More than one-quarter of American women today deliver via Cesarean section. Will you be one of them?
It took Holly Zboyan-Lee, 31, a split second to decide whether she wanted a Cesarean section. “I saw the look of concern on the doctors’ and nurses’ faces, and it was the worst feeling in the world,” she says. “I wanted my daughter out.” Fetal monitoring showed her baby’s heart rate was unusually slow to return to normal after each contraction, and there was meconium (waste from the baby’s intestines) in the amniotic fluid, another sign of possible distress. Zboyan-Lee was wheeled across the hall to an operating room, and less than half an hour later, she had a healthy baby girl. “I would definitely make the same choice again,” says the Bellaire, Texas, mother.
But many situations aren’t so clear-cut, and a lot of women are far less certain whether a C-section or a vaginal delivery would be best for them, their babies and future pregnancies. Understanding the risks and benefits before you go into labor is the surest way to feel confident about your decision.
Some background: The nation’s C-section rate rose from 5 percent in 1970 to an all-time high of 26.7 percent in 2003, according to the Centers for Disease Control and Prevention. (The World Health Organization maintains that 15 percent should be the maximum rate.) The boom can be traced to a steady decline in the number of women attempting a vaginal birth after a previous C-section, known as VBAC (just 10.6 percent of babies were delivered this way in 2003); an increase in C-sections due to “failure to progress”; greater attention to risks of vaginal deliveries; and safer surgical techniques. But that’s not all: “The popularity of televised cosmetic surgery may lead some people to have fewer fears about surgery,” says Howard Minkoff, M.D., chairman of the obstetrics and gynecology department at Maimonides Medical Center in Brooklyn, N.Y.
C-section pros and cons
Many experts find the burgeoning C-section rate troubling. The surgery poses serious potential risks, including blood clots, organ damage and, very rarely, maternal death. More commonly, studies show that women feel pain at the incision site, remain in the hospital longer and may develop a post-surgical infection. “Think of it as pay me now or pay me later,” says Gene Declercq, Ph.D., professor of maternal and child health at Boston University School of Public Health. “A woman who delivers vaginally will experience more discomfort during labor, while a woman with a Cesarean will experience much greater postpartum pain.”
As for the babies, in general, there’s less opportunity for complications when an infant is delivered surgically, says Charles J. Lockwood, M.D., chairman of the obstetrics, gynecology and reproductive sciences department at Yale University School of Medicine in New Haven, Conn. But such babies are less likely to be breastfed and more likely to have asthma later in life, according to the New York City-based Maternity Center Association (MCA), a nonprofit group that reviewed more than 300 studies on vaginal- and C-section-birth outcomes. Plus, there is a small but heightened chance of placental problems and stillbirths in future pregnancies; risk increases with each previous C-section.
The gray zone
Few question the value of C-sections—in certain instances. “When there are serious medical reasons or the life of the mother or baby is at risk, no one disputes that surgery is appropriate,” says MCA executive director Maureen Corry, M.P.H. Situations that nearly guarantee a C-section include a baby in the breech position (not head-down); a baby whose head is too large to fit through the birth canal; and placenta previa, a condition in which the placenta blocks the baby’s exit.
A small but rising number of women are having the surgery for no apparent medical reason, however. A British Medical Journal review of data from 1991 to 2001 showed a 67 percent increase in C-sections among American women with no reported medical risk. First-time mothers over age 34 were most likely to have such “elective” C-sections, though vaginal-delivery risks are no greater for a healthy 40-year-old than for a 20-year-old, Minkoff says. VBAC candidates with risk factors for uterine rupture, a potentially serious complication, are advised to schedule a C-section. (In a recent New England Journal of Medicine study of nearly 18,000 women who had VBACs, .7 percent, or 124 women, experienced a uterine rupture.) But sometimes, even women likely to have a successful VBAC, such as those with only one previous Cesarean and what’s called a low-transverse incision, are denied the chance. More than 300 hospitals nationwide have banned VBACs, according to a recent poll by the International Cesarean Awareness Network, a Redondo Beach, Calif.-based nonprofit group. That’s why groups like MCA say it’s important for first-time mothers to know all the facts when it comes to C-sections: A woman’s chances of trying for a vaginal birth the second time around are dwindling.
The controversy isn’t limited to VBACs. “The interpretation of fetal heart rate tracings and the diagnosis of failure to progress represent the most gray areas,” Lockwood says. In these cases, as well as situations such as twins or a woman with a health condition like high blood pressure, one physician or midwife may recommend surgery where another may not. Fear of malpractice suits plays a role, he adds: Opting for surgery almost always equates to less risk of being sued.
The decision is one that physicians and patients should make together—a fact easily forgotten when you’ve been laboring for what seems an eternity. When Carolyn Walkin, 36, of Brooklyn, N.Y., had a C-section after 26 hours of labor due to “failure to progress,” for example, she felt shut out of the decision-making process, partially due to exhaustion. Says Walkin, “I should have asked about alternatives.”
Decrease your C-section odds
Choose providers with low Cesarean rates Also ask questions to help put the number in perspective. For example, a doctor or hospital that handles a large number of high-risk patients may have higher rates. Ask doctors how they determine when surgery is necessary.
Hire a doula Studies show that women who labor with continuous support
are 26 percent less likely to have a C-section. (Visit www.dona.org to locate one.)
During labor, ask whether either you or your baby is in danger
if a C-section is being discussed. If the answer is no, inquire about alternatives.