Birthing by Appointment
Cesareans are in; pushing is out. The pros and cons of this new reality are laid out in the National Institutes of Health's report on the rising tide of cesareans by mother's choice, not medical necessity, published in the June issue of Obstetrics & Gynecology. Close to a third of our little ones enter the world through a surgical incision in their mom's belly, up from about 5 percent during most of the past century. And this is a worldwide phenomenon, particularly in private clinics and hospitals. Among Brazil's most educated and affluent women, for example, C-sections account for over 70 percent of deliveries. By World Health Organization standards, these rates are out of control and should be no more than 15 percent. The Department of Health and Human Services agrees and wants to bring our nation's numbers into that range by 2010. Good luck. As more women expect that the mode of delivery is up to them, the rate of C-sections is apt to rise even higher.
Current estimates suggest that as many as 18 percent of cesarean deliveries may be for nonmedical reasons. Some women are worried that vaginal births overstretch, and sometimes damage, pelvic tissues and lead to problems like incontinence. Birthing by appointment offers women and their families more control over their lives. Some women are sensitive to the less glamorous aspects of pushing to exhaustion as their husbands watch helplessly, or quite simply see no glory in the pain of it all. It was big news last year when singer Britney Spears reportedly opted for a C-section because she feared the agony of a vaginal birth.
Queen for a day. Fortunately, gone are the myths that women are meant to suffer in childbirth to atone for Eve's taking a big bite of the apple. On that score, bless Victoria, queen of England and head of its church, for taking chloroform anesthesia when she delivered two of her children back in the 1850s, quickly making pain control a sanctioned birthing option. But there's a downside; anesthesia, even the epidurals of today, can slow the progress of labor and up the odds of a surgical delivery. In reaction to this "medicalization" of maternity, baby boomers led a natural-childbirth movement that promoted delivery with little or no anesthesia. We've now come full circle, as their daughters--with normal pregnancies--seek the most medicalized births of all.
Concerns about this trend led the NIH to convene a "state of the science" conference to develop the new report. The experts conclude that evidence is simply inadequate to say that either an elective cesarean or a vaginal birth is the safer choice for low-risk pregnancies. More research must be done. But the National Institute of Child Health and Human Development's chief of pregnancy and perinatology, Catherine Spong, points out the limitations of comparing isolated birthing events without factoring in a woman's full reproductive life span. "There are serious implications to starting down the road of cesareans," she says. With each C-section, the womb is further injured, thereby decreasing fertility. It also compounds the risk that future pregnancies will face the infrequent but catastrophic complication of uterine rupture or distorted development of the placenta.
With the debate wide open, the panel dismissed the 15 percent public-health goal as "artificial," stating that "declarations of an ideal rate should be discouraged." This no doubt brings a sigh of relief to doctors who have been struggling to justify rising C-section rates that include high-risk pregnancies (where C-section rates are by necessity greater) with stated public-health goals. But what's a doctor to do in the face of limited research on an emerging practice that is changing how babies of low-risk pregnancies are born?
The answer is to be neither a robot nor a potted plant. Frank Chervenak, chairman of obstetrics and gynecology at New York Weill Cornell Medical Center, is upfront in saying that vaginal delivery is the better choice for childbirth, and he sees no evidence to recommend a nonmedically driven cesarean. Regardless of patients' requests, he says, doctors are obliged to offer clear and directed medical opinions--and they must avoid the ethical conflict of going along with elective cesareans in order to lower malpractice liabilities or create kinder, gentler working hours. But Chervenak readily admits that one must respect a woman's autonomy and ultimately accommodate her informed and thought-out decision. Welcome to the world of consumer-directed healthcare.
This story appears in the June 12, 2006 print edition of U.S. News & World Report.