Archive for Sunday, September 19, 2004

Too posh to push’

Rise in Caesareans spurs medical ethics debate

September 19, 2004


Legend has it that Julius Caesar, or at least one of his ancestors, was delivered by Caesarean section. That's tough to verify. Back then, given infection risk and primitive anesthesia, you didn't want to have one.

The Centers for Disease Control and Prevention last year reported a 7 percent increase in Caesarean deliveries between 2001 and 2002, to reach a rate of more than one in four births -- the highest ever reported in the United States.

For the past few decades, doctors were getting the blame, accused of opting for a sure-thing delivery instead of being summoned from the golf course.

But now, it seems, women increasingly may ask for them. In a pampered society where we're always on deadline and not big on suffering, and with the average labor for a first baby ranging from 12 to 14 hours, headlines are now hinting that women are increasingly "too posh to push."

A study published earlier this year estimated that 80,000 women had pre-planned, elective C-sections in 2002, up from just under an estimated 63,000 the year before. And even though that's still a smidgen of the nation's 4 million births annually, the trend is launching an ethics debate among obstetricians.

Samantha Collier, vice president of medical affairs for the Colorado-based HealthGrades, said it's clear that most women still prefer to deliver vaginally. "It's what we've been doing for eons, so the thinking is, why mess with something that seems to have worked in the past?"

But on the other hand, she said, some see Caesareans as a technological advance. "Why go through 24 hours of labor when you can pre-plan it? Yes, there may be longer recovery time, but for some women, they very much like to be in control."

There's also some thought, she said, that C-sections will catch on as society becomes increasingly comfortable with elective procedures, from cosmetic surgery to laser-vision correction.

The American College of Obstetricians and Gynecologists last year published an ethics policy. The group determined that without conclusive data on the long-term benefits of elective Caesarean vs. vaginal delivery, there is no single correct response. It concluded the physician is within rights to refuse to perform the surgery or to do it, given informed consent from the patient.

Dr. Martha Laird, an obstetrician and gynecologist at Ironwood OB/GYN in Tucson, Ariz., said that if a patient wants an elective procedure and if Laird is satisfied they've fully explored the risks and benefits together over several visits, she will usually do it. "I feel it's her body and her choice," she said.

Most of her patients seeking C-sections, she said, have had some trauma from a previous vaginal birth, from lacerations to trouble with incontinence.

Generally, she said, she tells patients that C-sections carry an increased risk of infection and damage to adjacent organs, such as the bladder. There is a risk of more bleeding and, therefore, a risk of transfusion.

On the other hand, she said, there is some thought that C-sections may better protect the pelvic structures and consequently preserve sexual and urinary functions.

For women who have wrestled with infertility problems, Caesareans provide a bit more confidence that the baby will turn out all right, she said. While Caesareans can reduce birth trauma, she added, labor can serve as a benefit to the baby. As babies are squeezed through the birth canal, it helps squeeze out fluids and triggers breathing reflexes when they emerge.

¢ The American College of Nurse-Midwives offers a free booklet on the risks of Caesarean section:¢ The Mayo Clinic offers a primer on C-sections. Type "caesarean" into the search engine and click on "C-section: A safe birthing option":

Although Laird envisions a day when elective C-sections will be more common, insurers are still reluctant to pay for them. A C-section usually means at least one more day in the hospital and more money in physician and anesthesia costs, adding at least $2,000 to the cost of delivery.

On the other hand, a recent University of Texas-Houston study showed they may actually be more cost-effective if the expense of long-term pelvic floor complications is taken into account.

Getting straight information online can be tricky, because many doctors and midwives feel strongly about the issue one way or the other. Talk to your doctor about your options, ask about the pros and cons, and ask what she would do if she was in your position. For a start, though, here's a list of risks and benefits generally highlighted by Dr. Martha Laird, an obstetrician and gynecologist in Tucson, Ariz
Advantages Disadvantages
¢ You swap painful labor for a longer recovery period.¢ You'll know in advance when your baby will arrive, allowing you to make necessary arrangements.¢ Although evidence is not conclusive, there is some suggestion that C-sections reduce risk that pelvic floor muscles will be damaged, presumably reducing the risk of incontinence.¢ Birth for the baby is less traumatic. ¢ Risk of infection.¢ Increased blood loss, although transfusions are rarely needed.¢ Longer recovery period requires at least one extra day in the hospital and could make breast-feeding uncomfortable initially.¢ Insurance isn't likely to kick in without medical necessity.¢ Babies are more likely to have breathing problems initially, because fluids aren't squeezed out during the birthing process.

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