March 5, 2003 -- More and more women appear to be choosing to have their babies delivered by cesarean section, even when there is no compelling medical reason to do so. Considered a radical idea just a few years ago, elective C-sections are still controversial, but more and more doctors are willing to give their patients the option of choosing surgery over vaginal birth.
Those who favor choice say C-sections are far less risky than they were even 10 years ago, and outcomes for both mother and baby are now comparable to vaginal delivery. All things being equal, vaginal birth is still preferable, New York ob-gyn Howard Minkoff, MD, tells WebMD. But in an editorial in the March 6 New England Journal of Medicine, Minkoff argues that women who are informed about the pros and cons of both procedures should be allowed to make their own decisions.
"I think there has been an evolution, instead of a revolution in this area," he tells WebMD. "There is more and more evidence of decreasing risk (with C-sections), and now we are starting to see evidence of potential benefits over vaginal birth."
A study in the same issue of the NEJM found the long-term risk of urinary incontinence to be higher among women who gave birth vaginally than among those whose babies were delivered by cesarean section. Women who had not given birth at all had the lowest rate of incontinence.
Minkoff, who chairs the OBGYN department at Brooklyn's Maimonides Medical Center, says the evidence is clear that planned C-sections are far safer for both the mother and baby than emergency surgery after failed vaginal delivery.
"A woman who chooses vaginal delivery isn't guaranteed of having it, and 22% of American women end up having a cesarean section after unsuccessful labor," he says. "A woman who has a C-section after 10 hours of labor at 3 o'clock in the morning is likely to have a worse outcome than one who had a planned cesarean."
After trending downward for more than a decade, the rate of cesarean deliveries in the United States has increased dramatically over the last few years. In just one year, between 2000 and 2001, C-sections jumped 7% to rival the all-time high. One in four babies is now delivered surgically, and Illinois ob-gyn David Walters, MD, says that figure is about right. Walters published the book Just Take it Out! The Ethics and Economics of Cesarean Section and Hysterectomy in 1999, in which he argues that elective C-section is a pregnant woman's right.
He calls a government push to lower the C-section rate to 15% nationwide "irresponsible" and says it is unethical to fail to offer cesarean sections to women who are at high risk for having them anyway.
"A good example is a woman who is shorter than 5'2", is having her first baby, is a week past her due date, and her cervix is firm," he says. "If the baby is around 8 pounds, she probably has at least a 50% chance of ending up with a C-section. Ethically, she should be offered a C-section at the outset. If she ends up having one after a long labor, which is very likely, it is much more dangerous."
He says women have not been told about the potential long-term consequences of vaginal birth, including urinary incontinence and loss of vaginal muscle tone, which could interfere with sexual satisfaction. And those who try to have a vaginal delivery after a C-section birth have a slightly higher risk of uterine rupture, research shows.
The obvious downside to cesarean deliveries is a longer recovery time for the mother -- roughly two weeks without complications, compared with a day or so for uncomplicated vaginal deliveries.
"There is no scientific data that supports one method of delivery unequivocally over another," he says. "Women should be told about the advantages and disadvantages of both, and should be trusted to make the right decision for them."