Caesarean deliveries are on the rise. Nearly three in 10 babies born in the United States are now delivered by C-section. Most are performed at the discretion of doctors. But, increasingly women are requesting elective Caesareans for non-medical reasons. Some mothers want the convenience of scheduling the delivery date. Others want to prevent damage to the pelvic floor in order to preserve sexual function and bladder control.
Jamie Seward, a 31-year-old attorney in Baltimore, Md., chose to deliver her son, Teddy, by C-section. She approached her doctor early in her pregnancy, and he advised her of the risks and benefits of the delivery option.
Seward says he encouraged her to make her own decision: "I thought it was great that women could choose the birth experience as opposed to having the experience forced upon them."
Seward says she does not regret her decision. She weighed her options carefully, and in the end she had an easy delivery with a healthy baby. She was able to begin jogging five weeks after her delivery and hasn't had any bladder problems.
Some women are critical of the choice, but Seward defends the choice. "It's not for everyone, but scheduling a C-section for me was a preference and I'm happy with the decision," she says.
Within the medical community, the trend is controversial. Many obstetricians encourage the choice. Sometimes they perform the procedure to prevent medical malpractice issues or to comply with hospital policies that require C-sections in certain instances.
For instance, several years ago, VBACs (vaginal births after Caesareans) were optional. Now, this practice is waning. Doctors and hospital administrators don't want the risk. Women who've delivered one child by C-section stand a greater chance of suffering a uterine rupture.
As a result, once a women has had one child by C-section, she's strongly encouraged to have the second child by Caesarean as well.
Groups that promote the natural childbirth process are critical of the C-section trend. Dr. Michael Klein, an emeritus professor of family practice and pediatrics at the University of British Columbia, is among the critics.
"Looking at the big picture and summarizing all the maternal and baby data, vaginal childbirth is the safest route for most women," says Dr. Klein. "Is it the safest for every woman? No."
Klein says many of the presumed benefits of Caesarean deliveries are overstated. For instance, Caesareans do seem to protect women's bladder function in the short-term. But it's not clear that this protection lasts. Studies show that by the time women are 50 years old, the rate of incontinence between women who've had vaginal deliveries and women who haven't is similar.
Klein argues that women may not be hearing enough about the risks of Caesarean deliveries. "For every 153 C-sections, one woman will be readmitted with a complication, meaning she will go back to the hospital," he says. This means a small number of women will have infections or bleeding, which can be serious. As for the newborns, Klein cites studies that show C-section babies are at greater risk of respiratory problems. Hospital records show they're admitted to the infant-intensive care units more often and require oxygen therapy more often than babies born vaginally. "We are not improving outcomes for babies, and we're damaging mothers," says Klein.
Klein's views do not represent the medical consensus. The National Institutes of Health just wrapped up a three-day state-of-the-science conference, Caesarean Delivery on Maternal Request. Hundreds of obstetricians, midwifes and family physicians attended.
Some speakers presented research and evidence that show Caesarean deliveries cut the risk of fetal injury and brain damage in babies. But the research is not conclusive. In the end, the conference panel decided that there's not enough evidence to suggest that one method of delivery is safer than the other.
Dr. James Nicholson of the University of Pennsylvania says the data is soft on both sides, and this makes it difficult to know if traditional, expectant labor, where women wait to deliver until they go into labor is preferable to Caesarean delivery on maternal request. "Again and again, the speakers were saying we don't have evidence to speak to this important question." Says Nicholson. He's calling for a prospective research trial to compare the risks and benefits. Also, he's researching the possible benefits of inducing women one week prior to their due-dates (at 39 weeks gestational age) in order to cut the rate of Caesareans. Initial data shows that this is effective, mostly because the babies are smaller.
The panel set up by the NIH to assess the science on mother-requested Caesarean deliveries reached several conclusions. It recommends that women who plan to have more than two children should not choose elective C-sections. The reason is that the risk of complication increases with multiple-Caesarean delivery. In addition, the panel recommends that obstetricians steer clear of promoting elective Caesarean deliveries for non-medical reasons. Instead, physicians should discuss the prospect of a C-section delivery only after a woman expresses an interest.