/scheduling (14.5%). Discussion: Media coverage suggests ECs are widely accepted by both women and doctors, with women choosing an EC mainly for convenience/scheduling and fear. However, 43 percent of doctors surveyed by ACOG said they were not willing to perform the procedure, and surveys report that mothers rarely request an EC. (BIRTH 2015) Key words: decision making, elective cesareans, media portrayal, social norms
Elective cesareans (ECs), defined as cesareans performed without a medical indication, have garnered increased media attention due in large part to the surging rates of all cesareans. Almost a third of all infants born in the United States are born by way of cesarean (1). Although media interest in EC birth has been significant, the Listening to Mothers Study indicated that only 2 percent of primary cesarean deliveries were for
no medical reason (2). This survey found, however, that most both primary and repeat cesarean mothers indicated that their practitioner was the one who recommended a cesarean either before or during labor (2). Though the overall prevalence of ECs is still low and estimates vary, recent data suggest that the prevalence is about 3 percent of all deliveries (3). This percentage, however, may be increasing (4) and is still a
Lisa Campo-Engelstein, Assistant Professor, Alden March Bioethics Institute & OBGYN Department, Albany Medical College; Lauren E. Howland, Doctoral Student, Department of Epidemiology & Biostatistics, University at Albany; Wendy M. Parker, Assistant Professor, School of Arts and Sciences, Albany College of Pharmacy and Health Sciences; and Paul Burcher, Associate Professor, Alden March Bioethics Institute & OBGYN Department, Albany Medical College, Albany, NY, USA.
The authors consider that the first two authors should be regarded as joint First Authors. Address correspondence to Lisa Campo-Engelstein, PhD, 47 New Scotland Avenue, MC 153, Albany, NY 12208, USA. Accepted December 25, 2014 © 2015 Wiley Periodicals, Inc.
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2 cause for concern. Infants born by way of cesarean can face increased respiratory morbidity (5,6) and have a lower rate of initial breastfeeding (5,7), and some evidence suggests that there may be longer-term impacts on chronic disease (5). Maternal morbidity can be 5 to 10 times greater and maternal mortality is 2 to 4 times higher after a cesarean compared with vaginal birth (8– 10). Cesarean delivery is a major surgery for a woman and increases her risk of postpartum infection, increases her recovery time and hospital stay, and has potential longer-term influence on a woman’s future reproductive health (5). In addition to the health risks, cesareans are a costly surgical procedure—almost 1.6 times more expensive than a vaginal birth without complications (11). However, research with respect to ECs, their justification, and true prevalence remains limited (3,5). To properly address the issue, it is important that health care practitioners and public health professionals understand the causes behind their increasing frequency. The popular press is rife with explanations for the increase in ECs, although these explanations are not always grounded in empirical research. Nonetheless, it is important to analyze how the issue is being discussed and portrayed to the public since the media plays a large role in providing information for health issues, and reflects and produces cultural ideologies and norms, particularly about gender (12). For example, Weaver and Magill-Cuerden (13) examine the increasing use of the phrase “too posh to push” in United Kingdom newspapers and conclude that the ubiquity of this phrase contributes to the impression that many women are selecting ECs. Consequently, pregnant women may view ECs as a viable option for themselves as a result of the misinformation presented to them about the frequency of the procedure. To our knowledge, there have not been any studies of the United States media’s coverage of ECs. The goal of our project was to examine United States magazine and newspaper articles for the reasons given by women and physicians around ECs. We hypothesized that the women would cite reasons of pain avoidance and convenience, whereas physicians would cite fears of malpractice and liability. The comparison of women’s and physicians’ reasons for ECs will provide insight into how the larger social norms around motherhood and medicine are connected to ECs in the mass media.
Methods Collection of Articles Two databases, Lexus Nexus and Proquest, were used to obtain the articles examined in this study. Separate
searches were conducted on each platform to identify relevant articles. Six different search terms were included to obtain articles discussing the area of interest: “elective c-section,” “elective cesarean,” “planned c-section,” “planned cesarean,” “scheduled c-section,” and “scheduled cesarean.” This method was employed since there are many common terms that are used by lay media to describe ECs. Each search was limited to English language articles published in the United States from January 2000 to December 2013. For inclusion in the study, the article must contain some discussion of ECs, rather than just the sole mention of one of the search terms. Only articles discussing human pregnancies were included. An article was included if it discussed primarily healthy, singleton pregnancies, and was excluded if the focus was on mothers with a previous cesarean or those with preexisting medical conditions (e.g., HIV/AIDS). During the exclusion process, articles were removed from the sample if the central focus was maternal requests for a cesarean made during labor or an emergency cesarean, rather than maternal requests for a cesarean made before labor. Furthermore, articles that did not have a focus on delivery practices within the United States or were published in scholarly journals and clinical/professional magazines or newspapers were excluded from the study. In addition, the following types of articles were excluded from the sample: letters to the editor, advertisements, and reviews of products, books, classes, etc. Reprints or duplicate articles were excluded from the study. The initial search generated 290 newspaper and 183 magazine articles from Lexus Nexus and 150 newspaper and 180 magazine articles from Proquest. Each article was downloaded from its respective database and reviewed in its entirety to determine if it met the inclusion criteria. After the exclusion process, the final sample contained 57 newspaper and 12 magazine articles from Lexus Nexus, and 31 newspaper and 31 magazine articles from Proquest for a total of 131 articles.
Data Analysis and Coding The data analysis process required three steps to build the thematic framework for coding articles, verify our coding reliability, and finalize the coding of all articles in our sample. A sample of 10 articles was selected to prepare an adequate coding framework to examine the decision-making process of women and physicians in regard to ECs. Two coders (LCE and LEH) read the first four sample articles together, chosen for their extensive length. Together they compiled a list of themes they had seen in the four articles. Each coder
8 3. Ecker J. Elective cesarean delivery on maternal request. JAMA 2013;309(18):1930–1936. 4. Coleman VH, Lawrence H, Schulkin J. Rising cesarean delivery rates: The impact of cesarean delivery on maternal request. Obstet Gynecol Surv 2009;64(2):115–119. 5. Lee YM, D’Alton ME. Cesarean delivery on maternal request: The impact on mother and newborn. Clin Perinatol 2008;35 (3):505–518, x. 6. Many A, Helpman L, Vilnai Y, et al. Neonatal respiratory morbidity after elective cesarean section. J Matern Fetal Neonatal Med 2006;19(2):75–78. 7. Zanardo V, Svegliado G, Cavallin F, et al. Elective cesarean delivery: Does it have a negative effect on breastfeeding? Birth 2010;37(4):275–279. 8. Shearer EL. Cesarean section: Medical benefits and costs. Soc Sci Med 1993;37(10):1223–1231. 9. Souza JP, Gulmezoglu A, Lumbiganon, P, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: The 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 2010;8:71. 10. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004;103(5 Pt 1):907–912. 11. Podulka J, Stranges E, Steiner C. Hospitalizations Related to Childbirth, 2008. HCUP Statistical Brief #110. Rockville, Maryland: Agency for Healthcare Research and Quality, 2011. 12. Kasper AS, Ferguson SJ. Breast Cancer: Society Shapes an Epidemic. New York, New York: Palgrave, 2002. xii, 388 p. 13. Weaver J, Magill-Cuerden J. “Too posh to push”: The rise and rise of a catchphrase. Birth 2013;40(4):264–271. 14. Neuendorf K. The Content Analysis Guidebook. Thousand Oaks, California: Sage Publications, 2002. 15. Feinstein A, Cicchetti D. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990;43(6): 543–549. 16. Cicchetti D, Feinstein A. High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol 1990;43(6):551–558. 17. Byrt T, Bishop J, Carlin J. Bias, prevalence and kappa. J Clin Epidemiol 1993;46(5):423–429. 18. Lantz C, Nebenzahl E. Behavior and interpretation of the kappa statistic: Resolution of the two paradoxes. J Clin Epidemiology 1996;49(4):431–434.
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19. Viera A, Garrett J. Understanding interobserver agreement: The kappa statistic. Fam Med 2005;37(5):360–363. 20. American College of Obstetrics & Gynecology. Cesarean Delivery on Maternal Request, 2013. 21. Childbirth Connection. Vaginal or Cesarean Birth: What is at Stake for Women and Babies? New York, New York: Childbirth Connection, 2012. 22. Kalish RB, McCullough L, Gupta M, et al. Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol 2004;103(6):1137–1141. 23. Bettes BA, Coleman VH, Zinberg S, et al. Cesarean delivery on maternal request: Obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007;109(1):57–66. 24. Charles SS. T, Mothers in the media: Blamed and celebrated— an examination of drug abuse and multiple births. Pediatric Nursing 2002;28(2):142–145. 25. Davis D-A. The politics of reproduction: The troubling case of Nadya Suleman and assisted reproductive technology. Trans Anthropol 2009;17(2):105–116. 26. Johnston DD, Swanson DH. Invisible mothers: A content analysis of motherhood ideologies and myths in magazines. Sex Roles 2003;49:21–33. 27. Campo-Engelstein L. Competing social norms: Why women are responsible for, but ultimately not trusted with contraception. Int J Appl Philos 2012;26(1):67–84. 28. De Konnick M. Reflections on the transfer of “progress”: The case of reproduction. In: Sherwin S, ed. The Politics of Women’s Health, Philadelphia, Pennsylvania: Temple University Press, 1998:150–177. 29. Burrow S. On the cutting edge: Ethical responsiveness to cesarean rates. Am J Bioeth 2012;12(7):44–52. 30. Blackman L. It’s down to you. Psychology, magazine culture and the governing of the female body. In: Reed L, Paula S, eds. Governing the Female Body: Gender, Health and Economies of Power, Albany, New York: State University of New York Press, 2010:19–36. 31. Morris T, McInerney K. Media representations of pregnancy and childbirth: An analysis of reality television programs in the United States. Birth 2010;37(2):134–140.
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4 Table 1. Coding Framework Frequency
Description
Mothers’ reasons for choosing an elective cesarean 48.9% Convenience, scheduling for the family, specific date desired, specific doctor desired
7.6% 29.8%
Sexual function, harm to vagina, vaginal preservation Avoid the pain and length of labor, believe that labor is difficult, fear of labor or labor pain
3.1%
Large baby (10 + pounds) expected and the associated pain and/or vaginal preservation
17.6%
Incontinence, pelvic organ prolapse (POP), physical harm to the woman
12.2%
“Too posh to push,” designer birth, vanity, preserving their figure
9.2%
Avoiding harm to baby, increasing benefits for baby Control how to give birth (cesarean)
7.6%
4.6% 6.1%
16.0%
5.3%
Avoid an emergency cesarean, easier to do ahead of time than wait and need an emergency cesarean Lack of information/counseling or misinformation about cesarean and vaginal birth such as harm of a cesarean delivery and benefits of vaginal birth General risks/harm to the woman or the baby (not specified), general safety concerns Discomfort, uncomfortable during pregnancy
Mothers’ reasons against choosing an elective cesarean 7.6% Against medicalization, want a natural experience, believe women are able to give birth and have confidence in women’s bodies 4.6%
Physical consequences for women as a result of surgery such as longer recovery, infection, decreased mobility, pelvic organ prolapse, and incontinence
0.8%
Vaginal birth is best for the baby, avoiding harm to baby, increasing benefits for baby
5.3%
Relationship between the mother and the child suffers as a result of a cesarean, vaginal birth is emotionally more satisfying
Example “The idea of an elective c-section in today’s busy world, where so many women continue to work, “is no longer frowned upon. . . . Most women want the convenience. They want to know when the baby is coming.” “Honestly, I didn’t want any [vaginal] tearing.” “Women are made to fear birth, and, as a consequence, they go after everything available to speed labor up, ease the pain and get over with the whole process.” “[She] got the news that she had a very big baby—close to, if not more than, 10 pounds. . . . She opted to schedule her cesarean for the next day.” “Fear of incontinence is one reason some pregnant women schedule an elective c-section, even though they could deliver vaginally.” “Certain celebrities have even reportedly scheduled cesareans 3 or 4 weeks before their due date, to minimize stretch marks and saggy loose skin.” “Some of the reasons women give are that they believe there is less risk of . . . injury to the baby.” “Mothers over 35 are more likely to have planned c-sections . . . possibly because they want more control over the birth process.” “I had heard horror stories of women going in and having to have an emergency c-section [anyway].” “Why had Dr. C offered a cesarean to me? . . . Why didn’t he discuss other options? . . . Why didn’t he tell me if I didn’t try to have this baby vaginally, I could end up having all my babies by cesarean?” “The vast majority of women merely agreed with the decision . . . or wanted [a cesarean section] in belief that it would be safer for themselves or their infants.” “When I inquired if radical abdominal surgery was really the way to go, choruses of elective c-section vets swore by it, saying . . . they were spared the last torturous weeks of pregnancy.” “I have never needed any study to prove to me that vaginal birth is anything but absolutely normal, that a woman’s body is designed specifically for this purpose and that the survival of our species depends on this perfect design.” “Dach had a c-section . . . she’d prefer a vaginal birth. ‘Even this week, I’m still having trouble picking up the baby,’ she said 13 days after the surgery. . .‘With vaginal births, you can see someone pop right back up and hold the baby. Recovery is much faster.’” “Medically necessary cesareans are one thing, but to give blanket approval to elective cesareans, instead of working with a mother to have a vaginal birth, could be dangerous to the health of the mother and the baby.” “Ms. Charles had a vaginal birth for her second baby, and said she preferred that experience. The c-section ‘was more a matter of being robbed of the whole experience of giving birth.’’’
(continued)
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Table 1 (continued) Frequency
Description
1.5%
Not medically indicated, not necessary, needless, questionable
0.8%
Control how to give birth (vaginal)
Physicians’ reasons for performing an elective cesarean 28.2% Malpractice, lawsuits 3.1% 14.5%
11.5%
1.5%
16.8%
Financial benefits such as making more money or making it quicker Convenience, scheduling, better work hours for the physician Support women’s choice, women’s autonomy and women’s preference, listen to what the woman wants Avoid an emergency cesarean, easier to do ahead of time than wait and need an emergency cesarean
Avoid physical harm to the women, concern for high-risk women, avoiding harm to the baby
Physicians’ reasons against performing an elective cesarean 0.8% Against medicalization, favor a natural experience, believe women are able to give birth and have confidence in women’s bodies 3.1% Not medically indicated, not necessary, needless, questionable
Discussion of choice regarding elective cesarean 18.3% Importance of choice, women should have a choice 3.8%
Limits of choice, should be solely a women’s decision, paternalism sometimes justified
publications were most likely to focus on avoiding the pain of labor (39.1%) and the convenience, timing theme for women (34.8%). Over two-thirds of specialty (69.6%) and 72.2 percent of general publications discussed women’s choices for ECs. Slightly more than half of the newspaper articles contained the theme of women’s reasons for having ECs. The most common reasons given were convenience, scheduling, or desire for a specific date or doctor (54.6%). These reasons were the most frequently discussed theme by a significant margin. Magazine pieces in contrast were more diverse: a full third focused on the theme of convenience of scheduling
Example “Because Hoover believed her c-section wasn’t medically necessary, she later did hours of research and created a desired delivery plan before she had her next three children, all of whom were delivered vaginally.” “Gryczka wanted more control the second time around. She hired a local midwife and planned for an at-home birth.” “Doctors often feel they must do a c-section to protect themselves from a malpractice suit.” “Hospitals and doctors make more money from c-section procedures.” “It means they can split their time . . . on a timetable of their choosing, and reduces the chance that they will be required to attend births at inconvenient times.” “A private-practice physician . . . said more women are requesting repeat c-sections. She said she takes a neutral approach and allows her patient to make the decision.” “But while physicians acknowledge room for debate . . . some noted that planned cesareans generally produced better outcomes than emergency procedures performed after problems arise.” “Some physicians believe cesarean sections pose fewer health risks and want to make elective c-section an option for all mothers.” “Labor is OK, and they’ll survive. Most births go very well; there’s no good evidence now to circumvent Mother Nature.” “Chairman of obstetrics and gynecology . . . is up front in saying that vaginal delivery is the better choice for childbirth, and he sees no evidence to recommend a nonmedically driven cesarean.” “Proponents of so-called elective c-section or cesarean on demand argue that women should have a say in how they give birth.” “‘The issue is, we’re not always listening to the patients,’ he said. ‘But sometimes what they want isn’t what’s best for them.’”
(37.2%), another 32.6 percent focused on the pain of labor, and 27.9 percent discussed the “too posh to push” idea. Fewer magazine pieces focused on the doctor’s perspective on ECs.
Discussion Our study demonstrates that media imagery perpetuates the notion that maternal-requested cesareans are a common practice for reasons of convenience. Yet, this media interest and perspective are not supported by survey and interview data that are found to date (4,21).
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Fig. 1. Percentage of articles expressing major themes. Kalish et al examined intrapartum cesarean deliveries at one facility over a 6-month period and found that cesarean delivery was offered for 13 percent of cases without any clear medical indication; women requested a cesarean in 8.8 percent of cases (22). Consequently, ECs may be more a result of physician preferences than women’s choices. This also correlates with the Listening to Mothers data that indicate women rarely request an EC; rather, in most cases, physicians are the ones to recommend a cesarean (2). Bettes et al detail the results of an ACOG survey about practice patterns and opinions of ECs by OB/ GYNs that demonstrate the complexity of the topic and doctors’ perspectives on approaching patients who request for an EC (23). The ACOG survey results suggest that women’s education around vaginal childbirth may be key to changing the cesarean trend, yet women’s education did not emerge as a theme in our study of United States newspaper and magazines, indicating that the national media is not focusing on women’s education around ECs at this time. A great deal of uncertainty and limited data in the medical literature around the risks and benefits of ECs are observed, yet some of the major risks and benefits associated with ECs are demonstrated by the themes in our study. For instance, a 2012 Childbirth Connections report (21) attempted to compile the best scientific evidence on cesarean versus vaginal births and concluded that while there is good evidence for many of the concerns around cesarean, the evidence is mixed in many cases. In short, the picture is more complicated and nuanced than would be evident from newspaper and magazine headlines.
In a related way, the topic of ECs taps into broader normative beliefs about being a good mother and the complex roles of women in society. The United States media typically treats “traditional” women (e.g., white, middle to upper class, heterosexual, married, able-bodied, Christian) as the cultural ideal for motherhood (24– 26). While compelling debates remain ongoing about women’s role in the workforce and childcare access and responsibility (e.g., the “mommy wars” and “can women have it all” discussions) (24–26), continued social perceptions of women place an emphasis on their perceived physical and emotional weakness that requires medical intervention especially around childbirth. Discussion of ECs may be more common in the media because it aligns with these broader cultural debates about what constitutes a good mother. There is a dominant social norm that good mothers are self-sacrificing (27) and women who violate this norm are often vilified by the media (24–26). Women who chose ECs were sometimes viewed as selfish in the articles in our sample because they were seen as prioritizing themselves and their careers over their children. However, other media portrayals were sympathetic toward women choosing ECs for convenience by acknowledging how difficult it is for women to balance their careers and family life. Nevertheless, the importance of the physician in influencing women’s decision making to undergo an EC is rarely discussed in any form of media. Reducing women’s selection of ECs to convenience places the locus of blame on women and fails to recognize the social constraints in which they are making such a decision, such as the physician–patient dynamic or their own social roles as wife, worker, and mother.
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The prevalence of fear-of-labor theme is not surprising, given the media portrayal of childbirth as extremely painful and dangerous in both fictional TV shows and movies and in reality TV shows such as “A Baby Story” and “Birth Day.” Underlying many women’s fear of labor, although not expressed in the media, is how the ubiquity of technological interventions during pregnancy and childbirth engenders feelings of incompetence among women with respect to their ability to engage in reproductive activities without medical assistance (21,28). Today, medical interventions are a normal part of childbearing experiences (e.g., fetal monitoring), which may contribute to women and physicians losing faith in physiologic birth (13,29). The medicalization of reproduction and childbirth contributes to high cesarean delivery rates, including ECs, and makes it easy and acceptable (and sometimes even socially required) to turn to cesarean delivery without much medical justification. As Sylvia Burrow explains, “Commonly recognized uses of technology in the antenatal and prenatal period foster the current social and medical view that women’s reproduction is an event intimately engaged with technology. . . . The normalization of reproductive technology elevates its importance, creating pressures on women to pursue it” (29, p 48). In short, women’s fear of labor may in fact be an expression of their fear of childbirth without technology. However, the articles did not discuss women’s fear within the framework of technology and medicalization, which is not surprising since these articles are in the lay literature and the focus of these articles was on women’s personal choices rather than how broader social factors subtly influence individual decision making. The social acceptance of the medicalization of childbirth is also reflected in our results, in that the doctors discussed in the articles were almost exclusively in support of ECs. The diversity of perspectives regarding EC means that there is little consensus about the advisability of this procedure. However, in our analysis, women’s autonomy was only the fourth most common reason (11.5%) physicians gave for performing ECs behind malpractice (28.2%), avoiding physical harm to the woman or baby (16.8%), and timing or scheduling for the doctor (14.5%). While there are perspectives on either side from clinical guidance on ECs to women’s health advocates that argue that women should resist scheduling childbirth and the “too posh to push” mantra and advocate for a vaginal birth for their child, there is less consensus in the medical literature or in advocacy circles than is preferred. In fact, the most recent ACOG statement on ECs argues that while performing ECs may at times be ethically permissible, in general ECs should be discouraged because the risks of vaginal birth are less than the risks of cesarean
birth (20). Our results illustrate that ECs are not being resisted within mainstream media in a substantial way. But is there another type of advocacy that women are taking up when they schedule the birth of their children? This study cannot answer that question but raises new questions around who is choosing to have ECs, whether women truly understand their options and risks, and whether more accurate or additional information could change these results. A great deal of academic literature exists on the decision-making process of electing for a cesarean, but how this scientific literature is conveyed in the media has not been a focus. This content analysis is subject to limitations in that we are exploring media portrayals of ECs and not surveying or speaking directly with expectant mothers, current mothers, or physicians to understand their rationale when deciding for or against EC. Other studies have included those perspectives; we are more concerned with how the facts and complexity of decision making is translated into headlines in broader media contexts.
Conclusion Our results demonstrate that much of the media attention to this topic has been devoted to the idea that women are electing to have cesareans out of convenience, scheduling, and fear concerns, with little clinical information that describes the potential risks of cesareans or complicates that decision in any meaningful way. We believe these themes were most frequent because they reflect and reinforce dominant societal perspectives with regard to women and mothers and technological interventions during childbirth as the standard. Additionally, these themes are simpler and more sensational than the nuanced and complex process of decision making that actually occurs with respect to cesarean. While “juicy” headlines may be good for newspapers and magazines, they may also be misleading to the public. Media content and imagery can alter self-perceptions and influence health behaviors, especially for women (2,30,31). The media portrayal of ECs as normal and even good from both women’s and doctors’ perspectives may lead women to choose ECs, thereby increasing the already high cesarean rate.
References 1. Osterman MJ, Martin JA. Changes in cesarean delivery rates by gestational age: United States, 1996-2011. NCHS Data Brief 2013;124:1–8. 2. Declereq E, Sakala C, Applebaum S. Listening to Mothers II: Report of the Second National US Survey of Women’s Childbearing Experiences. New York, New York: Childbirth Connection, 2006.
8 3. Ecker J. Elective cesarean delivery on maternal request. JAMA 2013;309(18):1930–1936. 4. Coleman VH, Lawrence H, Schulkin J. Rising cesarean delivery rates: The impact of cesarean delivery on maternal request. Obstet Gynecol Surv 2009;64(2):115–119. 5. Lee YM, D’Alton ME. Cesarean delivery on maternal request: The impact on mother and newborn. Clin Perinatol 2008;35 (3):505–518, x. 6. Many A, Helpman L, Vilnai Y, et al. Neonatal respiratory morbidity after elective cesarean section. J Matern Fetal Neonatal Med 2006;19(2):75–78. 7. Zanardo V, Svegliado G, Cavallin F, et al. Elective cesarean delivery: Does it have a negative effect on breastfeeding? Birth 2010;37(4):275–279. 8. Shearer EL. Cesarean section: Medical benefits and costs. Soc Sci Med 1993;37(10):1223–1231. 9. Souza JP, Gulmezoglu A, Lumbiganon, P, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: The 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 2010;8:71. 10. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004;103(5 Pt 1):907–912. 11. Podulka J, Stranges E, Steiner C. Hospitalizations Related to Childbirth, 2008. HCUP Statistical Brief #110. Rockville, Maryland: Agency for Healthcare Research and Quality, 2011. 12. Kasper AS, Ferguson SJ. Breast Cancer: Society Shapes an Epidemic. New York, New York: Palgrave, 2002. xii, 388 p. 13. Weaver J, Magill-Cuerden J. “Too posh to push”: The rise and rise of a catchphrase. Birth 2013;40(4):264–271. 14. Neuendorf K. The Content Analysis Guidebook. Thousand Oaks, California: Sage Publications, 2002. 15. Feinstein A, Cicchetti D. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990;43(6): 543–549. 16. Cicchetti D, Feinstein A. High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol 1990;43(6):551–558. 17. Byrt T, Bishop J, Carlin J. Bias, prevalence and kappa. J Clin Epidemiol 1993;46(5):423–429. 18. Lantz C, Nebenzahl E. Behavior and interpretation of the kappa statistic: Resolution of the two paradoxes. J Clin Epidemiology 1996;49(4):431–434.
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19. Viera A, Garrett J. Understanding interobserver agreement: The kappa statistic. Fam Med 2005;37(5):360–363. 20. American College of Obstetrics & Gynecology. Cesarean Delivery on Maternal Request, 2013. 21. Childbirth Connection. Vaginal or Cesarean Birth: What is at Stake for Women and Babies? New York, New York: Childbirth Connection, 2012. 22. Kalish RB, McCullough L, Gupta M, et al. Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol 2004;103(6):1137–1141. 23. Bettes BA, Coleman VH, Zinberg S, et al. Cesarean delivery on maternal request: Obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007;109(1):57–66. 24. Charles SS. T, Mothers in the media: Blamed and celebrated— an examination of drug abuse and multiple births. Pediatric Nursing 2002;28(2):142–145. 25. Davis D-A. The politics of reproduction: The troubling case of Nadya Suleman and assisted reproductive technology. Trans Anthropol 2009;17(2):105–116. 26. Johnston DD, Swanson DH. Invisible mothers: A content analysis of motherhood ideologies and myths in magazines. Sex Roles 2003;49:21–33. 27. Campo-Engelstein L. Competing social norms: Why women are responsible for, but ultimately not trusted with contraception. Int J Appl Philos 2012;26(1):67–84. 28. De Konnick M. Reflections on the transfer of “progress”: The case of reproduction. In: Sherwin S, ed. The Politics of Women’s Health, Philadelphia, Pennsylvania: Temple University Press, 1998:150–177. 29. Burrow S. On the cutting edge: Ethical responsiveness to cesarean rates. Am J Bioeth 2012;12(7):44–52. 30. Blackman L. It’s down to you. Psychology, magazine culture and the governing of the female body. In: Reed L, Paula S, eds. Governing the Female Body: Gender, Health and Economies of Power, Albany, New York: State University of New York Press, 2010:19–36. 31. Morris T, McInerney K. Media representations of pregnancy and childbirth: An analysis of reality television programs in the United States. Birth 2010;37(2):134–140.
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Scheduling the Stork: Media Portrayals of Women’s and Physicians’ Reasons for Elective Cesarean Delivery Lisa Campo-Engelstein, PhD, Lauren E. Howland, MPH, Wendy M. Parker, PhD, and Paul Burcher, MD, PhD ABSTRACT: Background: Media interest in cesarean delivery has grown in recent years
driven both by rising cesarean delivery rates and the decision by the American College of Obstetrics and Gynecology (ACOG) to permit elective cesarean (EC) delivery. Methods: A content analysis of United States newspaper and magazine articles from 2000 to 2013 (n = 131 articles) was completed to understand how the news media portrays ECs. Results: The majority of articles (71.8%) emphasized reasons to support women having an EC, while 38.2 percent of the articles exhibited themes of physician support for ECs. Relatively few articles mentioned reasons against ECs either from the women’s perspective (11.5%) or the practitioners’ (3.8%). The most common themes given for women choosing ECs were convenience/scheduling (48.9%), avoidance of pain or fear of labor (29.8%), and physical harm to women from vaginal birth (17.6%). Doctors’ perspectives were less prevalent in the media than women’s perspectives, but when mentioned they were almost exclusively in support of ECs for reasons including avoiding malpractice (28.2%), avoiding physical harm to the woman or baby (16.8%), and timing/scheduling (14.5%). Discussion: Media coverage suggests ECs are widely accepted by both women and doctors, with women choosing an EC mainly for convenience/scheduling and fear. However, 43 percent of doctors surveyed by ACOG said they were not willing to perform the procedure, and surveys report that mothers rarely request an EC. (BIRTH 2015) Key words: decision making, elective cesareans, media portrayal, social norms
Elective cesareans (ECs), defined as cesareans performed without a medical indication, have garnered increased media attention due in large part to the surging rates of all cesareans. Almost a third of all infants born in the United States are born by way of cesarean (1). Although media interest in EC birth has been significant, the Listening to Mothers Study indicated that only 2 percent of primary cesarean deliveries were for
no medical reason (2). This survey found, however, that most both primary and repeat cesarean mothers indicated that their practitioner was the one who recommended a cesarean either before or during labor (2). Though the overall prevalence of ECs is still low and estimates vary, recent data suggest that the prevalence is about 3 percent of all deliveries (3). This percentage, however, may be increasing (4) and is still a
Lisa Campo-Engelstein, Assistant Professor, Alden March Bioethics Institute & OBGYN Department, Albany Medical College; Lauren E. Howland, Doctoral Student, Department of Epidemiology & Biostatistics, University at Albany; Wendy M. Parker, Assistant Professor, School of Arts and Sciences, Albany College of Pharmacy and Health Sciences; and Paul Burcher, Associate Professor, Alden March Bioethics Institute & OBGYN Department, Albany Medical College, Albany, NY, USA.
The authors consider that the first two authors should be regarded as joint First Authors. Address correspondence to Lisa Campo-Engelstein, PhD, 47 New Scotland Avenue, MC 153, Albany, NY 12208, USA. Accepted December 25, 2014 © 2015 Wiley Periodicals, Inc.
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2 cause for concern. Infants born by way of cesarean can face increased respiratory morbidity (5,6) and have a lower rate of initial breastfeeding (5,7), and some evidence suggests that there may be longer-term impacts on chronic disease (5). Maternal morbidity can be 5 to 10 times greater and maternal mortality is 2 to 4 times higher after a cesarean compared with vaginal birth (8– 10). Cesarean delivery is a major surgery for a woman and increases her risk of postpartum infection, increases her recovery time and hospital stay, and has potential longer-term influence on a woman’s future reproductive health (5). In addition to the health risks, cesareans are a costly surgical procedure—almost 1.6 times more expensive than a vaginal birth without complications (11). However, research with respect to ECs, their justification, and true prevalence remains limited (3,5). To properly address the issue, it is important that health care practitioners and public health professionals understand the causes behind their increasing frequency. The popular press is rife with explanations for the increase in ECs, although these explanations are not always grounded in empirical research. Nonetheless, it is important to analyze how the issue is being discussed and portrayed to the public since the media plays a large role in providing information for health issues, and reflects and produces cultural ideologies and norms, particularly about gender (12). For example, Weaver and Magill-Cuerden (13) examine the increasing use of the phrase “too posh to push” in United Kingdom newspapers and conclude that the ubiquity of this phrase contributes to the impression that many women are selecting ECs. Consequently, pregnant women may view ECs as a viable option for themselves as a result of the misinformation presented to them about the frequency of the procedure. To our knowledge, there have not been any studies of the United States media’s coverage of ECs. The goal of our project was to examine United States magazine and newspaper articles for the reasons given by women and physicians around ECs. We hypothesized that the women would cite reasons of pain avoidance and convenience, whereas physicians would cite fears of malpractice and liability. The comparison of women’s and physicians’ reasons for ECs will provide insight into how the larger social norms around motherhood and medicine are connected to ECs in the mass media.
Methods Collection of Articles Two databases, Lexus Nexus and Proquest, were used to obtain the articles examined in this study. Separate
searches were conducted on each platform to identify relevant articles. Six different search terms were included to obtain articles discussing the area of interest: “elective c-section,” “elective cesarean,” “planned c-section,” “planned cesarean,” “scheduled c-section,” and “scheduled cesarean.” This method was employed since there are many common terms that are used by lay media to describe ECs. Each search was limited to English language articles published in the United States from January 2000 to December 2013. For inclusion in the study, the article must contain some discussion of ECs, rather than just the sole mention of one of the search terms. Only articles discussing human pregnancies were included. An article was included if it discussed primarily healthy, singleton pregnancies, and was excluded if the focus was on mothers with a previous cesarean or those with preexisting medical conditions (e.g., HIV/AIDS). During the exclusion process, articles were removed from the sample if the central focus was maternal requests for a cesarean made during labor or an emergency cesarean, rather than maternal requests for a cesarean made before labor. Furthermore, articles that did not have a focus on delivery practices within the United States or were published in scholarly journals and clinical/professional magazines or newspapers were excluded from the study. In addition, the following types of articles were excluded from the sample: letters to the editor, advertisements, and reviews of products, books, classes, etc. Reprints or duplicate articles were excluded from the study. The initial search generated 290 newspaper and 183 magazine articles from Lexus Nexus and 150 newspaper and 180 magazine articles from Proquest. Each article was downloaded from its respective database and reviewed in its entirety to determine if it met the inclusion criteria. After the exclusion process, the final sample contained 57 newspaper and 12 magazine articles from Lexus Nexus, and 31 newspaper and 31 magazine articles from Proquest for a total of 131 articles.
Data Analysis and Coding The data analysis process required three steps to build the thematic framework for coding articles, verify our coding reliability, and finalize the coding of all articles in our sample. A sample of 10 articles was selected to prepare an adequate coding framework to examine the decision-making process of women and physicians in regard to ECs. Two coders (LCE and LEH) read the first four sample articles together, chosen for their extensive length. Together they compiled a list of themes they had seen in the four articles. Each coder
8 3. Ecker J. Elective cesarean delivery on maternal request. JAMA 2013;309(18):1930–1936. 4. Coleman VH, Lawrence H, Schulkin J. Rising cesarean delivery rates: The impact of cesarean delivery on maternal request. Obstet Gynecol Surv 2009;64(2):115–119. 5. Lee YM, D’Alton ME. Cesarean delivery on maternal request: The impact on mother and newborn. Clin Perinatol 2008;35 (3):505–518, x. 6. Many A, Helpman L, Vilnai Y, et al. Neonatal respiratory morbidity after elective cesarean section. J Matern Fetal Neonatal Med 2006;19(2):75–78. 7. Zanardo V, Svegliado G, Cavallin F, et al. Elective cesarean delivery: Does it have a negative effect on breastfeeding? Birth 2010;37(4):275–279. 8. Shearer EL. Cesarean section: Medical benefits and costs. Soc Sci Med 1993;37(10):1223–1231. 9. Souza JP, Gulmezoglu A, Lumbiganon, P, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: The 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 2010;8:71. 10. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004;103(5 Pt 1):907–912. 11. Podulka J, Stranges E, Steiner C. Hospitalizations Related to Childbirth, 2008. HCUP Statistical Brief #110. Rockville, Maryland: Agency for Healthcare Research and Quality, 2011. 12. Kasper AS, Ferguson SJ. Breast Cancer: Society Shapes an Epidemic. New York, New York: Palgrave, 2002. xii, 388 p. 13. Weaver J, Magill-Cuerden J. “Too posh to push”: The rise and rise of a catchphrase. Birth 2013;40(4):264–271. 14. Neuendorf K. The Content Analysis Guidebook. Thousand Oaks, California: Sage Publications, 2002. 15. Feinstein A, Cicchetti D. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990;43(6): 543–549. 16. Cicchetti D, Feinstein A. High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol 1990;43(6):551–558. 17. Byrt T, Bishop J, Carlin J. Bias, prevalence and kappa. J Clin Epidemiol 1993;46(5):423–429. 18. Lantz C, Nebenzahl E. Behavior and interpretation of the kappa statistic: Resolution of the two paradoxes. J Clin Epidemiology 1996;49(4):431–434.
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19. Viera A, Garrett J. Understanding interobserver agreement: The kappa statistic. Fam Med 2005;37(5):360–363. 20. American College of Obstetrics & Gynecology. Cesarean Delivery on Maternal Request, 2013. 21. Childbirth Connection. Vaginal or Cesarean Birth: What is at Stake for Women and Babies? New York, New York: Childbirth Connection, 2012. 22. Kalish RB, McCullough L, Gupta M, et al. Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol 2004;103(6):1137–1141. 23. Bettes BA, Coleman VH, Zinberg S, et al. Cesarean delivery on maternal request: Obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007;109(1):57–66. 24. Charles SS. T, Mothers in the media: Blamed and celebrated— an examination of drug abuse and multiple births. Pediatric Nursing 2002;28(2):142–145. 25. Davis D-A. The politics of reproduction: The troubling case of Nadya Suleman and assisted reproductive technology. Trans Anthropol 2009;17(2):105–116. 26. Johnston DD, Swanson DH. Invisible mothers: A content analysis of motherhood ideologies and myths in magazines. Sex Roles 2003;49:21–33. 27. Campo-Engelstein L. Competing social norms: Why women are responsible for, but ultimately not trusted with contraception. Int J Appl Philos 2012;26(1):67–84. 28. De Konnick M. Reflections on the transfer of “progress”: The case of reproduction. In: Sherwin S, ed. The Politics of Women’s Health, Philadelphia, Pennsylvania: Temple University Press, 1998:150–177. 29. Burrow S. On the cutting edge: Ethical responsiveness to cesarean rates. Am J Bioeth 2012;12(7):44–52. 30. Blackman L. It’s down to you. Psychology, magazine culture and the governing of the female body. In: Reed L, Paula S, eds. Governing the Female Body: Gender, Health and Economies of Power, Albany, New York: State University of New York Press, 2010:19–36. 31. Morris T, McInerney K. Media representations of pregnancy and childbirth: An analysis of reality television programs in the United States. Birth 2010;37(2):134–140.
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4 Table 1. Coding Framework Frequency
Description
Mothers’ reasons for choosing an elective cesarean 48.9% Convenience, scheduling for the family, specific date desired, specific doctor desired
7.6% 29.8%
Sexual function, harm to vagina, vaginal preservation Avoid the pain and length of labor, believe that labor is difficult, fear of labor or labor pain
3.1%
Large baby (10 + pounds) expected and the associated pain and/or vaginal preservation
17.6%
Incontinence, pelvic organ prolapse (POP), physical harm to the woman
12.2%
“Too posh to push,” designer birth, vanity, preserving their figure
9.2%
Avoiding harm to baby, increasing benefits for baby Control how to give birth (cesarean)
7.6%
4.6% 6.1%
16.0%
5.3%
Avoid an emergency cesarean, easier to do ahead of time than wait and need an emergency cesarean Lack of information/counseling or misinformation about cesarean and vaginal birth such as harm of a cesarean delivery and benefits of vaginal birth General risks/harm to the woman or the baby (not specified), general safety concerns Discomfort, uncomfortable during pregnancy
Mothers’ reasons against choosing an elective cesarean 7.6% Against medicalization, want a natural experience, believe women are able to give birth and have confidence in women’s bodies 4.6%
Physical consequences for women as a result of surgery such as longer recovery, infection, decreased mobility, pelvic organ prolapse, and incontinence
0.8%
Vaginal birth is best for the baby, avoiding harm to baby, increasing benefits for baby
5.3%
Relationship between the mother and the child suffers as a result of a cesarean, vaginal birth is emotionally more satisfying
Example “The idea of an elective c-section in today’s busy world, where so many women continue to work, “is no longer frowned upon. . . . Most women want the convenience. They want to know when the baby is coming.” “Honestly, I didn’t want any [vaginal] tearing.” “Women are made to fear birth, and, as a consequence, they go after everything available to speed labor up, ease the pain and get over with the whole process.” “[She] got the news that she had a very big baby—close to, if not more than, 10 pounds. . . . She opted to schedule her cesarean for the next day.” “Fear of incontinence is one reason some pregnant women schedule an elective c-section, even though they could deliver vaginally.” “Certain celebrities have even reportedly scheduled cesareans 3 or 4 weeks before their due date, to minimize stretch marks and saggy loose skin.” “Some of the reasons women give are that they believe there is less risk of . . . injury to the baby.” “Mothers over 35 are more likely to have planned c-sections . . . possibly because they want more control over the birth process.” “I had heard horror stories of women going in and having to have an emergency c-section [anyway].” “Why had Dr. C offered a cesarean to me? . . . Why didn’t he discuss other options? . . . Why didn’t he tell me if I didn’t try to have this baby vaginally, I could end up having all my babies by cesarean?” “The vast majority of women merely agreed with the decision . . . or wanted [a cesarean section] in belief that it would be safer for themselves or their infants.” “When I inquired if radical abdominal surgery was really the way to go, choruses of elective c-section vets swore by it, saying . . . they were spared the last torturous weeks of pregnancy.” “I have never needed any study to prove to me that vaginal birth is anything but absolutely normal, that a woman’s body is designed specifically for this purpose and that the survival of our species depends on this perfect design.” “Dach had a c-section . . . she’d prefer a vaginal birth. ‘Even this week, I’m still having trouble picking up the baby,’ she said 13 days after the surgery. . .‘With vaginal births, you can see someone pop right back up and hold the baby. Recovery is much faster.’” “Medically necessary cesareans are one thing, but to give blanket approval to elective cesareans, instead of working with a mother to have a vaginal birth, could be dangerous to the health of the mother and the baby.” “Ms. Charles had a vaginal birth for her second baby, and said she preferred that experience. The c-section ‘was more a matter of being robbed of the whole experience of giving birth.’’’
(continued)
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Table 1 (continued) Frequency
Description
1.5%
Not medically indicated, not necessary, needless, questionable
0.8%
Control how to give birth (vaginal)
Physicians’ reasons for performing an elective cesarean 28.2% Malpractice, lawsuits 3.1% 14.5%
11.5%
1.5%
16.8%
Financial benefits such as making more money or making it quicker Convenience, scheduling, better work hours for the physician Support women’s choice, women’s autonomy and women’s preference, listen to what the woman wants Avoid an emergency cesarean, easier to do ahead of time than wait and need an emergency cesarean
Avoid physical harm to the women, concern for high-risk women, avoiding harm to the baby
Physicians’ reasons against performing an elective cesarean 0.8% Against medicalization, favor a natural experience, believe women are able to give birth and have confidence in women’s bodies 3.1% Not medically indicated, not necessary, needless, questionable
Discussion of choice regarding elective cesarean 18.3% Importance of choice, women should have a choice 3.8%
Limits of choice, should be solely a women’s decision, paternalism sometimes justified
publications were most likely to focus on avoiding the pain of labor (39.1%) and the convenience, timing theme for women (34.8%). Over two-thirds of specialty (69.6%) and 72.2 percent of general publications discussed women’s choices for ECs. Slightly more than half of the newspaper articles contained the theme of women’s reasons for having ECs. The most common reasons given were convenience, scheduling, or desire for a specific date or doctor (54.6%). These reasons were the most frequently discussed theme by a significant margin. Magazine pieces in contrast were more diverse: a full third focused on the theme of convenience of scheduling
Example “Because Hoover believed her c-section wasn’t medically necessary, she later did hours of research and created a desired delivery plan before she had her next three children, all of whom were delivered vaginally.” “Gryczka wanted more control the second time around. She hired a local midwife and planned for an at-home birth.” “Doctors often feel they must do a c-section to protect themselves from a malpractice suit.” “Hospitals and doctors make more money from c-section procedures.” “It means they can split their time . . . on a timetable of their choosing, and reduces the chance that they will be required to attend births at inconvenient times.” “A private-practice physician . . . said more women are requesting repeat c-sections. She said she takes a neutral approach and allows her patient to make the decision.” “But while physicians acknowledge room for debate . . . some noted that planned cesareans generally produced better outcomes than emergency procedures performed after problems arise.” “Some physicians believe cesarean sections pose fewer health risks and want to make elective c-section an option for all mothers.” “Labor is OK, and they’ll survive. Most births go very well; there’s no good evidence now to circumvent Mother Nature.” “Chairman of obstetrics and gynecology . . . is up front in saying that vaginal delivery is the better choice for childbirth, and he sees no evidence to recommend a nonmedically driven cesarean.” “Proponents of so-called elective c-section or cesarean on demand argue that women should have a say in how they give birth.” “‘The issue is, we’re not always listening to the patients,’ he said. ‘But sometimes what they want isn’t what’s best for them.’”
(37.2%), another 32.6 percent focused on the pain of labor, and 27.9 percent discussed the “too posh to push” idea. Fewer magazine pieces focused on the doctor’s perspective on ECs.
Discussion Our study demonstrates that media imagery perpetuates the notion that maternal-requested cesareans are a common practice for reasons of convenience. Yet, this media interest and perspective are not supported by survey and interview data that are found to date (4,21).
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Fig. 1. Percentage of articles expressing major themes. Kalish et al examined intrapartum cesarean deliveries at one facility over a 6-month period and found that cesarean delivery was offered for 13 percent of cases without any clear medical indication; women requested a cesarean in 8.8 percent of cases (22). Consequently, ECs may be more a result of physician preferences than women’s choices. This also correlates with the Listening to Mothers data that indicate women rarely request an EC; rather, in most cases, physicians are the ones to recommend a cesarean (2). Bettes et al detail the results of an ACOG survey about practice patterns and opinions of ECs by OB/ GYNs that demonstrate the complexity of the topic and doctors’ perspectives on approaching patients who request for an EC (23). The ACOG survey results suggest that women’s education around vaginal childbirth may be key to changing the cesarean trend, yet women’s education did not emerge as a theme in our study of United States newspaper and magazines, indicating that the national media is not focusing on women’s education around ECs at this time. A great deal of uncertainty and limited data in the medical literature around the risks and benefits of ECs are observed, yet some of the major risks and benefits associated with ECs are demonstrated by the themes in our study. For instance, a 2012 Childbirth Connections report (21) attempted to compile the best scientific evidence on cesarean versus vaginal births and concluded that while there is good evidence for many of the concerns around cesarean, the evidence is mixed in many cases. In short, the picture is more complicated and nuanced than would be evident from newspaper and magazine headlines.
In a related way, the topic of ECs taps into broader normative beliefs about being a good mother and the complex roles of women in society. The United States media typically treats “traditional” women (e.g., white, middle to upper class, heterosexual, married, able-bodied, Christian) as the cultural ideal for motherhood (24– 26). While compelling debates remain ongoing about women’s role in the workforce and childcare access and responsibility (e.g., the “mommy wars” and “can women have it all” discussions) (24–26), continued social perceptions of women place an emphasis on their perceived physical and emotional weakness that requires medical intervention especially around childbirth. Discussion of ECs may be more common in the media because it aligns with these broader cultural debates about what constitutes a good mother. There is a dominant social norm that good mothers are self-sacrificing (27) and women who violate this norm are often vilified by the media (24–26). Women who chose ECs were sometimes viewed as selfish in the articles in our sample because they were seen as prioritizing themselves and their careers over their children. However, other media portrayals were sympathetic toward women choosing ECs for convenience by acknowledging how difficult it is for women to balance their careers and family life. Nevertheless, the importance of the physician in influencing women’s decision making to undergo an EC is rarely discussed in any form of media. Reducing women’s selection of ECs to convenience places the locus of blame on women and fails to recognize the social constraints in which they are making such a decision, such as the physician–patient dynamic or their own social roles as wife, worker, and mother.
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The prevalence of fear-of-labor theme is not surprising, given the media portrayal of childbirth as extremely painful and dangerous in both fictional TV shows and movies and in reality TV shows such as “A Baby Story” and “Birth Day.” Underlying many women’s fear of labor, although not expressed in the media, is how the ubiquity of technological interventions during pregnancy and childbirth engenders feelings of incompetence among women with respect to their ability to engage in reproductive activities without medical assistance (21,28). Today, medical interventions are a normal part of childbearing experiences (e.g., fetal monitoring), which may contribute to women and physicians losing faith in physiologic birth (13,29). The medicalization of reproduction and childbirth contributes to high cesarean delivery rates, including ECs, and makes it easy and acceptable (and sometimes even socially required) to turn to cesarean delivery without much medical justification. As Sylvia Burrow explains, “Commonly recognized uses of technology in the antenatal and prenatal period foster the current social and medical view that women’s reproduction is an event intimately engaged with technology. . . . The normalization of reproductive technology elevates its importance, creating pressures on women to pursue it” (29, p 48). In short, women’s fear of labor may in fact be an expression of their fear of childbirth without technology. However, the articles did not discuss women’s fear within the framework of technology and medicalization, which is not surprising since these articles are in the lay literature and the focus of these articles was on women’s personal choices rather than how broader social factors subtly influence individual decision making. The social acceptance of the medicalization of childbirth is also reflected in our results, in that the doctors discussed in the articles were almost exclusively in support of ECs. The diversity of perspectives regarding EC means that there is little consensus about the advisability of this procedure. However, in our analysis, women’s autonomy was only the fourth most common reason (11.5%) physicians gave for performing ECs behind malpractice (28.2%), avoiding physical harm to the woman or baby (16.8%), and timing or scheduling for the doctor (14.5%). While there are perspectives on either side from clinical guidance on ECs to women’s health advocates that argue that women should resist scheduling childbirth and the “too posh to push” mantra and advocate for a vaginal birth for their child, there is less consensus in the medical literature or in advocacy circles than is preferred. In fact, the most recent ACOG statement on ECs argues that while performing ECs may at times be ethically permissible, in general ECs should be discouraged because the risks of vaginal birth are less than the risks of cesarean
birth (20). Our results illustrate that ECs are not being resisted within mainstream media in a substantial way. But is there another type of advocacy that women are taking up when they schedule the birth of their children? This study cannot answer that question but raises new questions around who is choosing to have ECs, whether women truly understand their options and risks, and whether more accurate or additional information could change these results. A great deal of academic literature exists on the decision-making process of electing for a cesarean, but how this scientific literature is conveyed in the media has not been a focus. This content analysis is subject to limitations in that we are exploring media portrayals of ECs and not surveying or speaking directly with expectant mothers, current mothers, or physicians to understand their rationale when deciding for or against EC. Other studies have included those perspectives; we are more concerned with how the facts and complexity of decision making is translated into headlines in broader media contexts.
Conclusion Our results demonstrate that much of the media attention to this topic has been devoted to the idea that women are electing to have cesareans out of convenience, scheduling, and fear concerns, with little clinical information that describes the potential risks of cesareans or complicates that decision in any meaningful way. We believe these themes were most frequent because they reflect and reinforce dominant societal perspectives with regard to women and mothers and technological interventions during childbirth as the standard. Additionally, these themes are simpler and more sensational than the nuanced and complex process of decision making that actually occurs with respect to cesarean. While “juicy” headlines may be good for newspapers and magazines, they may also be misleading to the public. Media content and imagery can alter self-perceptions and influence health behaviors, especially for women (2,30,31). The media portrayal of ECs as normal and even good from both women’s and doctors’ perspectives may lead women to choose ECs, thereby increasing the already high cesarean rate.
References 1. Osterman MJ, Martin JA. Changes in cesarean delivery rates by gestational age: United States, 1996-2011. NCHS Data Brief 2013;124:1–8. 2. Declereq E, Sakala C, Applebaum S. Listening to Mothers II: Report of the Second National US Survey of Women’s Childbearing Experiences. New York, New York: Childbirth Connection, 2006.
8 3. Ecker J. Elective cesarean delivery on maternal request. JAMA 2013;309(18):1930–1936. 4. Coleman VH, Lawrence H, Schulkin J. Rising cesarean delivery rates: The impact of cesarean delivery on maternal request. Obstet Gynecol Surv 2009;64(2):115–119. 5. Lee YM, D’Alton ME. Cesarean delivery on maternal request: The impact on mother and newborn. Clin Perinatol 2008;35 (3):505–518, x. 6. Many A, Helpman L, Vilnai Y, et al. Neonatal respiratory morbidity after elective cesarean section. J Matern Fetal Neonatal Med 2006;19(2):75–78. 7. Zanardo V, Svegliado G, Cavallin F, et al. Elective cesarean delivery: Does it have a negative effect on breastfeeding? Birth 2010;37(4):275–279. 8. Shearer EL. Cesarean section: Medical benefits and costs. Soc Sci Med 1993;37(10):1223–1231. 9. Souza JP, Gulmezoglu A, Lumbiganon, P, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: The 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 2010;8:71. 10. Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004;103(5 Pt 1):907–912. 11. Podulka J, Stranges E, Steiner C. Hospitalizations Related to Childbirth, 2008. HCUP Statistical Brief #110. Rockville, Maryland: Agency for Healthcare Research and Quality, 2011. 12. Kasper AS, Ferguson SJ. Breast Cancer: Society Shapes an Epidemic. New York, New York: Palgrave, 2002. xii, 388 p. 13. Weaver J, Magill-Cuerden J. “Too posh to push”: The rise and rise of a catchphrase. Birth 2013;40(4):264–271. 14. Neuendorf K. The Content Analysis Guidebook. Thousand Oaks, California: Sage Publications, 2002. 15. Feinstein A, Cicchetti D. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990;43(6): 543–549. 16. Cicchetti D, Feinstein A. High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol 1990;43(6):551–558. 17. Byrt T, Bishop J, Carlin J. Bias, prevalence and kappa. J Clin Epidemiol 1993;46(5):423–429. 18. Lantz C, Nebenzahl E. Behavior and interpretation of the kappa statistic: Resolution of the two paradoxes. J Clin Epidemiology 1996;49(4):431–434.
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19. Viera A, Garrett J. Understanding interobserver agreement: The kappa statistic. Fam Med 2005;37(5):360–363. 20. American College of Obstetrics & Gynecology. Cesarean Delivery on Maternal Request, 2013. 21. Childbirth Connection. Vaginal or Cesarean Birth: What is at Stake for Women and Babies? New York, New York: Childbirth Connection, 2012. 22. Kalish RB, McCullough L, Gupta M, et al. Intrapartum elective cesarean delivery: A previously unrecognized clinical entity. Obstet Gynecol 2004;103(6):1137–1141. 23. Bettes BA, Coleman VH, Zinberg S, et al. Cesarean delivery on maternal request: Obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007;109(1):57–66. 24. Charles SS. T, Mothers in the media: Blamed and celebrated— an examination of drug abuse and multiple births. Pediatric Nursing 2002;28(2):142–145. 25. Davis D-A. The politics of reproduction: The troubling case of Nadya Suleman and assisted reproductive technology. Trans Anthropol 2009;17(2):105–116. 26. Johnston DD, Swanson DH. Invisible mothers: A content analysis of motherhood ideologies and myths in magazines. Sex Roles 2003;49:21–33. 27. Campo-Engelstein L. Competing social norms: Why women are responsible for, but ultimately not trusted with contraception. Int J Appl Philos 2012;26(1):67–84. 28. De Konnick M. Reflections on the transfer of “progress”: The case of reproduction. In: Sherwin S, ed. The Politics of Women’s Health, Philadelphia, Pennsylvania: Temple University Press, 1998:150–177. 29. Burrow S. On the cutting edge: Ethical responsiveness to cesarean rates. Am J Bioeth 2012;12(7):44–52. 30. Blackman L. It’s down to you. Psychology, magazine culture and the governing of the female body. In: Reed L, Paula S, eds. Governing the Female Body: Gender, Health and Economies of Power, Albany, New York: State University of New York Press, 2010:19–36. 31. Morris T, McInerney K. Media representations of pregnancy and childbirth: An analysis of reality television programs in the United States. Birth 2010;37(2):134–140.
