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For other articles and previous issues click here. August 29, 2005 The
Lure of Cesarean Sections Are women opting for the medical procedure for all the wrong reasons? The battle over abortion is well known. A newer, and some would say equally, divisive issue is emerging in the field of women’s reproductive health: The growing number of cesarean births. Some members of the medical community consider this an advancement, while others view it in a more negative light. Those who maintain that cesarean sections are overused point to the fact that this mode of delivery accounts for 27.6% of all births, according to 2003 statistics. The U.S. Public Health Service has been seeking a reduction in the rate of cesareans to 15%. Furthermore, it has set a goal to have 37% of women who previously had a cesarean section to try vaginal delivery for the next child. In an article published in the December 16, 2004, issue of The New England Journal of Medicine, a team of medical researchers concluded that for pregnant women who previously had a cesarean delivery, a vaginal delivery is more dangerous for both the mother and baby. However, opponents of cesareans question the study’s results. What are the reasons behind the growth of cesareans? Even here there is disagreement. “Over the past several years or so, the needs for increased cesarean, from a purely medical perspective, have increased dramatically,” says Robert C. Hock, MD, FACS, FACOG, chairman of the department of obstetrics and gynecology, South Nassau Communities Hospital, Oceanside, N.Y. “These conditions are warranting far more cesareans than there were in the past. About this aspect there is little debate, and the medical community is comfortable with it.” Joel M. Evans, MD, OB/GYN, assistant clinical professor at Albert Einstein College of Medicine in Bronx, N.Y., disagrees. “Unfortunately, we’re in an environment in which more cesarean sections are performed than are necessary,” he says. “One of the reasons for this is the practice of defensive medicine. Doctors are making decisions to perform cesarean sections sooner than they did in the past to avoid lawsuits. What I mean by this is that some cesareans are clear medical necessities, but others lie in a gray area, where there are other possible medically appropriate options. Now, more and more physicians find it easier to follow the growing trend of just go ahead and do it, avoid a lawsuit.” “The perception that there is greater medical need for cesarean in women today ignores the reality that vast numbers of cesareans are the result of iatrogenic complications,” says Tonya Jamois, president of the International Cesarean Awareness Network. “Simply put, the obstetric community has been overly zealous in ‘treating’ a normal physiological process and has been triggering many of the medical crises that lead to cesarean surgery. Greater adherence to evidence-based medicine would drop the national cesarean rate dramatically.” A healthcare organization’s financial status may also play a role in the decision-making process. “Obstetricians and hospitals have found that high-intervention birth, warranted or not, is very profitable,” Jamois says. “So there is a tremendous financial incentive to bypass the clinically optimal approach, and opt for convenience and profit. For example, many hospitals across the country have eliminated facility-based midwifery practices simply because the low-intervention approach, while clinically sound, does not bring in as many dollars.” Evans says another reason for the increase in cesareans is that doctors are no longer being trained in the use of forceps or vacuum deliveries. Thus, when a baby is not progressing properly and may get stuck toward the end of the journey, doctors don’t have the skills to navigate the baby through the vaginal path. A forceps is a kind of pliers that grips the baby by the head and a vacuum delivery uses a suction cup on the baby’s head to pull. Should these techniques be discarded? “They sound barbaric,” Evans acknowledges, “but when used appropriately, they don’t harm the baby. You can destroy the baby or kill the mother through cesarean as well if you don’t do it properly.” Evans, the author of The Whole Pregnancy Handbook, is also the founder/director of the Center for Women’s Health in Darien, Conn. “We believe in a holistic approach, with the obstetrician working closely with the patient to create a healing partnership. If patients so choose, we also work with midwives and doulas [a specially trained person to help during labor and after the birth of a baby]. It’s a great combination, which can minimize the use of forceps, suction cups, or cesareans.” Nevertheless, the rate of cesareans continues to climb. Some experts have suggested that the increase is part of a larger trend. “Across the board, the movement in healthcare today is to involve the patient much more in the decision making of the care they receive,” Hock says. More specifically, he says, mothers are choosing cesareans because it’s their right. Sometimes, the decision is not based solely on medical considerations. “They [the decisions] can be [made] for convenience, so they don’t have to take time off for work, or so their spouses can be available,” Hock says. “It’s birth on demand. Or, the woman may simply not want to go through the labor, which can be painful.” “Women don’t want to be in an emergency situation, they may fear the baby may be harmed,” Evans says. “They may want to keep their vaginal muscle tone intact for intercourse, or to avoid a dropped bladder later in life.” How pronounced is this trend? “I can tell you that the opinion is rapidly developing that, as long as the appropriate discussion has taken place between the woman and her obstetrician, with all of the ramifications laid out, and that informed consent takes place, that the current trend is for the woman to exercise her right to choose, for any reason whatsoever, including nonmedical,” says Hock. Both doctors agree that there are dangers to cesarean births not present in normal births. “[There is] some increase in medical complications, such as womb infection, blood loss, length of hospital stay, and longer recovery time compared to a normal delivery,” Hock says. Evans adds that a cesarean birth “presents real risks for the mother and some for the baby, though not as much as for the mother. It’s very expensive. And it makes it much harder for the baby and mother to bond. The mothers are medicated for major surgery, and sometimes the babies are medicated. Those first few days after birth it’s very important for the mother and baby to get to know each other. I’m not saying that the babies are necessarily permanently harmed. But all too often there is a negative effect on bonding when compared to vaginal birth.” When asked whether he would perform a cesarean on a woman who requested one for a nonmedical reason such as convenience, Hock says given that the full disclosure discussion takes place, he would perform the procedure. However, it’s not a simple issue. “At this point in time, the medical community is clearly divided on this issue,” he says. “If an obstetrician is uncomfortable in this situation, I would not advocate that he be mandated to treat a patient that he felt did not meet his standards of care. “There is the opposing view of a significant body of both the medical community and general public who recognize that a cesarean section is not guaranteed to be without significant complications,” he continues. “In light of the potential for serious complications, healthcare professionals as well as patients and families should not take cesareans lightly or undergo them for convenience. Complications occur at a greater rate for cesareans than for vaginal deliveries.” “I think that if the woman has all the information, she would be less likely to opt for a nonnecessary cesarean,” Evans says. “Personally, I would never perform one of those operations.” Jamois says it is important for physicians to present women with all pertinent information in a fair and balanced manner. “With the small but growing number of women requesting elective cesaraeans, we must question the counsel they are getting from their doctors,” she says. “While they may say they are outlining all the risks, what we often hear is that the doctor will zip through all the lethal risks of surgery in 30 seconds and then spend the next 10 minutes talking about how a cesarean will save them from urinary incontinence. The short- and long-term risks of cesarean to mother and baby are tremendous, and if women were being given thorough counseling about the risks to themselves and their babies, we would rarely see elective cesareans.” Vaginal Births After Cesareans Nineteen academic health centers belonging to the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development participated in the study. During a four-year period, researchers monitored all pregnant women at the centers who had had a cesarean section and were carrying a single child. A total of 45,988 women fit the criteria. Of those, 17,898, or 38.9%, elected to try normal delivery, while 15,801, or 34.4%, chose a second cesarean. Of the remainder, 9,011 had medical reasons to have a second cesarean and 3,276 were already in labor when they arrived at the hospital. The results showed that the rate of uterine rupture was seven per 1,000 among mothers attempting vaginal delivery, compared with no uterine ruptures among the women who chose a second cesarean. Endometritis developed in 2.9% of the women who chose normal delivery, compared with 1.8% of the women who opted for a second cesarean. Of the women who delivered vaginally, 1.7% required a transfusion, compared with 1% of those in the cesarean group. The researchers said the results indicate that in approximately one in 2,000 cases, the baby would be affected adversely during the attempt at normal delivery. The risk “is quantitatively small but greater than that associated with elective repeated cesarean delivery.” The researchers found that one complication of birth—insufficient oxygen supply to the brain—was significantly greater among the infants of women who underwent labor than among the infants of women who elected a second cesarean. The rate was eight per 10,000 in the attempted vaginal delivery group while there were no cases in the repeat cesarean delivery group. The study concludes that vaginal birth after a cesarean section (VBAC) is more dangerous for the mother, leading to the possibility of a ruptured uterus and such complications as endometritis and the need for transfusions. Also, the study maintains that VBAC is more dangerous for the baby, possibly leading to serious brain damage. “This information is relevant for counseling women about their choices after a cesarean section,” says one of the researchers, Margaret A. Harper, MD, associate professor of obstetrics and gynecology at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. The researchers note that it has generally been accepted that vaginal delivery is associated with lower maternal morbidity and mortality rates than cesarean sections. However, the instances of infection or inflammation of the wall of the uterus and the increased rate of transfusion mitigate that advantage. “During the past 25 years, as the number of repeated cesarean sections grew, vaginal birth after cesarean section was increasingly recommended in clinical-management guidelines, prompting a rise in the use of this approach in the United States from 3% of deliveries after a cesarean section in 1981 to 31% in 1998,” the researchers wrote. Increasing concern about the risk of uterine rupture and the health of both the mother and the baby led to a sharp decline in VBAC to 12.7% in 2002. The new study was aimed at providing scientific evidence on which approach was better. “This study shows that the risk of adverse perinatal outcomes is increased with a trial of labor after a prior cesarean delivery but also confirms that the risk is still very small,” says Harper. “Therefore, the members of the network conducting this study recommend thorough counseling of women interested in VBAC, but have not recommended abandoning VBAC.” Evans, who is familiar with the study, says, “I disagree with some of the paper’s conclusions. For example, the study didn’t look at long-term complications such as scar tissue.” Moreover, Evans says, “what the study shows to me is that the frequency of severe things that can happen to a baby are statistically very, very low—12 babies out of almost 18,000 women, which is equal to a risk of 0.46 per 1,000. I believe if you handle a VBAC delivery in a very cautious way, it is possible to minimize even this low risk.” Backing up Evans’ viewpoint is the National Institute of Child Health and Human Development, which viewed the results as confirmation that VBAC is a safe and reasonable choice for women. It pointed out that study results indicate the risk for infection, surgical complications, and maternal death appear to be greater in women undergoing elective repeat cesarean (ERC) compared with those who have a successful VBAC. “Both VBAC and ERCs pose rare but important risks for mothers to consider,” Jamois notes. “The study authors noted that there is no clear winner in terms of safety and that VBAC is a reasonable choice for mothers to make. Yet more than 300 hospitals across the country have instituted formal bans on VBAC, essentially pushing mothers into ERCs against their will. These bans are clearly unethical when we consider basic tenets of patients’ rights, and they are absolutely unenforceable, since surgery against the consent of a patient constitutes assault and battery. Yet, hospitals are currently getting away with it because pregnant women are afraid to confront the system in labor and many are simply fleeing hospital care altogether, opting instead for birth at home.” — Thomas G. Dolan is a medical/business writer based in the Pacific Northwest. |
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