Should a woman be able to choose to have a Caesarean even when there may not be a medical reason?
This controversy has been growing for the past three years at the same time the numbers of Caesarean sections have been on the rise.
Everyone seems to agree that Caesarean deliveries are increasing. About three women in 10 now have a C-section, according to 2004 numbers from the Maternity Center Association, a New York-based group.
And when the procedure is medically required, there is no issue: The best delivery is one that ensures the mother and the baby are safe.
The problem comes when it is a Caesarean on demand.
In fact, the increases in C-sections prompted both the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists to issue reports in 2000 expressing concern about the number of C-sections among healthy women. Both groups said the United States can and should reduce the number.
Locally, Blue Cross Blue Shield of Illinois says the number of C-sections among 120,000 insured members rose from about 26 percent in 2003 to 30 percent in 2004.
And elective C-sections are growing as well, albeit not by as much.
A study released last year by Health Grades, a Colorado health care research company, found the number of C-sections by choice rose from 1.77 percent of all deliveries to 2.21—an increase of 25 percent from 2000 to 2002. And a survey of female obstetricians by the Gallup Organization—its first ever—found that 22 percent of C-sections were elective.
Birth is a natural process that has been going on for thousands of years and surgery—no matter how routine—always carries risks, which can be as extreme as death.
Yet, urogynecologists, who specialize in caring for women with pelvic floor dysfunction but do not deliver babies, argue that advances in surgery actually make C-sections safe. And, they say, C-sections prevent women from developing pelvic health problems including incontinence later in life.
So, women are requesting C-sections. Some because they may have heard that vaginal birth will lead to pelvic dysfunction in later years. Others because they are afraid of the pain of vaginal delivery. And others because they want the convenience that comes with knowing exactly when their baby will be born.
“It has become a fad that is being fueled by fear and by promises that are way too tempting,” says Deanne Williams, executive director of the American College of Nurse Midwives.
Risks for convenience
There is nothing confusing about the risk of C-sections, which include the possibility of such things as bladder injury and placenta accreta, a potentially life-threatening condition that can require an emergency hysterectomy, according to Dr. Ann Warren, an obstetrician and gynecologist in Barrington.
Warren says there should be a good reason for doing a C-section—not just avoiding pain. “I won’t tell them they don’t have the option, but I have some concerns about it. I need to have them vocalize to me their reasons for it.”
And the risks are not just for one delivery, they can have long term consequences.
“You need to look at the risk of the decision versus the complications of that procedure,” says Williams.
“This is not a single procedure decision. It is one that will affect subsequent births. And the risk after subsequent Caesarean goes up exponentially for you and your baby.”
Williams recommends the brochure “What Should I Know About Caesarean Section?” which can be found at www.maternitywise.org.
And while those risks vary, they can include the formation of scar tissue, hemorrhaging, infection and serious uterine damage. There is also evidence that women who have had a Caesarean delivery are at an increased risk for ectopic pregnancy.
“I run into [some patients who request a C-section]. It’s their first pregnancy and they have heard the buzz about it,” says Dr. Maryam Siddiqui, an obstetrician and gynecologist at Mt. Sinai Hospital in Chicago. “I try to talk them out of it. It’s major surgery.”
The American College of Obstetricians and Gynecologists has determined that the evidence to support “the benefit of elective Caesarean is still incomplete,” according to a study by the ethics committee.
But there is no blanket rule. There are times when surgery is called for.
It should be a discussion between the patient and the doctor.
Dr. Jennifer Berman, co-director of the Female Sexual Medicine Center at UCLA Medical Center and co-host of Discovery Health Channel’s “Berman & Berman,” chose a C-section for her second child. “I had a very traumatic, long labor [the first time],” Berman says. “I decided that since the baby was large I didn’t want to go through that again ... Women should choose how to deliver, assuming we understand the risks involved.”
Yet, there are doctors who believe C-sections are a better option even when not medically necessary.
“Vaginal delivery is the single biggest risk factor in developing pelvic floor dysfunction,” says Dr. Brett Vassallo, an urogynecologist in Park Ridge.
Pelvic floor dysfunction can cause urinary incontinence, fecal incontinence and pelvic organ prolapse, where organs such as the uterus are no longer supported and begin to drop down, causing blockages and pressure.
These problems are not as rare as you might think—many women who haven’t even given birth experience urinary incontinence, says Williams. When women age, this is a problem they can encounter, but no one is sure exactly what causes it.
“By age 40 about one-third of women will report some degree of problem,” says Dr. Roger Goldberg, director of urogynecology research at Evanston Continence Center. But Goldberg claims this is a result of how the women give birth. “[It doesn’t matter] how many babies they had, the birthmode was the important factor.”
Goldberg studied 542 identical twin sisters and found that those who had elective Caesareans were two to three times less likely to have bladder problems and were also less likely to have rectal incontinence, he says.
Williams says this one study is too small to draw a definitive conclusion. The one systematic review of the medical literature shows that a Caesarean is not an indicator one way or the other for later pelvic dysfunction.
“All of these women who are being promised that a C-section is going to prevent incontinence later in life are being sold a bill of goods,” Williams says. “We do not know.”
“More research has to be done on the risks and benefits,” says Dr. Sherman Elias, obstetrics and gynecology chair at Northwestern Memorial Hospital. “I don’t feel dogmatic [against] it, but there must be true informed consent.”
Exercise can help
Still, there are things women can do before and after giving birth to help overall health and to prevent later physical problems.
“Women go into childbirth with very little understanding of how it will affect their bodies. They are about to run the Boston Marathon—who would run a marathon unprepared?” Goldberg says.
Perineal massage, which stretches the skin between the anus and vagina, and Kegel exercises, which strengthen pelvic floor muscles, can help, adds Vassallo.
Goldberg says women who regularly do Kegel exercises during pregnancy prevent a loss of muscle strength and actually emerge with stronger pelvic muscles than their pre-pregnancy baseline, he says.
Williams agrees. “Kegeling is an old fashioned intervention,” she says, “but it works.”
Merry Mayer is a Chicago-based writer. She has two children. Susy Schultz is associate publisher and editor of Chicago Parent.