Choosing Cesarean Section
-by Marsden Wagner MD, MSPH. Published in
The Lancet, vol 356, pp 1677-80, November 11,
2000
Introduction
"With a scheduled Caesarean section, you
and your doctor have agreed to a time at which
you will enter the hospital in a fairly calm
and leisurely fashion, and he or she will extract
your baby through a small slit at the top of
your public hair. There are a lot of reasons
to schedule a caesarean section...Other women
elect to have a caesarean because they want
to maintain the vaginal tone of a teenager,
and their doctors find a medical explanation
that will suit the insurance company."
-Lovine V,"The Girlfriend's Guide to Pregnancy"
(1) [Note from LLM, site editor:
to see pictures of this "small slit",
go here.]
This statement from a currently popular paperback
book in the US illustrates the degree to which
that society appears to condone women choosing
Caesarean section (and doctors committing insurance
fraud). Such a statement is reinforced when the
incoming President of the American College of
Obstetricians and Gynecologists, in a leading
editorial by that organization promoting ‘patient
choice cesarean’, calls this major abdominal
surgical procedure "a life-enhancing operation".
(2)
Caesarean section (CS) is an essential surgical
procedure which, when properly applied, can and
has saved the lives of many women and babies around
the world. So why not allow pregnant women the
option to choose birth by CS?
Unfortunately giving women the option to choose
(or even demand) a CS is not that simple. CS,
even when elective and with no emergency, carries
serious risks including an increased chance the
woman will die and an increased chance the baby
will have life-threatening conditions which may
lead to death. (see below) Contrast the previous
sentence’s evidence based statement about
CS with the above glowing hype on the advantages
of choosing a CS.
There seems to be a movement afoot in medical
circles to promote the right of women to choose
CS. In 1997 an obstetric journal reported a survey
of female obstetricians in England in which 31%
said if they themselves had an uncomplicated singleton
pregnancy at term, they would choose an elective
CS. (3) In 1998 the British Medical Journal lent
legitimacy to the issue by publishing a discussion
on the question "Should doctors perform an
elective caesarean section on request?" (4)
Then the New England Journal of Medicine joined
in with a Sounding Board article "The Risks
of Lowering the Cesarean-delivery Rate" in
which setting a target for CS rates is condemned
as implying that women should have no say in their
own care. (5) More recently in the November 27,
1999 issue of the British Medical Journal, a feminist
Professor of English laments "medical and
social prejudices against women sidestepping their
biblical sentence to painful childbirth are still
with us" and a consumer advocate states "I
do not believe that anyone has the right to demand
women give birth vaginally." (6)
There is an interesting relationship between
promoting women’s choice for a certain obstetric
procedure and the degree to which that procedure
is doctor- friendly. While the scientific evidence
has existed for many years that a trial of vaginal
birth after a previous CS (VBAC) is safer than
a routine repeat CS, there are no articles in
medical journals promoting the right of women
to choose VBAC. CS is doctor-friendly (see below),
VBAC is not.
Risks of caesarean section
Yielding to the temptation to perform a CS because
a woman requests it can only be justified if the
CS carries no more risk for the woman and baby
than a vaginal birth. Thus basic to the attempts
to justify women choosing CS is the oft repeated
statement found in several of the above articles:
"caesarean section is safer than ever before".
There is a gradation of risk from CS for last
minute obstetric emergencies through planned CS
on maternal or fetal grounds (including elective
repeat CS) to women’s choice elective CS
with no medical indications. Most data on risks
only separate "emergency" CS from "elective"
CS but since many of the risks are related to
the surgical procedure itself and its effects
on the woman and baby and exist regardless of
why the CS is done, women’s choice elective
CS, as major abdominal surgery, still has proven
higher risks.
The answer to ‘how safe is CS’ varies
depending on who is answering since if a CS is
done, the woman and her baby take the risks while
if the CS is not done, the doctor takes the risk
(see below). This helps to explain why the scientifically
documented risks of CS to woman and to baby are
not widely discussed and often not presented to
patients.
Risks to the woman
First is the increased risk the woman will die-
maternal mortality is associated with CS. The
most reliable maternal mortality data come from
the UK Confidential Enquiries into maternal deaths.
While it may have been obstetric politics which
prompted the omission of the usual chapter on
maternal mortality with CS from the latest UK
Maternal Mortality Report from 1998, two scientists
calculated CS fatality rates from the data in
the Report. (7) With regard to women’s choice
CS, the most relevant statistic, the case fatality
ratio for elective CS, documents that an elective
CS with no emergency present has a 2.84 fold (almost
three times) greater chance of the woman’s
death than if she has a vaginal birth. [View
information about the Maternal Mortality Report
here-"Why
Mothers Die".]
Ideally, one might wish for a randomized controlled
trial (RCT) comparing women’s choice elective
CS to vaginal birth, using intention to treat
in which the outcome measures for those few women
in the vaginal birth group who ended up with emergency
CS still would be counted in the vaginal group.
But since such an RCT is not ethically possible
(women cannot be asked to be randomly allocated
to elective CS or vaginal birth), the above data
on 153,929 elective CSs give powerful enough evidence
of the increased risk of maternal mortality with
women’s choice elective CS. The lack of an
RCT cannot be used as an excuse for questioning
the proven higher maternal mortality with elective
CS.
In addition to the increased risk the woman will
die with an elective CS, there are other risks
for the woman including the usual morbidity associated
with any major abdominal surgical procedure- anesthesia
accidents, damage to blood vessels, accidental
extension of the uterine incision, damage to the
urinary bladder and other abdominal organs. (8)
Some of these risks are common- 20% of women develop
fever after CS, most due to iatrogenic infections
requiring diagnostic fever evaluation for both
woman and baby. (8).
There are also risks women carry to subsequent
pregnancies due to scarring of the uterus including
decreased fertility, increased miscarriage, increased
ectopic pregnancy, increased placenta abruptio,
increased placenta previa (8,9,10). Recently in
the US the widespread use of the unapproved drug
misoprostol (Cytotec) for labor induction has
created a new risk of CS in subsequent pregnancies.
Women attempting VBAC who are given misoprostol
have a rate of uterine rupture of 5.6% compared
with a rupture rate of 0.2% for women attempting
VBAC not given misoprostol, a 28 fold increase
in risk of uterine rupture. (11) For women choosing
CS, all of these risks exist in all of their subsequent
pregnancies even if the original CS was not an
emergency and the increased risks of ectopic pregnancy,
abruptio placenta, placenta previa and ruptured
uterus are all life threatening to both woman
and baby.
Risks to the baby
For whatever reasons women choose CS, very few
are clearly informed about fetal risks. In an
emergency CS where the baby has developed a problem
during the labor, the risks to the baby of doing
the CS will likely be outweighed by the risks
to the baby of not doing it. In an elective CS
where the baby is not in trouble, the risks to
the baby of doing a CS still exist, meaning the
woman who chooses CS puts her baby in unnecessary
danger. That some women are choosing CS strongly
suggests women are not told this scientific fact.
The first danger to the baby during CS is the
1.9% chance the surgeon’s knife will accidentally
lacerate the fetus (6.0 % when there is a non-vertex
fetal position). (12) Obstetricians may be less
aware of this risk- in one study only one of the
17 documented fetal lacerations was recorded by
the obstetrician doing the surgery. (12)
A much more serious risk to babies born by CS
is respiratory distress. Many reports in the scientific
literature document the CS procedure per se is
a potent risk factor for respiratory distress
syndrome (RDS) in preterm infants and for other
forms of respiratory distress in mature infants.
(8) RDS is a major cause of neonatal mortality.
The risk of newborn RDS is greatly reduced if
the woman is allowed to go into labor prior to
the CS.
Another serious risk to the baby born by CS is
iatrogenic prematurity (the baby is premature
because the CS was performed too early). Even
with repeated ultrasound scans, the standard deviation
for estimating gestational age is large, creating
errors in judging when to do an elective CS. Doing
the elective CS after the woman goes into spontaneous
labor would markedly reduce this risk as well.
A vast literature documents the increased mortality
and morbidity, including neurological disability,
associated with premature birth.
For elective CS, then, the logical time is at
the onset of labour for two reasons: prevention
of respiratory problems in the baby; prevention
of prematurity. For women with compelling reasons
for CS , such as a phobia about vaginal birth
as a result of earlier rape, CS at the onset of
labour might be a reasonable clinical compromise
even though it rules out convenient scheduling.
Benefits of Choosing Caesarean section
While the risks of CS are present regardless
of whether it is an emergency CS or an elective
CS chosen by the woman, the benefits of CS depend
on the reason for doing it. When the CS is chosen
by the woman, the lifesaving benefits from an
emergency CS are not present. The following are
benefits when the CS is not an emergency but chosen
by the woman and elective.
Benefits to the woman
While absence of the pain of childbirth with
a CS is claimed to be one of the benefits to the
woman, it is a false promise (see below). The
ability to schedule a CS in advance does provide
convenience to the woman and her family. The promise
of maintaining "the vaginal tone of a teenager",
frequently promoted not only in popular books
but also by hospitals in Latin America and elsewhere,
is real although more likely a benefit to the
woman’s sexual partner than to her. While
less damage to the genitalia is claimed with CS,
much of the damage in vaginal birth today is iatrogenic,
caused by hurrying thorough an uncomplicated second
stage, unnecessary use of forceps or vacuum extraction,
unnecessary episiotomy (8,9,10). In countries
like Brazil where full reproductive rights are
not available for women, CS provides an opportunity
for sterilization without openly contravening
the law.
Benefits to the baby
While an emergency CS may save the life of a
baby, when there is no medical indication for
CS, only the woman’s choice, there is no
scientific evidence to suggest any benefits for
the baby. Women who chose a ‘natural birth’
or a home birth have been criticized by the medical
profession as selfish, concerned with their own
needs rather than the safety of the baby, a criticism
not based on evidence. Given the evidence above
on the many risks to the baby and absence of benefits
to the baby when women choose CS, the label of
selfish would better fits women choosing CS were
it not that to do so would blame the victims.
Too often today women’s basis for choosing
CS is deep seated fear and lack of confidence
in their own biological abilities as a result
of those doctors who themselves fear vaginal birth
and fuel their patients’ anxieties.
Benefits to the doctor when women choose CS
In contrast, there are many benefits for the
doctor doing a CS rather than assisting at a vaginal
birth.
Avoiding litigation
The most common reason given by doctors for the
excessively high rates of CS is "defensive
obstetrics"- a CS is performed as a defense
against litigation. In a recent survey 82% of
physicians employed such defensive approaches
to avoid negligence claims. (13) Presently, with
a bad birth outcome doctors are sued and during
the trial find themselves criticized for not performing
interventions such as CS. There are few or no
cases of litigation in which doctors are criticized
for performing unnecessary interventions. As a
result, doctors take a risk doing fewer interventions
and gain insurance against litigation doing more
interventions, including CS.
Defensive obstetrics violates a fundamental principle
of medical practice: whatever the physician does
must be first and foremost for the benefit of
the patient. If a doctor performs a CS because
he or she is afraid of going to court or afraid
of rising insurance costs, the doctor is not practicing
medicine but practicing fear and greed.
Defensive obstetrics treats the symptom, not the
disease. The medical profession tends to blame
women, lawyers and the legal system for so much
litigation, rather than looking at its own role
in precipitating litigation. The situation in
Ireland is illustrative with a 450% rise from
1990 to1998 in medical negligence claims, with
obstetrics and gynecology cases accounting for
nearly half of the payouts. (13) The Medical Defense
Union (MDU) proposes a more accessible complaints
procedure, a solution which may prevent complaints
from reaching the courts but does nothing to address
the underlying dissatisfaction of women which
leads to complaints.
Rather than just tinkering with complaints procedures,
perhaps in addition attempts are needed to find
out why there is such widespread dissatisfaction
with maternity care in Ireland. Some of this dissatisfaction
may be because today in Ireland there is very
little choice about maternity care. Nearly every
hospital practices the highly structured "active
management" approach first started in Dublin
in which "active" refers to staff, not
to women giving birth and choice is effectively
eliminated.
Another source of women’s dissatisfaction
with present maternity care in Ireland and elsewhere
undoubtedly stems from a broken promise. In order
to convince women to give up the comfort and security
of their homes and come to hospitals to give birth
where they give up any possibility truly to control
what happens to them, doctors and hospitals have
found it necessary to promise women a perfect
birth and perfect baby.
But if you play God, you are blamed for natural
disasters. Nowhere is the maternal mortality nor
perinatal mortality zero. Women and babies die
or are injured around the time of birth and sometimes
it is because of a mistake in care. Throughout
history women have accepted this harsh reality
until recently when doctor’s began to promise
perfect births. Now we find statements in the
medical literature such as: "Childbirth has
become very safe for both mothers and babies".
(5) Instead of understanding their own role in
generating such false hope, doctors in the same
article blame the women- "A couple’s
expectation of a perfect baby". (5) So when
something goes wrong during birth, women and families
correctly feel deceived and seek answers but are
often met by a stone-wall from doctors and hospitals.
Given the present situation, perhaps litigation
is not a bad thing but a necessary evil. It provides
a setting where women and families can attempt
to address and answer their priorities and concerns,
holding doctors to account in the one public forum
even the doctors cannot always evade. Litigation
also serves as a symptom, alerting us to look
for serious underlying problems in maternity care.
Another problem with defensive obstetrics is
that it doesn’t work. During the years that
defensive obstetrics has increased there has been
no slowdown in litigation as a result. This suggests
that, to some extent, fear of litigation is an
excuse to allow the continuing use of interventions
such as CS that many doctors prefer anyway.
Other benefits to the doctor when women choose
CS
Elective CS is of great convenience to the doctor
as he may plan and schedule and get closer to
‘daylight obstetrics’. UK and US studies
not only show all births occur much more commonly
Monday through Friday during daylight hours but,
much more surprisingly, emergency CS shows a distribution
skewed to favor weekdays and daylight. (8) CS
takes the doctor 20 minutes while with a vaginal
birth the doctor is in the hospital or on call
for 12 hours or more on average. In systems such
as the US, Canada, Belgium, and Brazil where obstetricians
do primary maternity care, including routine prenatal
checkups and attending normal births, the convenience
of CS is vital to their practice.
In nearly all systems of private maternity care,
doctors and hospitals earn considerably more money
from a CS than from a vaginal birth. US studies
show women most likely to receive a CS are white,
married, have private health insurance and give
birth in private hospitals. (8) These are the
women at lowest risk of any medical complications
at birth that might necessitate a CS- a rare example
of wealthy women receiving less safe care than
poor women. WHO reports: "In the United States
the profit motive explained hospital-specific
cesarean section rates that were high even by
United States standards." (14)
Doctors performing CS have the satisfaction of
using surgical skills for which they have spent
years in training. Once the doctor and woman have
agreed on a CS, the doctor has complete control
and the elevated status of surgeon. The woman
and her family, rather than partners in the birth
of their child, become passive spectators, turning
everything over to the doctor whom they may hold
in awe or even see as a hero.
Benefits to hospitals and industry when women
choose CS
In private health care, hospitals receive considerable
benefits from CS as it is one of the most common
major surgical procedures, filling beds and operating
rooms and providing important hospital income.
Private hospitals compete for patients and want
to discourage out-of-hospital birth. High CS rates
reinforce the perceived need for hospitals. In
both private and public hospitals the convenience
of elective CS is important, scheduled during
daylight hours when most staff are present.
Commercial interests need to promote ‘high
tech’ birth which uses the maximum equipment
and technology. High CS rates mean increased profit
for the medical, hospital, medical technology
and pharmaceutical industries.
The Right to Choose
Fully informed choice?
A woman consenting to or choosing any medical
or surgical procedure first must be given full,
unbiased information on what is known scientifically
about the chances that the procedure will make
things better (efficacy) and the chances it will
make things worse (risks). While this principle
of informed choice is gaining acceptance, there
remain doubters such as the clinician who, after
reading a draft of this paper, commented: "I
wonder if any doctor has the time to give, or
any patient the patience to listen to full unbiased
information on what is known". Hopefully
such attitudes will soon be a thing of the past.
The clinician who is to do the procedure has
the obligation to give this information to the
woman, requiring the clinician to have that information.
This can be problematic for several reasons. The
tradition in modern medical practice is for clinicians
to base their knowledge and practices on ‘standards
of practice’ generated by other clinicians-
standards often at odds with the scientific evidence.
(15) More recently there is a desirable movement
towards basing medical knowledge and practice
on evidence, but still today many doctors are
not familiar with recent evidence nor with the
means to obtain it. In a 1998 study 76% of practicing
physicians surveyed were aware of the concept
of evidence based practice, but only 40% believe
that evidence is very applicable to their practice,
only 27% were familiar with methods of critical
literature review and, faced with a difficult
clinical problem, the majority would first consult
another doctor rather than the evidence. (16)
The clinicians’ insufficient knowledge of
scientific evidence is compounded further since
scientific data on efficacy and risks of procedures
keeps evolving- a moving target requiring keeping
up to date on the literature. Modifications are
made in procedures requiring new data on efficacy
and risks and more reading by the clinician.
Information available to the clinician may be
bias, generated by commercial firms interested
in profits or by professional organizations interested
in promoting the more doctor-friendly data on
procedures. For example, many obstetrical organizations
promote hospital birth, suppressing the evidence
documenting the safety of planned home birth because
the latter is doctor-unfriendly. Now clinicians
are turning more and more to the internet where
medical chat lines are full of misinformation
on efficacy and risks with no mechanism to control
validity.
The result is many badly informed clinicians
unqualified to provide full, unbiased information
to women. Some believe clinician’s ignorance
to be a form of medical misconduct. (17) Without
clinicians able to provide correct information,
women are unable to make truly informed choices
about their maternity care. As an example, a woman
who chooses CS as a means of avoiding the "
biblical sentence to a painful childbirth "
is badly misinformed. By choosing a CS, she exchanges
12 hours of labor pain for severe postoperative
pain and debility and a longer recovery period
with weeks or even months of pain.
A liberated woman correctly strives not to be
controlled by men but if she accepts the male
dominated obstetric model of care, she gives up
any chance to control her own body and make true
choices. Volumes have been written about how liberating
and empowering it is for a woman to give birth
when she controls what happens. Without fully
informed choice, she will give up any control
and comply with the wishes of the doctors and
hospitals. Women who demand choice but get only
selected doctor-friendly information unwittingly
buy into the medical position and call it feminism.
Ethical issues
Does a woman have an inalienable ‘right’
to choose a CS? It has been clearly established
in international law through such means as the
Helsinki Accord that an individual has the right
to refuse medical treatment, even when it is medically
indicated. (As an example, legal precedent has
been set in the UK and the US against forced CS.)
But it does not logically follow that the converse
is also true- that an individual has the right
to demand treatment which is not medically indicated.
If a woman chooses a CS but is refused because
there are no medical indications, is it correct
to say she will have a "forced vaginal birth"?
Pregnancy is not an illness or disease, not a
medical condition. For the great majority of women,
no medical or surgical treatment is absolutely
required during pregnancy, birth and the puerperium.
Vaginal birth is the inevitable consequence of
being pregnant and is not a medical treatment.
The woman is not forced to have a vaginal birth
by anyone but by her pregnant state, a state for
which she and her sexual partner must take responsibility,
not the medical profession.
Clinicians as well as patients have rights in
deciding a course of treatment. For example, if
a particular procedure is against the clinician’s
religious principles, he or she has the right
to refuse to perform the procedure. Thus, a doctor
cannot use the excuse that the woman chose a CS
and I am thereby obliged to perform it. A clinician’s
first obligation is to the well being of his or
her patient and if a woman asks for a CS for which
the doctor can find no medical indication and
which, to the best of the doctor’s knowledge,
carries risks for the woman and her baby which
outweigh any possible benefit, the doctor has
the right, perhaps even the duty to refuse to
do the CS. No one is holding a gun to the doctor’s
head.
The clinician has an obligation not only for
the well being of his patients but also for the
welfare of his/her community. If a patient presents
with all the evidence of viral influenza and then
demands antibiotics, the clinician has the right
to refuse for two reasons: the knowledge that
antibiotics will not help this patient and the
knowledge that the overuse of antibiotics in his
community will lead to antibiotic resistant microorganisms
which will threaten all his patients and the wider
community.
The overuse of elective CS also will threaten
the larger community. Not even the richest countries
in the world have the financial resources to transplant
all the hearts, dialyze all the kidneys, give
new hips to all the people who might benefit from
these procedures. Choices must be made about which
medical and surgical treatments to fund and these
choices will determine who shall live. A CS which
is done because a woman chooses it requires a
surgeon, possibly a second doctor to assist, an
anesthesiologist, surgical nurses, equipment,
an operating theatre, blood ready for transfusion
if necessary, a longer post-operative hospital
stay, etc. This costs a great deal of money and,
equally importantly, a great deal of training
of health personnel, most of which is at government
expense, even if the CS is done by a private physician
in a private hospital. If a woman receives an
elective CS simply because she prefers it, there
will be less human and financial resources for
the rest of health care.
For example, in Brazil there are hospitals with
100% CS rates, health districts with 85% CS rates,
an entire State with a CS rate of 47.7 %. (18)
Clearly this is a huge drain on the limited health
resources of that country. And the women of Brazil
also are paying another price. The data given
above proving the higher maternal mortality with
elective CS in the UK is further substantiated
by data showing a recent rise in maternal mortality
rates in those areas of Brazil with these shockingly
high CS rates.(19) CS on demand is an expensive
and dangerous luxury.
Another ethical issue surrounding the question
of women choosing CS is the right to equal access
in health care. Most everyone would agree it is
not right that in many countries there is not
equal access of all women to basic, essential
maternity care such as emergency CS for serious
medical complications. But it is a very different
ethical issue to ask: if wealthy women can choose
CS, shouldn’t all women have this right?
Discussions of equal access need to start with
the question: access to what? Few would insist
everyone has the right to access to blood letting
as a form of medical treatment. But would some
insist that since wealthy women can buy surgical
augmentation when they feel their breasts are
too small, we should use public funds for health
care, even though limited in every country, to
allow all women the right to access to such surgical
breast augmentation?
In the light of these ethical issues, the Committee
for the Ethical Aspects of Human Reproduction
and Women’s Health of FIGO (the international
umbrella organization of national obstetric organizations)
states in a 1999 report: "Performing cesarean
section for non-medical reasons is ethically not
justified." (20)
Why is there promotion of women choosing CS?
After a two decade rise in CS rates in many countries,
the efforts to bring this rate back down have
finally begun to take effect- CS rates in the
US, Canada and elsewhere have fallen several percentage
points the last few years. In the US, the goal
of the Federal Government to reduce the rate from
25% to 15% by the year 2000 was not quite met.
However, some are fighting against this effort
to lower CS rates through such means as: questioning
the recommended optimal CS rates (2,5,6); suggesting
lowering the rates may be dangerous (5); grasping
the excuse this is what women want. (2 –
6)
Do we know what the optimal rate of CS should
be? There is no evidence that a rate of CS over
7% saves lives. (9) The most quoted optimal CS
rate is that given by the World Health Organization,
10 to 15% of all live births. (21) Now this figure
is challenged and called arbitrary. (6) It is
important to know that this figure was arrived
at during a WHO consensus conference attended
by 62 participants from over 20 countries. (8)
Following a thorough literature review, participants
were aware of all the risks of CS to woman and
baby and the need for an optimal rate to be the
minimal optimal rate. The participants then studied
variations in CS rates across countries. As several
countries with the lowest maternal and perinatal
mortality rates were found to have national CS
rates close to 10%, this appeared to be a minimal
optimal rate, saving the maximum number of lives.
Furthermore, studies sponsored by WHO and involving
many countries found no evidence that CS rates
above this level lower mortality rates.(8) Because
the participants were aware that some hospitals
and some districts have higher risk populations,
the final consensus recommendation was modified
to 10 to 15%- 10% for general populations and
15% for high risk populations. This recommendation
was based on the best scientific evidence, thorough
discussion among many experts and final consensus
and was anything but arbitrary.
Medical factors behind the promotion of women’s
choice of CS
Some believe there is an increased need for CS
because babies are getting bigger and women’s
pelvic outlets are not. A search fails to reveal
data proving babies are getting bigger. But it
shouldn’t matter. In Sweden, Denmark, The
Netherlands the present national CS rate is close
to 10% with some of the world’s lowest maternal
and perinatal mortality rates and there is no
known data proving their babies are smaller or
their women’s hips bigger than in the US,
Canada or Brazil.
Promoting higher CS rates also is related to
the many claims that technological advances are
the reason that "Childbirth has become very
safe for both mothers and babies". (5) Scientifically
there are two problems with this idea: where is
the data showing improved outcomes; where is proof
of a causal relationship between outcomes and
use of technology or increasing CS?
Has the past two decades of rapidly increasing
CS rates seen improved birth outcomes? There has
been no significant improvement in the highly
industrialized countries the past 20 years in:
cerebral palsy rates; low birth weight rates;
maternal mortality rates (in the US the rate may
be rising); the fetal component of perinatal mortality
rates. Attempts to show lower perinatal mortality
rates with higher CS rates have failed. (8) A
US National Center for Health Statistics study
comments:
"The comparisons of perinatal mortality
ratios with cesarean section and with operative
vaginal rates finds no consistent correlations
across countries". (22)
A review of the scientific literature on this
issue by the Oxford National Perinatal Epidemiology
Unit states:
"A number of studies have failed to detect
any relation between crude perinatal mortality
rates and the level of operative deliveries".
(23)
In summary, there is no evidence that the rise
in CS rates the past two decades has improved
birth outcomes. Since it is true that CS does
save babies lives, how can this be? As indications
for CS broaden and rates go up, lives are saved
in a smaller and smaller proportion of all CS
cases. But the risks of this major surgical procedure
do not decrease with increasing rates. It is only
logical that eventually a point is reached at
which CS kills almost as many babies as it saves.
This possibility is, for the most part, invisible
to obstetricians: they may experience cases in
which babies lives are saved, but often may not
see the death of a baby, for example from respiratory
distress syndrome in a neonatal intensive care
unit, hours or days after CS.
Non-medical factors behind promoting women’s
choice of CS
Litigation, money and convenience, three non-medical
factors underlying doctors encouragement of women
to choose CS, were discussed earlier. Another
important factor behind the promotion of maintaining
high CS rates is one rarely if ever discussed.
When maternity care systems are characterized
by medical hegemony and midwives are marginalized
or absent, higher CS rates are found. It is no
coincidence that in the US, Canada and urban Brazil
where obstetricians attend the majority of normal
births and there are few midwives attending few
births, the highest CS rates in the world are
found. Having a highly trained gynecological surgeon
attend a normal birth is analogous to having a
pediatric surgeon baby-sit a normal two-year old
child. It would be a waste of the pediatric surgeon’s
time and skills and, when the young child gets
tired and fussy, the surgeon might be tempted
inappropriately to use drugs, where a properly
trained babysitter would soothe the baby with
a variety of non-medical techniques for many hours-
the medicalization of normal childhood similar
to the medicalization of normal birth.
While doctors use the medical model of birth,
the midwifery approach to birth uses a different
paradigm. Medicine focuses on the pathological
potential of pregnancy and birth, midwifery focuses
on its normalcy and potential for health- to midwives
breech birth is a variation of normal while to
doctors it is a pathological condition. Many studies
demonstrating lower CS rates when midwives rather
than doctors attend birth are reviewed in a recent
paper. (24) Promoting more CS by encouraging women
to choose CS is part of a campaign to keep the
obstetric profession in control of maternity care,
a campaign which also includes marginalizing midwives
through witch-hunts. (25)
A more subtle but pervasive non-medical factor
promoting CS is the belief system underlying the
medical approach to birth. In general, medical
doctors trust technology, not nature. A leading
obstetrician in Canada said it well: "Nature
is a bad obstetrician".
A blind trust in technology leads to misunderstandings.
It is commonly believed that technology equals
science equals progress. Whether in London or
in a small village in rural China, a visit to
a hospital inevitably begins with showing new
equipment.
A few scientific truths are hard to sell in a
medical setting: science may be used in the development
of technology but technology is not science; the
use of technology does not mean the practice of
scientific medicine- evidence based practice is
scientific medicine; technological advances may
or may not mean progress; technology is neither
good nor bad and the use of technology can have
good or bad results.
Behind these misunderstandings is the reality
that most practicing doctors have little or no
training in science. Furthermore, there is a fundamental
difference between the practice of science and
the practice of medicine. To generate hypotheses,
scientists must believe they don’t know while
practicing doctors, to have the confidence to
make life and death decisions, must believe they
do know.
The medical approach, with diagnosis and treatment,
assumes the practitioner will ‘do something’.
The surgical approach is a subset of the medical
approach, assuming in addition that cutting it
out or repairing it is the ultimate solution and
that a cut is better than a tear. That a survey
of practicing women doctors found that some of
them would choose CS for themselves only shows
that, after years of training in the medical and
surgical approach, there are some who have come
to believe in technology, not nature.
The medical and surgical approaches work well
for diseases and injuries but may be inappropriate
at birth where often the most important thing
is to do nothing. A midwife is someone with good
hands who knows when to sit on them.
Conclusions
The current promotion of allowing women to choose
CS is not because the medical profession has suddenly
recognized women’s rights but rather because
surgical birth leads to many benefits and fewer
risks for doctors and hospitals. Doctors are using
the rhetoric of patients rights and women’s
rights and making capital of the ‘choices’
of a few well-off women to have a CS- a recent
headline in a UK newspaper "Too posh to push"
referred to a singer from the pop group ‘Spice
Girls’ choosing CS. Much the same thing happened
earlier with the promotion of hospital birth which
was similarly scientifically unjustified but doctor-friendly.
When a women chooses an elective CS rather than
a vaginal birth it means: major and minor risks
and no benefit for her baby; major and minor risks
and limited benefits for the woman; major benefits
and little or no risk for doctors, hospitals,
medical and drug industries.
It is highly unlikely women would ever consider
choosing CS if they were given the full scientific
evidence on the risks for themselves and their
babies. The key ethical issue is not the right
to choose or demand a major surgical procedure
for which there is no medical indication but the
right to receive and discuss full, unbiased information
prior to any medical or surgical procedure.
Women and their babies are currently paying a
big price for the promotion of CS. The scientific
data on maternal mortality associated with CS
suggest the apparent rising maternal mortality
rates in the US and Brazil may be, at least in
part, the result of their high CS rates. The data
on other risks for both woman and baby associated
with CS mean both are paying a big price in the
current birth. Additional data on risks associated
with CS mean both woman and baby are paying a
big price in future pregnancies as well.
The health of the public is affected by the contribution
which women choosing CS makes to the high number
of unnecessary CSs performed in some countries.
Unnecessary CS is a drain on health resources,
even when performed in the private sector. Demanding
equal access to unnecessary major surgery means
less access to essential care. The luxury of women
choosing CS means other women dying of cancer
not found early enough because of lack of attention
and funds for such unglamorous but essential care
as outreach cancer screening programs for poor
women. Who shall live?
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