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 C-section aftershocks 
The following is one in an ongoing series of columns entitled What Doctors Don't Tell You by . View all columns in series

There is some evidence for this.
A research group at Imperial College in London recently collated the UK's CS data according to social class, and found that elective CS operations are not so much the province of the top social classes, but rather more a no-go area for the lower classes-as they put it: "not a case of too posh to push", but "too proletarian for a caesar-ean" (BMJ, 2004; 328: 1399).

Although fear and distaste for labour may play a part, another is that doctors often pressgang women into having 'just-in-case' caesareans for dubious reasons, such as the fact that the baby is large, is slightly overdue or in a breech position.

CS allows the doctor to do 'daylight obstetrics', obviating the need to hang around for a woman to deliver her baby, often in the middle of the night (birth rates peak at about 4 o'clock in the morning). While labour can last for hours, a typical CS is usually done and dusted in less than 40 minutes.

Money's a factor, too. In the private American health system, doctors and hospitals find CS more profitable than natural births, according to a World Health Organization (WHO) report. "In the USA, the profit motive explains hospital-specific CS rates that are high even by US standards" (Stephenson P. International Differences in the Use of Obstetrical Interventions. Copenhagen: WHO European Regional Office, 1992). That report came out 15 years ago-and CS rates have soared since then.

Another factor is litigation. "Some caesareans are clear medical necessities," says Professor Joel Evans of the Albert Einstein College in New York, "but others lie in a gray area, where there are other possible medically appropriate options. Now, more and more physicians find it easier to follow the growing trend of just go ahead and do it, avoid a lawsuit."

Advances in surgery and anesthesia have made an operation that was almost always fatal as recently as the mid-19th century a routine one 150 years later. And yet, CS is still not to be undertaken lightly. The most recent mortality figures come from a huge study on over 150,000 elective CS operations in Britain, and shows that mothers run nearly three times the risk of dying from a CS than from a natural delivery (Lancet, 1999; 354: 776).

Other risks to the mother include the potential problems associated with any major abdominal surgery-anesthesia accidents, damage to blood vessels, and injury to the bladder, uterus or other organs. Also, perhaps surprisingly, CS comes with a much higher risk of infection than natural birth (Cochrane Database Syst Rev, 2002; 3: CD000933). Other, longer-term risks include possible decreased fertility, ectopic pregnancy and miscarriage (Lancet, 2003; 362: 1779-84).

But it's the newly discovered risk to the newborn child that has so shocked obstetricians. The report recently published in a peer-reviewed journal was a four year survey of all CS operations performed in the US from 1998 to 2001. The researchers, led by Dr Marian MacDorman of the Centers for Disease Control and Prevention (CDC), studied the records of nearly 5.8 million live births and almost 12,000 subsequent infant deaths, and found a nearly three-fold increase in the death rates of elective CS babies within four weeks of birth. The figures are relatively small, but nevertheless highly significant. While there were only 62 deaths per 100,000 natural births, a staggering 177 babies died within a few weeks of CS surgery (Birth, 2006; 33: 175).

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