Gimme a C

Is choosing a Cesarean for a nonmedical reason wise?

Carla and Louis Gericke began planning for a family after returning from a trip around the world. The Gerickes, both in their 30s, may not know whether they will have a boy or girl or if they want to raise their child in New York, where they now live, but they do know how their baby will be delivered. Carla, an attorney and writer, is insisting on a Cesarean birth, and not because of any medical necessity. “My primary reasons are to avoid tearing, vaginal stretching and incontinence,” she says. “I believe elective C-section is a personal choice. In my opinion, it is simply the next evolutionary step in childbirth—sort of the chloroform of the new millennium.”

There are several medically valid reasons for a planned C-section. For example, the baby is predicted to be too large to pass through the pelvis or is in a breech (feet first) or transverse (sideways) position. Or the mother has pregnancy-induced high blood pressure, placenta previa or an active genital herpes infection. Like Carla Gericke, however, many women today are choosing C-sections for nonmedical reasons. While the World Health Organization and the U.S. Department of Health and Human Services have stated that ideally no more than 15 percent of babies should be delivered via Cesarean section, the rate of such births in America has increased six years in a row. In 2002, 26.1 percent of babies were born by C-section, up 7 percent from the previous year, the Centers for Disease Control and Prevention reports. A study by Health Grades Inc., a Denver-based organization that rates the quality of doctors and hospitals, concluded that patient-choice Cesareans are partially responsible. But the wisdom of those choices is controversial.

Why women choose C-sections Women who opt for the surgery do so for convenience, fear of the pain and/or unpredictability of labor, the desire to avoid pelvic damage and other reasons. Some women who’ve had a previous C-section don’t want to risk the potential complications of delivering vaginally, which include (albeit rarely) a ruptured uterus. Others, including some older mothers and those who’ve had infertility problems, believe a C-section is safer for the baby, especially if a forceps or vacuum-extraction delivery becomes necessary during a vaginal birth. Though the American College of Obstetricians and Gynecologists (ACOG) has stated that it is ethical for doctors to perform elective Cesareans, many physicians and midwives contend that women are not adequately counseled about the risks, which include infection, blood loss and damage to adjacent organs, to make informed decisions. In fact, the American College of Nurse-Midwives recently issued a statement opposing ACOG’s stance. Others argue that none of those possibilities is life-threatening. “At least two large studies suggest that the risk of [maternal] death is greater for vaginal delivery than for elective Cesarean section,” says William A. Growdon, M.D., a clinical associate professor of obstetrics and gynecology at the UCLA School of Medicine. C-sections require a longer hospitalization and recovery time than do vaginal deliveries and, like any surgery, they do pose some risks. However, obstetricians agree that an emergency C-section, which typically follows a lengthy labor, is far more dangerous to both mother and baby. Some women and their doctors choose to avoid this possibility altogether by simply scheduling the procedure. Many patients feel that any drawbacks of elective surgery are canceled out by the potential benefits, notably the reduced likelihood of pelvic injury that can result in urinary and/or fecal incontinence and pelvic-organ prolapse (when the uterus, bladder, intestine or rectum protrudes into the vagina).

In fact, in 2003, The New England Journal of Medicine cited five studies that linked higher incontinence rates to vaginal deliveries than to C-sections. But while two concluded that the problem is best prevented when a Cesarean delivery is performed before labor begins, some critics of elective C-sections point out that the risk of incontinence wasn’t reduced enough to justify the procedure. Danger down the line? Having a C-section—either emergency or scheduled—may pose a small but increased risk to a baby in a subsequent pregnancy, a new British study suggests. Cambridge University research found that when a woman had a previous C-section, the risk of unexplained stillbirth in a second pregnancy increased with each week past 34 weeks. While the risk was twice as high among women who had C-sections than among other women, it was still low—less than one in 1,000 births. Still, if a woman is planning to have more than one child, it’s a factor to be considered. Growdon says that ideally a physician will discuss a woman’s personal and medical history and any worries she has about labor, which typically brings up the issue. “In the final analysis, after discussing the possible complications, pain management and extra days in the hospital, the patient has autonomy, and the doctor can either perform a requested C-section or refer her to another physician,” Growdon says. “But doctors do have an ethical obligation to discuss the risks and benefits.”

Fighting for “normal birth”

Lamaze International recently launched a worldwide campaign to promote what it calls normal birth. The goals include allowing labor to begin on its own; permitting women to move around during labor and to give birth in nonsupine (e.g., squatting, side-lying) positions; and avoiding routine interventions, including medically unnecessary C-sections.