Too Posh to Push?
Cesarian sections have spiked dramatically. Progress or convenience?
The fact is indisputable: The number of babies being delivered by cesarean section is rising sharply. But beyond that fact are vast uncertainties, including the cause of the increase and even whether it's a good or bad thing. Some blame a generation of new mothers unwilling to endure the pain and inconvenience of having a baby the old-fashioned way. Accustomed to controlling every detail of their lives, these women are too impatient for the uncertain timing of labor and too pampered for hours of contractions. They are, in short, too posh to push.
But not everyone is ready to blame the mothers. Others say it's doctors who are cloaking their own preference for C-sections in "women's choice" rhetoric. Worried about malpractice suits and protective of their own free time, OB-GYNs are telling prospective mothers that cesarean sections today are safe--or at least safer than vaginal deliveries. Indeed, some may be using the pain of contractions as a tool to coerce women into surgery, critics say. "You can take almost any laboring patient and talk her into a C-section," says Green Bay, Wis., obstetrician Robert DeMott. "That's part of the reason why we have a tremendous variation in C-section rates in the country."
Trend spotting. Whatever the reason, the U.S. rate of cesarean section spiked in 2001, up 7 percent since 2000 to the highest rate since the government began keeping tabs. Today, 1 in 4 babies in the United States is delivered by cesarean section. The rate of first-time C-sections, at 16.9 percent, is also the highest ever reported, up from a low of 14.6 percent in 1996 and 1997. Adding to the trend is a drop in the rate of vaginal births after a previous cesarean, which fell from 20.6 percent in 2000 to 16.5 percent in 2001.
Certainly, there are good reasons for a C-section, and the availability of the surgery has saved countless lives. A rise in the rate of herpes and in the number of first-time mothers at risk because they are older could account for some of the rise. But not all, and that's why experts are focusing on legal concerns and our culture of convenience and control. The debate among women can be as heated as among doctors. "This is a horrible trend that is in total opposition to natural law," says Anita Woods, vice president of the International Cesarean Awareness Network. Moya Cook of Marion, Ill., has a rebuttal: "I'm a nurse, and I've seen a lot of complications such as prolapsed uterus, prolapsed bladders. When I found out that I was having twins, I up front told them I wanted a C-section." Cook did indeed have the C-section she wanted.
In her case, the twins presented breech--feet first, a difficult vaginal delivery. Fortunately for Cook, this is a medical indication for the procedure that satisfied insurers. Without a medical reason, physicians cannot ethically perform a cesarean section simply because a woman wants it, says David Walters, Cook's obstetrician and author of Just Take It Out!: The Ethics and Economics of Cesarean Section and Hysterectomy. But that doesn't necessarily stop a doctor, Walters notes: "What people do is they'll make up some kind of bogus reason, like `the umbilical cord is in front of the head.' "
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
1995 20.8
2001 24.4
[labels]
20
21
22
23
24
Source: Centers for Disease Control and Prevention
Rod Little--USN&WR
This story appears in the August 5, 2002 print edition of U.S. News & World Report.