After a seven-year decline, the C-section rate is increasing again. Twenty-two percent of the 4 million women who gave birth last year had the operation, nearing the all-time high of 25 percent recorded in 1988. At that time, public-health officials began a campaign against non-emergency C-sections. They cited the dangers inherent in major abdominal surgery: infection, hemorrhage, organ injury, complications from anesthesia and even death. They pointed to the risk to babies of premature birth and respiratory problems, which can land them in the intensive-care unit. And insurers crunched the numbers: cesareans cost at least $900 more than vaginal births and typically result in at least one extra day in the hospital. The Public Citizen Health Research Group said half of C-sections are unwarranted. The experts’ bottom line: a cesarean rate of more than 15 percent is medically unsound.
Today that view is under challenge, with patients demanding more choice and many obstetricians declaring C-sections to be their right. Almost two years ago an editorial in the New England Journal of Medicine argued that “setting a target rate is an authoritarian approach to health-care delivery. It implies that women should have no say in their own care.” The article, written by a team of Harvard physicians, went on to say that “economic forces are driving the cesarean-delivery rate toward the… goal of 15 percent. Before we permit this trend to continue, we need to ensure the safety and health of mothers and their babies.” W. Benson Harer Jr., president of the American College of Obstetricians and Gynecologists, puts it more plainly: “Women are being bullied not to get cesareans.”
What’s a mother to do? Cesareans are not risk free. “Women are losing lives because of unnecessary surgery,” says Connie Banack, president of the International Cesarean Awareness Network. But C-sections have some advantages. Here are facts cesarean advocates urge women to consider before assuming that “natural” childbirth is always best:
Vaginal delivery is painful. Other animals deliver quickly, but “it’s uniquely humans who lie around for 24 or 36 hours suffering,” says Ob-Gyn David Campbell Walters, author of “Just Take It Out!” He says the evolution of the human head has made it too big to fit comfortably into the birth canal. A 1997 study found that 31 percent of female British obstetricians would prefer to deliver their own babies by cesarean.
Vaginal delivery can have serious–and costly–medical consequences. Especially if doctors use mechanical interventions, such as forceps, vacuum extraction or episiotomy, vaginal delivery can increase the risk of lasting problems like gas and urinary incontinence. And long labors–particularly when followed by unplanned C-sections (and lawsuits)–can add thousands to the overall price tag.
Vaginal births after cesareans (VBAC) can be dangerous. Many women with prior cesareans don’t want to risk rupturing the uterus during labor, so they often reject the medical establishment’s encouragement to undergo a VBAC. “If a woman ruptures her uterus, you have about 17 minutes to have the baby out before you begin to have [brain] damage,” says Dr. Roger Freeman, chair of the American College of Obstetricians and Gynecologists task force on cesarean-delivery rates. ACOG said in August of 1999 that a physician should be “immediately” available, not just “readily available,” during VBACs. That’s not always possible, especially in rural areas. If a clinic isn’t equipped to perform VBAC safely, cesarean delivery isn’t just a convenience but a practical necessity.
In the end, both sides are half right. Vaginal delivery is the cheaper method of childbirth–and, unlike a cesarean, is not major abdominal surgery. But from the perspective of some Ob-Gyns, restricting a woman’s right to choose a form of childbirth makes no more sense than forcing her into the cheaper of two cancer therapies. “In natural childbirth,” says Walters, “we don’t even mention that there is an alternative. They’re not told their bladder is likely to be negatively impacted. They’re not told about the possibility of worse sexuality. We are keeping the advantages of cesarean delivery secret.”
A cesarean isn’t for everyone–and insurance may not cover it if you’re doing it just for your own convenience. Talk to your doctor to decide whether a C-section is right for you. Wanting more peace of mind after a previous cesarean or being certain your own doctor is on hand may be reason enough. Just make sure you understand the risks as well as the benefits.
