Cut and run
An increasing number of American women are choosing C-sections. Is this trend a risky indulgence, or a sign of female empowerment?
By Dana Hudepohl
The debate over elective cesareans started publicly in the spring of 2000 when then-president of the American College of Obstetricians and Gynecologists (ACOG), Dr. W. Benson Harer Jr., argued for "maternal-choice cesarean" in an editorial printed in the association's journal. Doctors were forced to pick a side as more patients entered their offices with requests. From 1999 through 2002, the number of elective C-sections provided to women with no previous C-section rose almost 42 percent, accounting for more than 2 percent of more than 4 million deliveries. If more women start getting their way, that number could skyrocket.
In an online survey at Newshe.com, a Web site put out by sexual health experts Drs. Laura and Jennifer Berman, when nearly 2,500 women were asked, "Would you opt for a C-section over a vaginal delivery if you had the choice?" 37 percent answered "Yes"; another 9 percent answered "Not sure."
Proponents point to evidence showing that when healthy women choose to have C-sections, the risks, benefits and costs are balanced between C-sections and vaginal delivery. They conclude that the choice should be the mother's. Critics — doctors, midwives and women among them — answer back that a C-section is major surgery with risk of complications, longer recovery and potential problems with future deliveries.
After more than a year of deliberation, the group concluded that it is ethical to provide an elective C-section if the doctor believes it is in the best interest of the woman and her fetus and if he has advised her of the risks involved. If the doctor believes a C-section would be detrimental to the health and welfare of the woman and her fetus, he is ethically obliged to refrain from performing the surgery. If the patient and doctor cannot agree on a method of delivery, he should refer the woman to another doctor. The ACOG cautioned that evidence to support the benefit of elective cesarean is still incomplete and that there are not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. In other words, the jury is still out.
It's no wonder: A recent Gallup survey of 301 female OB/GYNs showed that even women who take care of other women are sharply split. Thirty-six percent said they would not perform a C-section if a woman asked for it, 32 percent said they would, and 28 percent said it would depend on the woman's circumstances.
"C-sections are incredibly safe, but bad things can happen during medical procedures," says Dr. Jerome Yankowitz, director of the division of maternal and fetal medicine at University of Iowa College of Medicine, who is against elective C-sections unless a patient has been thoroughly counseled. "It can be unnecessary surgery analogous to liposuction. Most people have no complications, but then there are a few who do. Afterwards people think, 'Why did they do that? They weren't that heavy!'" Yankowitz says he knows of many cases of bladder damage in the mother, bad wound infections and bowel injury as a result of C-sections. Many doctors advise against elective C-section if a woman plans on having more than two children since subsequent surgeries become riskier. "
Her organization issued a statement last fall against elective C-sections, stating that "purported benefits of cesarean section on demand are unproven and the known risks place the woman's life and reproductive future on the line."
The fact that no large-scale studies have been done to compare apples to apples is what concerns nurse-midwife McCartney. "Before physicians jump in and say there are no problems with C-sections, I'd like to see a study comparing a healthy vaginal delivery to a healthy C-section," she says. "Most people think the study has been done already and it hasn't. Women think they're having an opportunity to make a choice, but what they're really getting is their provider's opinion."
Stephanie Higgins, 24, had planned to have a drug-free natural delivery, but when her baby was three weeks late and estimated to be over 11 pounds, her doctor recommended that she schedule a C-section. "I feel like I missed out on an easier, more natural process," says Higgins, who couldn't get out of bed or pick up her newborn — who, it turned out, only weighed in at 8 pounds, 15 ounces — for days because of the pain from her cut stomach muscles. More distressing than the soreness was that she had difficulty nursing. "Since my body had not gone through labor, it took longer for my milk to come in," she says. "My baby was hungry and I had nothing for her for a good five days. It was a really difficult experience." While Higgins believes that women should have a choice how they deliver, she wishes she had been able to stick to her original birthing plan. "People say, 'I wouldn't want to go through the pain of childbirth,' but there's a lot of pain with a C-section — and I had an uncomplicated one. The recovery was much more difficult than anyone I knew who had a vaginal delivery."
Proponents of elective C-section are more interested in talking about the mother's long-term health than the weeks after the baby is born. "The first few weeks after you have the baby is a lot different than the rest of your life," says Bost. Studies have associated vaginal delivery with higher risk of lasting consequences, including pelvic organ prolapse and urinary or fecal incontinence.
But a new study of 363 women from Tel Aviv University does show that elective C-section can have a protective effect. The prevalence of urinary incontinence one year after women delivered vaginally was 10.3 percent, but for women who had an elective C-section with no labor, it was only 3.4 percent. (It was 12 percent for women who had a C-section after laboring).
"This is a very touchy topic," she admits. "But in my mind, it should be an individualized decision between a patient and a doctor. When you need treatment for, say, prostate cancer, you have options. I don't understand why delivery of an infant is any different."
In Brazil , the overall cesarean delivery rate is 50 to 60 percent and climbs to 90 percent among wealthy women delivering in private hospitals. South Korea has one of the highest C-section rates in the world, with almost half of Korean women delivering by C-section (up from 6 percent in 1985 and 21.3 percent in 1995). In Denmark , nearly 40 percent of OB/GYNs agree with the woman's right to request a C-section. But recent media coverage of Hollywood 's elective C-section trend with headlines like "Too Posh To Push" (Time) have given the issue a sense of elitism.
On average, C-sections are twice as expensive as vaginal deliveries. Can maternity wards handle a rising demand for elective C-sections? Yes, says Bost, since those numbers don't apply to elective C-sections. His research, published in the Journal of Obstetrics and Gynecology, found that when you factor in nursing, medication, and monitoring during long labor, the costs of vaginal deliveries and elective C-sections balance out. He concluded, "Adopting a policy of cesarean on demand should have little impact on the overall cost of patient care."
click to close
