Too Posh to Push?
Cesarian sections have spiked dramatically. Progress or convenience?
Side effects. There are some shreds of medical evidence on long-term risks of vaginal delivery--damage to the pelvic floor, for example. But they are now just shreds of evidence, nothing strong enough to settle the matter. There is solid science linking vaginal delivery to what are often called "female problems" later in life--the largely unmentionable issues of incontinence and prolapse, or sagging pelvic organs. But no one knows just who may suffer decades later. "C-section has been vilified," says Walters. "But go talk to women who are peeing in their pants 20 years later."
That's what Joseph Schaffer has done. He is director of urogynecology and reconstructive pelvic surgery at the University of Texas Southwestern, and he sees women largely for problems of pelvic floor damage, including incontinence and prolapse. An estimated 11 percent of women will undergo surgery in their lifetime for incontinence or prolapse. Two of the biggest known risk factors for pelvic floor damage are forceps delivery and episiotomy, a surgical cut to allow more room for the baby. Both procedures are less common today.
While no one can predict which new mothers will have future medical problems, women who have had incontinence or prolapse following an earlier vaginal delivery, even if the condition got better shortly after delivery, are likely at increased risk for future problems. They might do better with cesarean deliveries. "That's not a big group," said Schaffer. "We don't have the answer about who is at risk, other than forceps and episiotomy are probably not good."
Cesarean deliveries, while safe for the vast majority of mothers and babies, are major surgery. They carry risks to the mother such as potentially life-threatening blood clots, infection from surgery, longer recovery time, and a risk of placenta accreta, in which the placenta attaches to the incision in a subsequent pregnancy. While most elective surgery is a one-time event, cesarean section often means additional surgery for each pregnancy that follows.
The primary risk to the baby, deprived of that long, hard trip through the birth canal, is lung problems. "Vaginal birth gives the baby a massage, squeezing out the lungs and stimulating the heart," says Robbie Davis-Floyd, author of Birth as an American Rite of Passage. Premature birth is also a risk with a C-section because, without the natural trigger of labor, no one really knows when it is time for a baby to be born. And some cesarean-delivered babies have problems feeding at first.
The World Health Organization has recommended a cesarean rate of 10 percent to 15 percent, says Marsden Wagner, a perinatologist who has worked on the WHO studies. The U.S. Department of Health and Human Services would also like the C-section rate in American hospitals to be no more than 15 percent. But if society begins talking about surgical delivery as a woman's right, a choice equal to requesting a face-lift or a tummy tuck, obstetricians trying to keep their C-section rates down will have a harder time. "Doctors will use the rationale that if women can come to me for an elective C-section, why should I work hard to keep the rate down?" says Richard Waldman, an obstetrician in Syracuse, N.Y.
Women have fought for three decades to demedicalize childbirth without sacrificing safety, says Jan Christilaw, an obstetrician from White Rock, British Columbia. She predicts a backlash against the growing C-section rate: "This is a way of remedicalizing birth. I think birth is such an important cultural process that to divorce ourselves from its natural course is horrific."
The cesarean spike
[Complete chart data are not available.]
Per 100 births
Source: Centers for Disease Control and Prevention