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More Women Choosing C-Sections, Despite Risks

Monday, March 24, 2003

Women and health care providers are increasingly choosing Caesarean sections instead of vaginal birth in order to avoid labor pain and to schedule delivery at a convenient time. Ignored, are the higher risks and the longer recovery time.

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Women and health care providers are increasingly choosing Caesarean sections instead of vaginal birth in order to avoid labor pain and to schedule delivery at a convenient time. Ignored, are the higher risks and the longer recovery time.
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Deanne Williams

(WOMENSENEWS)--A growing number of medical experts and expecting moms suggest women should be allowed Caesarean sections for reasons other than medical necessity, an assertion that gives new meaning to the phrase "the right to choose." This newest trend has many women's health leaders, still trying to reduce the nation's C-section rate, up in arms.

Caesarean sections, known as C-sections, also run a greater risk of child and maternal mortality. According to research by the International Cesarean Awareness Network, Inc. the risk of a mother dying from a C-section is 4 in 10,000, while vaginal births carry a 1 in 10,000 risk. The risk of stillbirth during a Caesarean is 4 in 1,000 compared to 3 in 1,000 for a vaginal birth.

Vaginal childbirth is considered by many to be best for both mother and baby, though it also runs the risk of incontinence, perineal tearing, pelvic floor damage that could then cause potential sexual difficulties for the mother and risks to the baby should the fetus struggle to pass through the birth canal. Side effects from Caesarean include greater risk of blood loss, risk of injury to the mother's internal organs and repeat Caesareans could also increase the risk of uterine rupture and need for hysterectomy.

The ballooning interest in convenience Caesarean sections may become somewhat deflated after a study published earlier this month in The New England Journal of Medicine found women who delivered their babies via C-section also developed bladder control problems, a finding that counters the widespread belief among the public that only vaginal deliveries led to incontinence. The study, based on 15,307 Norwegian women, showed that urinary incontinence developed among 16 percent of those who underwent surgical delivery, compared to 21 percent of those who delivered vaginally. Experts say The New England Journal study confirms what health authorities already believed about incontinence. The key is now to get expecting moms-to-be to realize convenience comes at a price.

"As a general population, everybody wants things fast and convenient," Deanne Williams, executive director of the American College of Nurse-Midwives in Washington, D.C. "We want control. It would be great for everybody to say 'I know what day I'm going to have this baby.'"

Caesarean delivery is typically reserved for medical emergencies--if the fetus is too large to pass through the birth canal or if there are pre-existing or sudden maternal or fetal health complications. In the past few years, however, Caesarean rates rose overall throughout the country as more women began expressing interest in Caesarean delivery for personal reasons, even if they were healthy enough for vaginal births. Also, Cesareans have become popular among first-time older mothers, having babies in their late 30s and 40s. As a rule: The older the new mom, the greater the chance of her needing a Caesarean delivery.


Doctors and Patients Alike Find C-Sections Convenient

Williams said that women have been increasingly choosing elective Caesareans for reasons such as avoidance of labor pain, patient or health care provider convenience, legal concerns of the health care provider and women's concerns over vaginal birth side effects, such as urinary incontinence. Doctors feel more vulnerable to malpractice lawsuits if something were to go wrong during a vaginal birth and Caesareans are seen as a safer alternative because the physician has more control. However, the flip-side is that patients can also legally blame the physician should something go wrong during the C-section, whether it's to the mother or the baby.

There are other reasons why both patient and doctor desire Caesareans: It gives both parties more control over the delivery and yields convenience to both anxious moms-to-be and busy physicians who would understandably prefer a scheduled Caesarean over a midnight pager call to rush to the aid of a woman in labor.

"Personally, I hold the medical community responsible because we are the ones who have the information that we should be sharing with the women," Williams said. "There are physicians who believe and tell their clients C-sections are no riskier than vaginal births. It's major abdominal surgery. You slice through several layers of the abdomen. You slice through the uterus and once you get the baby and the placenta out, you have to get all those layers back again."

Dr. Yvonne S. Thornton, author of "Woman to Woman: A Leading Gynecologist Tells You All You Need to Know About Your Body and Your Health" and vice-chair of obstetrics and gynecology at Jamaica Medical Center in New York, said women forget C-sections are surgery, and like any other surgery, there is risk of infection when a doctor places a scalpel on the skin.

"If you have a hammer, everything's a nail," Thornton said of the current attitude toward Caesareans. "Just because we have scalpels, not everything is a Caesarean delivery." Women today have the impression Caesareans are harmless, she added. Although the procedure's safety improved over the decades, it still comes with risks. Surgery, she said, is not natural.

"We're doing something unnatural and the bottom line is that it's unnatural. We pay the consequences for not being a little more patient and this impatience leads to the drive-through deliveries."

And the convenience may stop at the hospital doors. New mothers may be discharged from the hospital between 24 to 48 hours after the birth, while the average C-section hospital stay is ranges from three days to five days.


Ethical Concerns about Elective Caesareans

The reasons for choosing a C-section have been put under the spotlight most recently by supermodel Claudia Schiffer, Williams said, who delivered a baby boy in London on January 30. Reports said she underwent a Caesarean instead of vaginal childbirth because of a broken foot.

"Some argue that, from an ethical point of view, allowing a patient to choose to deliver by Caesarean is not substantially different from allowing her to choose to undergo cosmetic surgery," Dr. Peter S. Bernstein, professor of clinical obstetrics and gynecology and women's health at the Albert Einstein School of Medicine in New York, wrote last September in Medscape Ob/Gyn and Women's Health. "But Caesarean delivery is very different. The benefits of elective Caesarean delivery relative to vaginal delivery are not established, and the risks are substantial, especially given the potential for future repeat Caesareans."

A report issued by the Centers for Disease Control and Prevention indicated that nearly one in four babies in the United States, or 24.4 percent, is delivered via Caesarean section. Cesareans were used in about 5 percent of all births in the 1970s; by the 1980s they used in about 16.5 percent, according to the CDC data.

While there are no hard figures for the number of women who give birth by Caesarean for reasons other than medical necessity--these so-called "drive-through deliveries," meaning quick and easy deliveries of babies--several experts report the trend is continuing despite warnings from various medical groups, including the American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists.

A majority of physicians appear to discourage convenience Caesareans, but a strong minority challenge the notion that Caesareans should only be for medical necessity. Doctors have suggested vaginal birth comes with many risks to the newborn and Caesarean deliveries could be an optimal choice for women living in developed nations, who have access to adequate medical care, and who want only one or two children.

Women's concerns about the risks of labor "can be eliminated by doing a Caesarean," said Dr. Paul Burka, a private practicing obstetrician. "The same informed consent should be given to women when they go into labor and deliver vaginally. And when you go through the list of things it's fairly daunting." He cites fetal asphyxia, when the fetus struggles to get oxygen during childbirth, as a major worry.

"There's great appreciation from patients of the risks of labor and what it can do to a newborn." Burka said. "There are times things can go wrong and by the time it's recognized and attempts are made to remedy it, it may be too late."

Burka said how a woman delivers her child should be "a parental decision" that's made with her doctor.

"We're way beyond the point now of physicians dictating what patients should do," he said. His top priority is figuring out the safest way to deliver the baby, which he said could mean by Caesarean section.

"I take care of one patient at a time," Burka said. "I don't take care of populations. I'm dealing with this woman and her life and her fears and her hopes and all that's riding in the future of this pregnancy."

Katrina Woznicki is a freelance journalist in Washington, D.C.

For more information:

The New England Journal of Medicine--
"Urinary Incontinence after Vaginal Delivery or Cesarean Section":
http://content.nejm.org/cgi/content/abstract/348/10/900

The American College of Nurse-Midwives--
"Women Urged to Proceed with Caution in Age of 'Designer Deliveries'":
http://www.midwife.org/press/article-oped.cfm

American College of Obstetricians and Gynecologists--
"Ob-gyns issue recommendations on cesarean delivery rates":
http://www.acog.org/from_home/publications/press_releases/nr08-09-00.cfm