What are the benefits and risks of elective cesarean section?
Safe Birth Practices Editorial
Erika Harding, Doula and Childbirth Educator
owner of Body, Mind & Spirit Childbirth and Family Resource Center

Women giving birth in Albuquerque are lucky. We have many options that other women around the country and even around the state don’t have, and in general we have a relatively humane birthing and maternity care system. I could cite many examples of this, but I’ll limit myself to one anecdote: as a Doula, or professional labor support person, here in Albuquerque I have attended about 90 births, the majority in hospitals. Out of these 100+ births, I have only once seen a doctor or midwife perform an episiotomy on a birthing mother. In contrast, I have a friend who is a Doula in Boulder, Colorado. My friend has attended 10 hospital births in Boulder, and each and every one of those women had her perineum cut by her doctor. In spite of Boulder’s reputation as a progressive town, they do not have midwives attending births in the hospitals, as we do here. The presence of midwives delivering babies in both hospital and out-of-hospital settings has a tremendous influence on obstetrical practice. In
New Mexico, home birth is legal, state licensed and regulated, and widely practiced. In Albuquerque, we have three hospitals that offer the Midwife Model of Care, an advantage we have over Santa Fe, where no Certified Nurse Midwives have been allowed to practice at the one maternity hospital, St. Vincent’s. Our hospitals are large enough to offer high-level emergency medicine when needed by mothers and babies, and there are still doctors and
midwives in Albuquerque who offer mothers who have experienced a previous cesarean birth the chance to birth their subsequent children vaginally. In addition, we have a large community of professional Doulas, and one hospital even employs Doulas on staff.

This is all to our advantage. However, Albuquerque and the country at large tands to take a major step back in maternal health as a consequence of a position taken by the American College of Obstetrician Gynecologists, or ACOG, the primary association of ObGyns in the country. ACOG regularly makes policy statements which have a powerful effect on obstetrical practice around the country. On October 31 of 2003, ACOG released a statement declaring as ethical” the practice of offering a healthy woman pregnant with her first baby
the option of scheduling an elective cesarean. Let me repeat. ACOG is opening the door for what they call a “shift in clinical practice,” allowing doctors to perform major abdominal surgery on healthy women without any medical ustification.

Does this surprise you? It certainly surprised me. I felt that it must be based on research, some evidence that shows that women or babies benefit fromcesarean birth, whether or not they have risk factors or complications. Strangely, no. About 36 of 100,000 women die in cesarean sections, compared to 9.2 per 100,000 for vaginal birth. In addition to the increased risk of dying, other risks to mothers include wound and uterine infection, hemorrhage, ureter injury, injury to bowels, urinary tract infection, thromboembolic conditions and incisional endometriosis. Their future births are also affected by a cesarean, which increases the likelihood of placenta previa, placental abruption, ectopic pregnancy, placenta accreta and uterine rupture. In addition, women who have their first baby by cesarean section are at higher risk of losing their next baby to an unexplained stillbirth before going into labor.

Ok, so elective (not medically necessary) cesareans are not a good thing for women and their future babies. How about for the baby? Babies delivered by elective cesarean section are cut during surgery 2-6% of the time, have a 9% chance of being born prematurely, and risk a 0.2-1.7% chance of developing respiratory distress syndrome, a potentially fatal complication. They spend more time in neonatal intensive care units and have more breastfeeding difficulties than babies born vaginally.

This is made even more clear by the following. We have a trust that our medical system is one of the best in the world, and that mothers and babies are lucky to birth in America, right? As of 1999 (the most recent data available), the US ranked 21st in the world for maternal mortality, and 28th among industrialized nations in infant mortality as of 1998, behind both the Czech Republic and Cuba. In spite of the tremendous financial resources we spend on maternal and infant health, our country loses a remarkable number of mothers
and babies.

This newest policy statement is not the first time ACOG has pushed for
increased surgical deliveries. During the 1980s and early 1990s, ACOG was
leading the push to reduce the number of cesarean births. However, in the
mid-1990’s ACOG, and obstetricians subsequently, experienced a policy shift
and cesarean rates for first-time mothers have been on a steady increase ever
since. In addition, the option for VBAC, or vaginal birth after cesarean, has
been removed from many mothers since an influential ACOG policy statement in
1999 advocated that only hospitals able to have a doctor and anesthesiologist
“immediately” available for each and every laboring mother who has previously
had a cesarean. As a result, successful VBAC rates fell by 42% between 1996 and
2001 and cesarean rates overall skyrocketted. In 2002, the U.S. cesarean rate
reached 26.1% overall. The World Health Organization has called for a
worldwide cap on c-sections at 10-15%, a rate that was found to be sufficient
to reflect complications requiring or benefitting from a cesarean delivery.

There is an old saying that there are lies, damn lies and statistics. It seems
clear from the extensive research that elective cesarean carries significant
risks to both mother and baby. But statistics can be manipulated and we don’t
always trust them to be definitive. So the question remains, does this policy
statement make good sense? Are birthing mothers here in Albuquerque and around
the country going to benefit from the option to choose surgery over pushing
their babies out the old-fashioned way? The answer is clear, submitting to or
requesting unnecessary major abdominal surgery makes no sense and does not
benefit women or their babies.

Unfortunately, given the constraints placed on OBs by malpractice insurance and
the fear of lawsuits, and the difficulty of scheduling prenatal care and
deliveries for large patient loads, scheduling a surgical delivery can make
sense for some doctors. Cesarean delivery is quick, carries a large paycheck,
and, as one OB quoted, “The in–laws get to use supersaver fares.” Some may
even believe it benefits the mother. ACOG president Benson Harer has
repeatedly expressed his belief that elective cesarean is just as safe as
vaginal birth, and that normal vaginal delivery is actually damaging to the
mother.

For mothers fearful of birth, or who have had previous cesarean deliveries, the
option of elective cesarean also has a veneer of sensibility. However, if women
are supported during the prenatal period and given good, inspiring childbirth
education to prepare for the challenges of the process, fears can be addressed
and the birth experience can be a powerful event that inspires self-confidence
and good mothering. This is just not true of an unnecessary cesarean birth.
Similarly, if women who have had a previous cesarean section are allowed to
birth without induction or augmentation by pitocin or prostoglandins, their
actual risks are much lower if they give birth vaginally.

Nationwide, and here locally, mothers and birth professionals are rising up in
opposition this push by ACOG for more elective cesareans, which leads to more
repeat cesareans down the road. Here in Albuquerque we have formed the Safe
Birth Information Initiative. The key word here is INFORMATION. Along with
many other groups around the country who are taking action against ACOG, we are
not opposed to women’s right to choose a cesarean birth, or any other birth
option that may be available, as long as this is an informed choice. Thus far,
women have been presented only with the risks and benefits of natural birth,
home birth and VBACs, while the true risks and benefits of elective cesareans
have been neglected. This is not informed choice on the part of parents as
health care consumers and is not good policy.

We need to work against this disturbing trend. Encourage your doctor to stand
up for a woman’s right to give birth normally, without unnecessary surgical
intervention. Encourage hospitals, doctors and midwives to support women who
wish to have a VBAC. Encourage hospitals to employ midwives and follow
low-intervention protocols for low-risk birthing mothers. For more information
on research cited in this article contact Body, Mind & Spirit Childbirth and
Family Resource Center at 232-2772.