C-Section Debate Is Back

Celina Sotomayor, mother of Supeeme Court nominee Sonia Sotomayor, wipes her eyes on Capitol Hill in Washington, Monday, July 13, 2009, during a confirmation hearing before the Senate Judiciary Committee. AP Photo/Ron Edmonds

Doctors reassured Randi Rosenberg there was no reason to fear natural childbirth — she was in fine shape. But she so wanted to skip labor with her first baby that she switched doctors to get an elective Caesarean section.

It's still very rare — and intensely controversial — but more expectant mothers seem to be choosing C-sections even when there's no clear medical need.

So says a new study that, by counting insurance claims data, estimates some 80,000 women had pre-planned, elective C-sections in 2002, up from an estimate of just under 63,000 the year before.

That's a tiny fraction of the nation's 4 million births. But the numbers have revived a long-running debate among obstetricians who for years have been urged, by the government and consumer groups, to lower the overall number of Caesareans they perform. In 2002, C-sections accounted for 26.1 percent of all births, a record high.

Make no mistake: Caesareans can be life- or health-saving for many mothers and babies. Fetal distress, breech babies, twins or more, or diseases that make labor risky for the mother can all be important reasons to have one.

Still, it's major abdominal surgery that, although safer today than ever before, still carries some serious, occasionally life-threatening, side effects: hemorrhage, infection, blood clots. Possibly more important, one C-section brings even more risks to future pregnancies.

So critics insist C-sections require a compelling medical reason.

But proponents of elective C-sections say the worst risks are extremely rare, especially in a healthy, rested woman — and that vaginal birth has its own problems, including a possible but unproven higher risk of incontinence from vaginal tears or use of forceps. They say fully informed women should be able to choose.

"Most doctors, when they are being honest... recognize there are cases to be made for both sides — and also recognize that the question hasn't been studied in a way that permits anyone to know for certain what the best course is," says Dr. Jeffrey Ecker, a Massachusetts General Hospital high-risk obstetrician.

He co-wrote recent ethics guidelines for the American College of Obstetricians and Gynecologists to help doctors determine how to weigh the pros and cons with interested patients, and when to refer them to another physician.

"This is surgery, this is not getting your nails done," adds Dr. Jacques Moritz of St. Luke's-Roosevelt Hospital in New York.

He performs some elective C-sections, including Rosenberg's, but makes women debate the options — plus his hospital wants such patients to get a second opinion.

"It felt like the right thing to do," said Rosenberg, 38, whose daughter Alexandra Marais was born June 8.

Years ago, Rosenberg had surgery to remove a fibroid. Now she feared that pushing during natural childbirth could rupture her uterus. Moritz and another doctor said the old scar wasn't a threat, but she wasn't convinced. And the convenience of knowing when to temporarily close her business added to the allure of a planned C-section.

"There are lifestyle considerations on top of the health considerations," she says. "In the end, you have to make the decision that fits your life."

Rosenberg seems typical of the fledgling trend: Women getting elective C-sections are usually over 35, more affluent, and planning only one child, says Dr. Samantha Collier of HealthGrades, a Denver-based company that studies health care quality.

HealthGrades culled insurance claims from 16 states, covering half the nation's deliveries, in estimating first-time, preplanned C-sections without a clear medical indication. They accounted for 2.2 percent of deliveries in 2002, a 25 percent increase in three years, the study says.

Isn't increased cost a barrier? Not necessarily, Moritz says. C-sections usually cost more because of an extra day or two in the hospital. But many women spend so long laboring in the hospital before a vaginal delivery that they can cost as much in extra nursing care and pain relief, he says.

So what should women consider?

Discuss your delivery concerns, Ecker says, because they might be addressed without surgery. Labor pain can be controlled. As for incontinence, some research suggests simply being pregnant raises that risk.

Think seriously about future children. One C-section "may doom you for life to have repetitive C-sections," each one riskier, Moritz cautions.


By Lauran Neergaard
  • Raksha Shetty

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