With Childbirth, Now It's What the Mother Orders

By Jane Brody
New York Time
December 9, 2003

When my twin sons were born 34 years ago, the goal of every woman I knew, myself included, was a vaginal delivery.

Alas, for me, that was not to be: the babies were just too big to make it through my narrow pelvis, and after a nightlong labor they had to be delivered surgically by Caesarean section.

Such so-called emergency Caesareans will always be with us, the result of labors that fail to progress, fetuses that are too big or in the wrong position, multiple fetuses, placentas that block the uterine opening, infections, severe hypertension or other complications in the mother and health- or life-threatening problems in the fetus.

If surgical births occurred only for such reasons, the Caesarean rate would be about 10 percent of live births, 15 percent at most.

But the rate in the United States now exceeds 25 percent, in part because a growing number of women are requesting "elective Caesareans" - planned surgical deliveries. The rise in elective Caesareans has created a controversy in obstetrics, with some physicians strongly in favor of letting informed women choose their mode of childbirth and other physicians and nurse-midwives just as strongly opposed when no clear-cut medical reason arises.

The controversy, long brewing behind the scenes, went public three years ago.

Dr. W. Benson Harer, then president of the American College of Obstetricians and Gynecologists, declared, "Perhaps the time has come when risks, benefits and costs are so balanced between Caesarean and vaginal delivery that the deciding factor should simply be the mother's preference for how her baby is to be delivered."

While cost was once an impediment to elective Caesareans, Dr. Harer said they were now no more expensive, and sometimes cost less than vaginal deliveries that involve epidural anesthesia and labor-stimulating drugs.

On the other hand, an expert committee of the college this fall took a more conservative stance: "In the absence of significant data on the risks and benefits of Caesarean delivery, the burden of proof should fall on those who advocate for a change in policy in support of elective Caesarean delivery."

Why Choose a Caesarean?

With the passing of paternalism in obstetrics, women have had an ever-increasing voice in how their bodies are treated by the medical profession. This has had both good and bad consequences.

The good is obvious: every conscious, rational patient should be well informed about treatment options and able to participate in treatment decisions. The bad is less obvious: doctors at risk of devastating malpractice suits, should things not go as well as expected, are often afraid to go against a patient's choice even if they consider it ill-advised.

There are a number of reasons women may request elective Caesareans. One is convenience - the ability to fit childbirth into their work schedules, plan for the care of their other children, or have spouses, parents or both present at the birth.

Another is fear for the baby's safety. With so many women delaying childbirth and struggling with infertility, concerns are rising over vaginal births and possible harmful complications to hard-won babies.

A third factor involves possible pelvic injury that can result in urinary or fecal incontinence, complications that are more likely to follow a vaginal delivery. And, of course, there are always some women who are so afraid of the pain of labor and delivery that they prefer the major surgery of a Caesarean, which nowadays is nearly always done under regional anesthesia, allowing the woman to remain awake and able to hold her baby immediately after the birth.

The doctor, too, may benefit from a birth that can be scheduled outside of office hours and apart from vacations, and when the doctor and staff members are well-rested.

A Look at the Facts

The most important question - which method of delivery is safer for an otherwise healthy woman with an uncomplicated pregnancy? - cannot be fully answered at this time.

The data elaborating the risks of Caesareans include those performed in emergencies - after labor has begun and medical problems have developed. These emergency Caesareans still make up a majority, and they are much more likely to result in complications, like infections or hemorrhage, than elective Caesareans.

As with any operation, there is a very small risk of a postoperative pulmonary embolism, but this complication can also occur after a vaginal delivery.

Of course, a planned Caesarean would obviate the need for a far riskier emergency Caesarean should a problem arise during labor.

In decades past, the main drawback of Caesareans was a higher mortality rate. But recent data from Britain and Israel reveal a lower death rate from scheduled Caesareans than from vaginal deliveries.

Although incontinence problems are more common soon after vaginal delivery, years later the method of childbirth seems to make little or no difference in the incidence of these disorders.

Women who are concerned about pain should be told that various safe procedures are now available to relieve the pain of labor. And while the birth itself will probably be painful, the process of delivery is quite brief.

Once a woman has a Caesarean, chances are all later births will also be Caesarean. Although about 16 percent of women deliver their next babies vaginally, they risk uterine rupture, which can prove fatal to the baby and force the mother to have a hysterectomy.

And, Caesareans can increase the risk of placental abnormalities in future pregnancies.

As for the welfare of the baby, planned Caesareans bring benefits and risks. The risk of stillbirth rises, albeit slightly, when pregnancies go beyond 39 weeks. The risk of birth-related cerebral palsy, also very low, is greater with vaginal deliveries. And vaginal births that require instruments (forceps or vacuum extraction) are more likely to result in injuries to the baby, including bleeding, fractures and nerve injuries.

When mothers are carriers of infectious agents like H.I.V., hepatitis B or C virus or human papillomavirus, Caesarean delivery can prevent transmission to the baby.

On the other hand, if there is any uncertainty about the mother's due date, an elective Caesarean can result in the birth of a premature baby. Also, there is often a delay in the onset of lactation when babies are born before labor begins, although no ill effects on breast-feeding or mother-infant bonding have been demonstrated.

In an analysis published in March in The New England Journal of Medicine, Dr. Howard Minkoff, an obstetrician at Maimonides Medical Center in Brooklyn, and Dr. Frank A. Chervenak, an obstetrician at New York-Presbyterian Hospital in Manhattan, concluded that "although the evidence does not support the routine recommendation of elective Caesarean delivery, we believe that it does support a physician's decision to accede to an informed patient's request for such a delivery."

Any woman considering an elective Caesarean should discuss the benefits and risks fully with her physician early in the pregnancy. If the doctor opposes her choice, referral to another physician may be the wisest course.

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