Giving birth in the USA has become increasingly controversial, especially for women hoping to have a natural and intervention-free birth. Hospitals are becoming increasingly dependent on medicalized birth and as a response, many women are turning to alternatives including delivering at free-standing birth centers and home births. Meanwhile, home births continue to be threatened by state legislation and many birth centers are closing due to high insurance rates.

April is Cesarean Awareness Month. According to the World Health Organization, “Cesarean section rates should range from about 5% to 15% in any facility, depending on its level.” With a 31.8 percent Cesarean rate in the US (nearly one third of women give birth surgically), many questions are arising regarding the necessity and safety of Cesarean sections. C-sections can be a life saving procedure in an emergency and because of the advances of medicine in the last century, many babies have been born alive and healthy who might not have survived otherwise. However a C-section, like any major surgery, can be dangerous for the mother and the baby and can add risk rather than reduce it when the procedure is done unnecessarily. Further, many other forms of medical interventions pushed in hospitals such as induction and use of pain medication can increase the need for a C-section..

I have put together some maps that may help shed light on the subject and even help women looking for alternatives to a hospital birth.

C-Section Rates
Not many states publish C-section rates at the county level and it is difficult to find rates for individual hospitals. New Jersey does have public rates by hospital. The map below shows those rates. What is alarming is that there is such a wide range of rates from hospital to hospital (18% to 62%), even when they are very close to each other geographically. For a procedure that is meant for emergencies, it is not logical that women in different hospitals would have such different chances in ending up in surgery. One major factor in this discrepancy is the individual hospital’s policy on Vaginal Birth after Cesarean (VBAC). Other hospital or individual OB protocols have an influence such as limiting the time of labor or use of drugs to augment labor.

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Birth Centers
This next map shows C-section rates by state and the locations of birth centers throughout the US. This map does show a spatial trend in C-section rates with the South and much of the Northeast and West Coast experiencing the highest rates and the group of states including New Mexico, Arizona, Utah, Colorado, Wyoming, and Idaho with the lowest rates. It is difficult to determine a certain relationship between a state’s C-section rate and the number of birth centers. Some states may have more supportive policies towards home birth such as New Mexico and therefore do not have the demand for birth centers. Other states, where the C-section rate is high, have many birth centers because women are looking for alternatives, such as in Florida. Also, more rural states may have more birth centers because of the long distances to hospitals. There are probably not enough birth centers anywhere for them to have a significant impact on the C-section rate.

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To show the number of birth centers normalized by the population of each state, the map below shows the total number of births divided by the number of birth centers. In this map, the blue states have no birth centers. The white states have the most for the population and the orange states have the least number of birth centers for the population.

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Homebirth
What used to be a normal custom, home births have become controversial to the point of being outlawed in many states, even though studies have shown that for low risk births, home births are as safe as hospital births and much less likely to end up with unnecessary medical intervention. While parents can not be persecuted for having their baby at home (although sometimes may be investigated by social services for neglect), the midwives who attend home births are in many states doing so against state laws and can face jail time. The next map shows the legal status of these mid-wives, know as Direst-Entry Midwives, for each state. The blue states are where it is legal and regulated by the state and then the others are various levels of legality with the dark orange states being the ones where home births are totally illegal. The dots on the map show the C-section rates for each state. Here you do see some relationship between the C-section rate and the legality of home birth.

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International Birth
While the US is know for having some of the most advanced medicine in the world, we rank below 45 other countries in our infant mortality rate which is 6.26. This is mostly due to a lack of access to health care however it does not speak well for the form of highly medicalized maternity care practiced in this country. Countries such as the Netherlands where home births and drug free births are more common have much lower rates of infant mortality (4.73). Also developed countries with lower C-section rates (12% in the Netherlands and 18% in France) tend to have lower infant mortality rates. This last map shows the world infant mortality rate rankings (with rank 1 having the highest rate) as well as some country’s C-section rates. C-section rates are not available for all countries and some of the rates shown on the map are from the 1990’s.

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What is most important is that the choice of birth place and method is left up to the women, which is less and less the case in the US. Policies against home births and VBACS and medical staff that push induction, C-sections, use of forceps and other interventions take away the ability of a mother to have a natural and normal birth. While all of these procedures are necessary in certain circumstances, they are abused and too often the mother is not informed of risks and other options. Further, alternatives are being taken away from mothers by state legislation. Check out these maps to find out the legality of home birth and the C-section rate in your state, to find the birth center nearest you, or to just learn more on the subject.

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