The Cesarean Delivery Question We Never Ask

We argue endlessly about whether there are too many cesarean deliveries. That is the wrong fight — the real question is whether each one, done or not done, was right.

Picture two women in the same hospital on the same day. One has a cesarean delivery she did not need. The other needed one and did not get it in time. We have a word for the first woman: unnecessary. We have no word for the second. That silence is the whole problem.

For years, people have argued about a single number: the cesarean delivery rate. Are there too many cesarean deliveries? It is the wrong question. A rate only tells you how often the surgery happened. It says nothing about whether it should have.

Here is the question that matters. Every cesarean delivery that is done, was it the right call? And every cesarean delivery that is not done, was that the right call too? Both are decisions. Both can be wrong. We spend almost all our attention on the first and almost none on the second.

Look at three wealthy countries. In the United States, about 32 out of every 100 births in 2024 were cesarean deliveries. In Germany, it was about 33 out of 100 in 2023, the highest in that country’s history. In England, it is now about 42 out of 100.

That is a huge gap. Are English babies really sicker than American babies? Are English mothers weaker? No. The number mostly reflects local habits, fear of lawsuits, and how a hospital is run, not what mothers and babies actually need. And when you compare countries, the ones with more cesarean deliveries do not have fewer baby deaths. Chasing the rate misses the point.

We count the cesarean delivery that should not have happened. We do not count the one that should have. And that second mistake is invisible. A low rate can look like good care while babies are being harmed.

England already lived this. In 2022, an official review of hospitals in Shrewsbury and Telford found something chilling. For twenty years, those hospitals worked to keep their cesarean delivery rate low, and they were proud of it. The review tied serious failures to the deaths of more than 200 babies and nine mothers. Some of that harm happened because a cesarean delivery that could have helped was delayed or never done. Soon after, England told its hospitals to stop treating a low cesarean delivery rate as a goal.

A cesarean delivery that is wrongly avoided has a face. It is the baby whose heartbeat is dropping while everyone waits. It is the shoulder that gets stuck during birth. It is the baby who dies during labor when a timely cesarean delivery would have prevented it. Nobody keeps a list of the cesarean deliveries we should have done. We should.

And England is still failing, now from the other side. In June 2026, a national investigation led by Baroness Amos looked at 12 hospitals. In every one, it found women who were not listened to and were shut out of decisions about their own care. Shrewsbury kept its cesarean delivery rate low and babies died. Today England’s rate is high. The number swung all the way across. What never got fixed was the decision itself.

There is one more decision that leads straight to the operating room: starting labor with medicine instead of waiting for it to begin on its own. This is called induction, and it is rising fast. In the United States, about 35 out of every 100 labors were started this way in 2024, up from 25 out of 100 in 2016. In England it is about 1 in 3.

Starting labor early is a real decision, just like a cesarean delivery. A failed induction is one of the most common paths to an unplanned cesarean delivery. When labor is started for a weak reason, a due date on the calendar, a guess that the baby is big, a schedule that is convenient, and it ends in surgery, that is two interventions, and neither was clearly needed.

We were promised that more inductions would mean fewer cesarean deliveries. It did not happen. As inductions climbed, the cesarean delivery rate did not fall. A woman’s chance of her first cesarean delivery has actually gone up since 2019. More inductions, not fewer cesarean deliveries.

Here is my take. Stop arguing about whether the rate is too high or too low. Ask whether each choice was right. Every cesarean delivery that is done should answer one simple question: why? Every cesarean delivery that is not done should answer the same question. So should every induction that comes before them.

A woman deserves the full truth before labor, not a number and not a shrug. Tell her what the evidence shows. Tell her what you would recommend, and why. Hiding behind “it is your choice” is not respect. It is walking away. That conversation belongs before the emergency, while there is still time to think.

A number cannot protect a mother or her baby. A good reason can, offered to her honestly and in time. The newest national report says the same from the other direction: the harm was never the number, it was shutting women out of the choice. The day we take both mistakes seriously, the cesarean delivery wrongly done and the cesarean delivery wrongly skipped, is the day this debate finally grows up.

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References

1. National Center for Health Statistics. Births: provisional and final natality data, 2023–2024. Centers for Disease Control and Prevention; 2024–2025. (US cesarean 32.4% in 2024; first cesarean delivery rate 22.9%, up since 2019.)

2. National Center for Health Statistics. Induction of Labor Increases in the United States: 2016–2024. NCHS Data Brief No. 554. Centers for Disease Control and Prevention; March 2026.

3. Statistisches Bundesamt (Destatis). Fast ein Drittel aller Geburten im Jahr 2023 durch Kaiserschnitt. Press release; May 2025. (German cesarean delivery rate 32.6% in 2023.)

4. NHS England Digital. NHS Maternity Statistics, England 2023–24; 2024. National Maternity and Perinatal Audit. State of the Nation report; 2025. (England cesarean deliveries ~42%; induction ~33%.)

5. Ockenden D. Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust: Final Report; 2022.

6. Amos V. Independent National Maternity and Neonatal Investigation: Final Report and Recommendations. England; 30 June 2026.