Women turn to C-section

By MARIE MCCULLOUGH
Knight Ridder Newspapers

Just 10 years ago, cesarean section was considered a dangerous, costly surgery that doctors overused, insurers discouraged and women dreaded.

Now, more and more people see vaginal birth that way.

Hundreds of small community hospitals across the country will no longer allow vaginal birth after a previous cesarean. Doctors are warning women that it is riskier for babies than a cesarean. And first-time mothers may now make a choice that their mothers could not: to have a c-section instead of a vaginal delivery simply because they want to.

“Vaginal birth may be nature’s way, but nature’s way has always been hazardous,” write physicians Ralph W. Hale and W. Benson Harer Jr. in an editorial advocating elective first-time cesarean delivery, which they contend preserves the health of mother and baby.

The editorial appears in the newsletter of the American College of Obstetricians and Gynecologists.

Federal data show the about-face: After declining from 1989 through 1996, cesarean deliveries soared from 21 percent to an all-time high of 28 percent of U.S. births in 2003. The rate for vaginal birth after cesarean plunged from 28 percent in 1996 to 11 percent in 2003.

Why is having a baby the way women always have suddenly so fearsome? Recent research shows vaginal birth after cesarean is riskier than once thought, which has intensified liability jitters. Conflicting research has fueled debate about whether vaginal birth damages pelvic anatomy.

But a social shift is also under way. Gone are the days when women demanded drug-free, low-tech, all-natural childbirth — to the dismay of midwives and maternity-care activists.

These days, pushing a baby into the world is a profound experience some women would just as soon skip.

“It’s very disturbing,” said obstetrics nurse manager Betsy Blaine at Tyler Memorial Hospital in Wyoming, Pa., where two first-time mothers opted for medically unnecessary cesareans in the last few months. “I just can’t believe God would create a way to have babies if it was wrong. It’s like telling God he made a mistake.”

Laura Ann Porter cannot imagine why a woman would want to have her abdominal tissues and pelvic organs variously dissected, stretched and retracted, risking heavy blood loss and infection.

Porter’s first two pregnancies ended with cesareans because of fetal distress, leaving her uterus too battered to ever try vaginal birth.

Recently, she was cut open for a third time and her daughter, Ashanti Fundenberg, was pulled out. The operation was long and difficult because scar tissue was stuck to Porter’s uterus and other organs.

She will not suffer it again.

“I had my tubes tied,” the 21-year-old said from Pennsylvania Hospital, where she was to spend five days recovering.

Marie O’Neill, 41, an obstetrician gynecologist at Thomas Jefferson University Hospital, chose a cesarean for her first, and probably last, delivery nine months ago.

She had no medical need, but hoped surgery would protect her pelvic muscles, nerves and organs from possible incontinence, sagging and sexual dysfunction in the future.

Fans of elective, medically unnecessary cesareans argue that they provide such protection, although even the American College of Obstetricians and Gynecologists, which two years ago concluded such cesareans can be ethical, said the benefits are unclear.

Cesarean rates have always reflected a complex mix of medical, economic and social forces.

In 1965, only 5 percent of U.S. births were by cesarean. Even abnormally long labors — the leading reason for cesareans today — usually ended with vaginal delivery.

Not until the 1970s did the cesarean rate climb sharply. This was driven not only by surgical advances and new fetal monitors but also because doctors feared lawsuits, got paid more for surgery or disliked wee-hour deliveries. By 1988, nearly a quarter of U.S. deliveries were surgical.

Fans of cesarean point out that the surge in surgeries coincided with a decline in maternal deaths, which plunged from 32 women per 100,000 deliveries in 1965, to 8 per 100,000 in 1985.

Still, there was a backlash against cesareans that pushed the rates down slightly in the early 1990s.

A huge study comparing vaginal birth after cesarean to repeat cesarean followed 33,600 women at Thomas Jefferson University Hospital and 18 other medical centers.

The study found that trying vaginal delivery was linked to higher risk of stillbirth, newborn death and newborn brain damage due to lack of oxygen.

The brain-damage comparison was striking: In the vaginal birth after cesarean group, 12 babies, including two who died, suffered this complication — a risk of 1 in 2,000 tries of labor. In the repeat cesarean group, no babies suffered the brain damage.

The two groups had the same risk of maternal death — about 3 in 10,000 deliveries — but vaginal birth after cesarean led to 124 uterine ruptures, while the elective cesarean group had none.

Maternity-care advocates say women are being scared away from vaginal birth. The newborn’s 1 in 2,000 risk is lower than the estimated lifetime odds of accidental death from falling or drowning.

“As a woman, your No. 1 job is to protect the baby,” said Tonya Jamois, president of the International Cesarean Awareness Network Inc. “I know women who have been told: ‘If you have a VBAC, you’re signing your baby’s death warrant.’ I think it’s a shame that women are being manipulated that way.”