Elective Cesarean Choice
Written by Pauline McDonagh Hull
In a consumer driven world, we’ve become increasingly accustomed to demanding and attaining choice - be that the place we want to shop, the things we want to buy, the price we’re willing to pay or the quality we expect to receive. And rightly or wrongly, the 21st Century has continued to witness one of the most controversial developments in consumer choice of all - its emergence within the traditionally revered boundaries of medicine.
As technological advances expand and new methodologies emerge, options for treatment and care multiply, leaving choices to be made. Patient-doctor consultation is vital, as is a patient’s own knowledge, understanding and responsibility (e.g. researching your doctor’s credentials and reading about your condition). And yet nowhere is the controversy surrounding patient choice more heightened than on the painfully sensitive issue of childbirth.
Advocates of natural childbirth argue that choice is restricted in overly medical environments where fetal monitoring, epidurals and emergency cesareans are too readily administered. They believe more home births should be supported. Conversely, there are women who choose hospital-assisted vaginal delivery but in the end, feel that their specific ideal birth plan was neither respected nor accomplished.
Then there are women who decide to have a cesarean - the most contentious choice of all - a decision they soon discover must be defended far beyond the reach of a hospital ward. Which brings us to perhaps the most commonly asked cesarean question: “Why would any intelligent woman choose surgery ahead of entrusting her own body to deliver her baby safely?”
Major Surgery versus Mother Nature
As we might expect, there is no simple ‘catch all’ answer to this because every woman is different, but fundamentally, it boils down to her own personal assessment of the risks and benefits involved in each type of delivery. Unfortunately, this assessment is far from straightforward, largely because the data available is limited - a fact highlighted by the National Institutes of Health in 2006: “There is insufficient evidence to evaluate fully the benefits and risks of CDMR as compared to PVD, and more research is needed.”*
Incorporating the vast majority of comparative birth studies to date in a contemporary appraisal of elective cesarean delivery in healthy women is flawed, primarily because their data includes outcomes from emergency surgeries and elective surgeries in women (and babies) with pre-existing medical conditions. In addition, much of the data compiled on vaginal delivery looks at ‘positive outcomes’ alone (i.e. a planned vaginal delivery that ends up as a vaginal delivery) rather than ‘all planned vaginal delivery outcomes’ (including those that result in emergency cesareans) and their subsequent mortalities or morbidities.
There is also a tendency to place more emphasis on grave cesarean morbidities such as hemorrhage and infection (regardless of prevalence), and apply reduced significance to the less extreme (but nonetheless frequent) vaginal delivery morbidities such as immediate post-birth pelvic floor pain and long-term repercussions. Unless genuine comparative studies can look at healthy women who deliver vaginally and surgically, relevant debate (including the debate over cesarean cost) is hampered.
Until then, it is comforting to know that an increasing number of obstetricians and other health professionals worldwide (including the current Vice-President and former President of the American College of Obstetricians and Gynecologists) are satisfied that elective surgery is favorably comaparable with vaginal delivery, and therefore they support a woman’s right to request it. Furthermore, in 2003, an ACOG ethics committee stated that it is ethical for doctors to perform elective caesarean sections on pregnant women who face no known risks from vaginal delivery.**
This is good news for women in America, although there are always medical caveats to be mindful of (e.g. cesareans are not recommended for women who plan to have large families or who are obese, and babies should not be delivered prior to 39 weeks or without verification of lung maturity). Overall, cesarean delivery appeals to a minority of women in much the same way as do the options of home birth, water birth or drug-free delivery, but ultimately, all birth
choices should be respected.
Society may still be slightly more inclined to give out medals to women who achieve a DIY vaginal delivery while making disparaging comments about women who are “too posh to push,” but the fact remains that if a baby is born healthy and a woman has had a positive birth experience, the prospect for their future health and relationship is equally good, and for most mothers, that’s all that really matters in the end.
Pauline McDonagh Hull is a journalist and pregnant with her first child. She founded the website electivecesarean.com in 2006, which provides more detailed information on the risks and benefits of planned cesarean delivery, in-depth interviews with a range of medical professionals, plus much more. If you have any questions or feedback on the site or if you’re a medical professional who would like to talk about your views on cesarean delivery, you can reach Pauline via the elective cesarean ‘Contact us’ page.