The term “misogyny” is hardly ever used here, but it aptly describes the problem when a pregnant woman comes into the delivery room around the 40th week of pregnancy with regular contractions and wants a caesarean section as the mode of birth. Refusal is almost the rule and the persuasion to have a vaginal birth begins. In this situation, the pregnant woman can hardly “resist”. The right to self-determination, enshrined in the Basic Law, is thus disregarded. Consequently, the Federal Court of Justice has ruled that the pregnant woman herself decides on the mode of birth if this does not pose a risk to the child.

• Misogyny reactions

• Caesarean section

• Persuasion

• Vaginal birth

Wenderlein JM (2024) C-Section on Demand-Avoiding Misogyny Reactions. Ann Pregnancy Care 6(1): 1014.

The term “misogyny” is hardly ever used here, but it aptly describes the problem when a pregnant woman comes into the delivery room around the 40th week of pregnancy with regular contractions and wants a caesarean section as the mode of birth. Refusal is almost the rule and the persuasion to have a vaginal birth begins. In this situation, the pregnant woman can hardly “resist”. The right to self-determination, enshrined in the Basic Law, is thus disregarded. Consequently, the Federal Court of Justice has ruled that the pregnant woman herself decides on the mode of birth if this does not pose a risk to the child.

Section-bashing (literally hitting, attacking) is partly responsible for this: prejudiced attacks on this mode of birth. This causes considerable costs for our healthcare system every year, which has so far been ignored or concealed. If midwives and doctors in the delivery room say: “We don’t do elective caesarean sections” instead of asking women for the reasons, then forensic problems are to be expected. According to the author’s experience in two university delivery rooms with regular activity there (2,400 births per year), the pregnant women gave convincing reasons for elective caesarean sections. These included the fear of injury to the genital area. Given the one-to-one risk of pelvic floor damage resulting in urinary incontinence, this is justified. No man would ever allow such a risk to his genital area.

C-Section Education now based on Swedish Data

According to Swedish data from a registry study from 2022 [1], women who have had a cesarean section have a similarly stable pelvic floor as women without a history of childbirth. This was estimated via prolapse and descensus operations (21 times more frequent after vaginal birth), the “tip of the iceberg” urinary incontinence (UI). Depending on the severity of HI, it can lead to reduced performance in many areas of life and reduced quality of life, and even shortened life expectancy by years due to social isolation.

The 1st vaginal birth in particular leads to pelvic floor damage [1]. Incontinence 1 to 4.5 in men to women no longer acceptable These Swedish data confirm the hypothesis: without vaginal birth, the urinary incontinence frequency ratio of 1 to 4.5 in men to women could be significantly reduced. This is relevant in the long term for women with an average life expectancy of 82 years. Pelvic floor problems due to pregnancy usually disappear quickly after birth and are rather marginal in terms of numbers [1].

Hypothetically, imagine a cesarean rate of 60 % with a birth rate of 795,000 (2021) and 30 % of these currently being cesarean births, i.e. 240,000 pregnant women. C-section costs of €3,500 are compared to those of vaginal birth at €2,500, i.e. a difference of €1,000. This would result in additional costs of around €240 million per year if the rate of caesarean births were 60%.

This must be set against the costs of incontinence. This is based on data from France of around €4.5 trillion per year. In relation to the number of inhabitants in Germany, we would have to assume approx. 5.5 trillion € per year. With the incontinence ratio of 1 to 4.5 men to women, this is distributed over approx. 22% for men, i.e. approx. 1.3 trillion € in costs for incontinence. This leaves around €4.2 trillion for women. This means that there is an immense potential for annual savings through a “hypothetical” doubling of the rate of section. The latter is to be expected if pregnant women were informed about the stressful consequences of incontinence in many areas of life. The monograph “Comparison of benefits and risks of caesarean section”, requested by Springer Nature, was published in November 2022 [2].

First of all: there are also caesarean section risks, such as rupture during subsequent vaginal birth of approx. 44 in 1,000 and approx. 7 in 1,000 with an integumentary uterus. This difference may seem “dramatic”. Women who want an elective caesarean section plan to have a resection as the mode of birth.

Pelvic floor damage with 1 to 1 risk hardly acceptable anymore surgical reconstructions of the pelvic floor after damage caused by childbirth are quite sobering after 20 years. Therefore studies on the consequences of HI should therefore be taken seriously. HI forms are hardly discussed below, as they occur too often in combination and are all quite stressful in terms of symptoms. Stress incontinence is the most common form of HI in women after childbirth.

From the menopause onwards, weakened connective tissue in the pelvic floor area due to oestrogen deficiency is added and HI problems are exacerbated. From the menopause onwards, the loss of collagen in the bone system, resulting in osteoporosis, is not taboo. Similar problems in the pelvic floor are rarely discussed.

HI frequencies too little General Knowledge

Pelvic floor damage during vaginal birth with HI consequences is reported in the USA in 30-39 year old women with an incidence of 25% and from 50 years onwards 50% are affected [3].

This corresponds to data from Norway and the UK, with HI frequencies of 30 - 50 % [4,5]. In US outpatient clinics, HI is documented in 35 % [6]. In women up to the age of 34, this is often associated with depression-with no significant relationship to the severity of HI.

Even “weaker” forms of HI in the months and years after birth are to be classified as problematic. The association with depression leads to a variety of performance impairments.

According to a large meta-analysis from 2022 [7], even the first depressive episodes caused reduced cognition, psychometrically verifiable. In the above US study [6], the reference HI depression was independent of the health status of the women.

In a large population-based US study [8], the combination of HI and overactive bladder in particular resulted in economic disadvantages for the women affected: more than half were unemployed. The US authors classified HI problems as serious as chronic diseases. Informing pregnant women preventively about HI risks is almost a taboo.

Multi Morbidity often combined with HI

HI can be exacerbated by multi morbidity, but also vice versa. See a US study from 2021 [9] (n=23,000). The women included were on average 50 years old. Those with chronic diseases were 5 times more likely to have HI than those without HI.

The risk of chronic diseases increases with age and, if the pelvic floor is already damaged as a result of childbirth, HI is often an additional burden.

In extreme cases, HI, regardless of its form, can double the risk of mortality, with pronounced HI by a factor of 3 [10]. This result of a meta-analysis of 38 studies from Switzerland in 2010 is plausible: prolonged social isolation shortens life by many years.

There is also a pragmatic aspect: up to 65-year-olds with HI feel 40% insecure due to urine odor [11]. The latter is often experienced by pregnant women who want to have a caesarean section: Mother and other close female relatives have HI problems. These experiences are rarely shared spontaneously, as they are too taboo.

Delivery room staff should “internalize” the latter and reconsider persuading women to give birth vaginally. This is exacerbated by the misconduct of health insurance companies: no assumption of costs for elective cesarean section.

Psychiatrists get to the Heart of HI problems

HI should not be prematurely classified as a one-sided consequence of psychiatric illness. A longitudinal study from 2018 (n=7,486) argues against this [12]. Psychometrically, pronounced HI was confirmed as doubling the risk of depression (RR 2.15). This also applied to moderate HI as a trigger for depression (RR 1.51).

In addition, the major form of depression due to HI. This psychiatric illness occurs more frequently in people with HI by a factor of 3 [13], and the risk may appear “low” in absolute figures.

It is therefore a more frequent problem for a pregnant woman in relation to her partner relationship. According to a US study from 2002 [14], the combination of HI and depression usually causes sexual dysfunction. Of 30-39 year olds, 3 out of 10 had HI problems after vaginal birth. The US authors [14] made the “neutral” comment that cesarean section was an independent factor for less HI. This does not only apply to the USA. Sweden is cited [15] with HI incidences in women after vaginal birth of between 25 % and 45 %.

Mandatory Information about HI risks before birth?

This demand may seem provocative, but it is obvious given the right to physical integrity under Article 2 of the German Basic Law.

Many significantly lower risks as a result of diagnostic and therapeutic measures are now part of the obligation to provide information. Why should vaginal birth be excluded from this? We have the alternative mode of birth- in contrast to developing countries with low medical standards.

Is the fundamental right to the protection of health too often disregarded by those involved in the delivery room? In the future, there is a threat of forensic problems with considerable claims for damages.

Putting Caesarean section into Perspective as Bodily Harm

Of course, a caesarean section is also a bodily injury, but in an anatomically “simple” region of the body. The comparison with the complexity of the pelvic floor hardly ever happens for pregnant women when they are advised on the mode of birth. Lacerations with confusing reconstruction options should by no means be presented as “horror” scenarios. However, an objective anatomical presentation of both birth canals including lesion aspects is feasible.

In the pelvic floor with 3 muscle layers, the pudendal nerve becomes a problem during vaginal birth if it is severely overstretched/compressed. Painful neuralgia occurs and the pelvic floor muscles, including the sphincter muscles, are functionally impaired. Damage to connective tissue and tendons is not addressed, as these cannot be “reconstructed” by “training” after birth.

Gender-specific Assessment of Urinary Incontinence in Old Age

If women under the age of 80 suffer more frequently from HI than men of the same age by a factor of 3, then today’s obstetrics should think critically about this, based on the Swedish data cited.

Why is the principle of equality according to the Basic Law for generally healthy women with pregnancy cited again? The HI ratio of men to women of 1 to 4.5 could be significantly reduced if there were a rethink of the mode of birth.

C-section birth can be further Optimized

Two aspects should be mentioned with regard to the potential for improvement in performing a caesarean section. These can be implemented easily, with little effort and great benefit, especially for the newborn.

2. There are no justifying large studies on pre-, peri-and postpartum antibiotic infection prophylaxis in healthy women. This more or less disrupts the maternal microbiome/vaginoma transmission to the newborn. This also applies to breastfeeding: antibiotic substances can also reach the breast milk.

Maternal vaginoma/microbiome should pass undisturbed to the child. In the case of vaginal birth, this happens without “external influence”: vaginoma transmission of approx. 10 million germs per milliliter. Lactobacilli represent the largest germ population. This is what evolution demands: rapid development of the immune system, which begins immediately after birth and mainly takes place in the newborn intestine. In the case of section children, this germ transmission should be obligatory via vaginal seeding: the mother’s finger contaminated with vaginal secretions “inoculates” the child’s oral cavity immediately after birth. If this is not done, more autoimmune diseases are to be expected later on. According to a Canadian study [16], children who do not have vaginal seeding have a higher risk of cancer between the ages of 2 and 4. Intact vaginoma is a “visual diagnosis”: abundant lactobacilli are visible in the vaginal secretions under the microscope (in every delivery room).

2. Elective cesarean section around the 38th week of pregnancy is to be classified as forensically problematic. See a study from Australia from 2016 [17]. The study included 154,000 children between the ages of 4 and 6. Half of them were born around 38 weeks’ gestation. Developmental disorders were significantly more common in this group. The comparison group consisted of children born around 40 weeks’ gestation.

The result is evident: at the age of school entry, five categories were recorded, including language, cognition, social competence and emotional maturity. Almost 10 % of these children, who were too often born iatrogenically prematurely via elective caesarean section, had developmental deficits. As expected, this was more pronounced with more immaturity at birth: at 37 weeks’ gestation RR 1.17 and at 34-36 weeks’ gestation RR1, 26.

If pregnant women were aware of these Australian data, they would insist on elective caesarean section around 40 weeks’ gestation with onset of labour instead of around 38 weeks’ gestation, as this is “more convenient” for the hospital organization. The later higher costs for the solidarity community due to the iatrogenically non-optimal timing of the elective caesarean section are hardly associated with lower performance of women born this way. Informed women are best able to push through rapid changes, as the well-being of their children is a high priority for them.

According to current data from Sweden, the 1:4.5 ratio of urinary incontinence in men to women can be significantly reduced in the long term. The 1 to 1 risk of pelvic floor damage as a result of vaginal birth can no longer be classified as “fateful”.

The consequences of incontinence are too often accompanied by reduced performance in many areas of life. Our society should no longer accept this. The resulting costs amount to many billions of euros every year. In extreme cases, depression due to incontinence can shorten life expectancy by many years.

Obstetrics should be called upon to rethink the mode of birth. If a healthy and not very obese pregnant woman wants an elective caesarean section around the due date, then this is in line with BGH rulings. If health insurance companies refuse to cover the costs, then the provisions of the Basic Law are being disregarded.

1. Larsudd-Kaverud J, Gyhagen J, Åkervall S, Molin M, Milsom I, Wagg A, et al. The influence of pregnancy, parity and mode of delivery on urinary incontinence and prolapse surgery-a national register study. Am J Obstet Gynecol. 2022; 591-599.
2. Wenderlein JM, Stolz D. Sectio caesarea Gegenüberstellung von Nutzen und Risiken. Spring Nat Buchreihe Essent. 2022.
3. Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a population-based study. Arch Intern Med. 2005; 165: 537-542.
4. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community- based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the Country of Nord Trondelag. J Clin Epidemiol. 2000; 53: 1150-1157.
5. Swithinbank LV, Donovan JL, du Heaume JC, Rogers CA, James MC, Yang Q, et al. Urinary symptoms and incontinence in women: relationships between occurrence, age, and perceived impact. Br J Gen Pract. 1999; 49: 897-900.
6. Broome BA. The impact of urinary incontinence on self-efficacy and quality of life. Health Qual Life Outcomes. 2003; 1: 35.
7. Varghese S, Frey BN, Schneider MA, Kapczinski F, de Azevedo Cardoso T. Functional and cognitive impairment in the first episode of depression: A systematic review. Acta Psychiatr Scand. 2022; 145: 156-185.
8. Coyne S, Sexton CC, Thompson CL, Clemens JQ, Chen CI, Bavendam T, et al. Impact of overactive bladder on work productivity. Urol. 2012; 80: 97-103.
9. López-Sánchez GF, Jacob L, Jacob L, Shin JI, Grabovac I, Soysal P, et al. Association of multi morbidity with higher levels of urinary incontinence: a cross-sectional study of 23 089 individuals aged ≥15 years residing in Spain. Br J Gen Pract. 2021; 71: 71-77.
10. Bardini C, John G, Combescure C, Dällenbach P. Urinary Incontinence as a Predictor of Death: A Systematic Review and Meta-Analysis. PloS one. 2016; 11: 0158992.
11. Lagro-Janssen T, Smits A, Van Weel C. Urinary incontinence in women and the effects on their lives. Scand J Prim Health Care. 1992; 10: 211- 216.
12. Lim YM, Lee SR, Choi EJ, Jeong K, Chung HW. Urinary incontinence is strongly associated with depression in middle-aged and older Korean women: Data from the Korean longitudinal study of ageing. Eur J Obstet, Gynecol Reprod Biol. 2018; 220: 69-73.
13. Melville JL, Delaney K, Delaney K, Katon W. Incontinence severity and major depression in incontinent women. Obstet Gynecol. 2005; 106: 585-592.
14. Littlejohn JO Jr, Kaplan SA. An unexpected association between urinary incontinence, depression and sexual dysfunction. Drugs Today (Barc). 2002; 38: 777-782.
15. Milsom I. The prevalence of urinary incontinence. Climacteric. 2019; 22: 217-222.
16. Marcoux S, Soullane S, Lee GE, Auger N. Association between cesarean birth and childhood cancer: An age-lagged approach. Acta Paediatr. 2022; 112: 313-320.
17. Bently JP, Roberts CL, Bowen JR, Martin AJ, Morris JM, Nassar N. Planned Birth Before 39 Weeks and Child Development: A Population- Based Study. Pediatrics. 2016; 138: e20162002.