Cesarean Awareness

Expectant Parents Face Increased Risks as American Obstetrics Drifts Toward Cesarean on Demand

Albuquerque, New Mexico: by Pam England, CNM, MA and Rob Horowitz, PhD

For many women, the experience of childbirth is an empowering, confidence-building rite of passage, where previously untapped emotional and physical strength is discovered. However, there is a crisis brewing for parents birthing in the pastel-colored birthing rooms of American hospitals. Throughout the 1980’s and into the mid-1990’s the cesarean birth rate declined while the incidence of vaginal birth after a previous cesarean increased. Unfortunately, both of those trends have been reversed in recent years as hospital protocols have changed and cesareans have entered the realm of “patient choice”/elective surgery.

More than one-fourth of all children born in 2002 in the United States were delivered by cesarean surgery; that rate of 26.1 percent was the highest level ever reported in this country. Why should our society be worried about this trend toward normalizing cesarean surgery?

Cesarean section is major abdominal surgery requiring anesthesia, which means it carries with it all the numerous risks of complications associated with any abdominal surgery. The World Health Organization (WHO) has expressed its alarm and has urged the United States to lower its cesarean rate to 15% or less. Here’s what WHO knows and that you should know too:

• Even though we lead the world in birth technology, the US is ranked only 21st in the world for maternal death during childbirth (that ranking has not improved since 1982).
• According to the International Cesarean Awareness Network (ICAN), the risk of a mother dying from complications related to cesarean surgery soars when compared to women giving birth vaginally. The maternal death rate is 0.5 per 10,000 vaginal births but jumps to 2.0 per 10,000 with elective (i.e., medically unnecessary) cesarean surgery. The overall maternal death rate related to all cesareans is 8 times greater (4.0 per 10,000) than the rate associated with vaginal birth.
• [With cesareans] “there is an increased incidence of drug-resistant infections as well as the potential for life-threatening complications from blood transfusions,” cautions Mary Ann Shah, President of the American College of Nurse-Midwives. In addition, “women risk permanent damage to abdominal and urinary tract organs and face longer and more painful postpartum recovery time.”

First-time parents and physicians should think carefully not only before scheduling patient choice/elective cesareans but also before turning to cesareans during labor when other safer alternatives have yet to be tried.

• The availability of vaginal birth after cesarean (VBAC) is decreasing. This is due to several factors, not the least of which is the American College of Obstetricians and Gynecologists’ (ACOG) 1999 recommendation that a physician and anesthesiologist be immediately available in the hospital throughout labor, which is not cost effective for hospitals. In 2000, VBAC’s were offered to 20.6% of birthing women, in 2001 that number had dropped to 16.4% (National Center for Health Statistics).
• The chance of uterine rupture during pregnancy, a life-threatening complication, is twenty times higher in women who have had uterine surgery, including cesarean section. This risk understandably contributes to obstetricians’ growing anxiety and apprehension, leading to their discouraging women to birth vaginally after a previous cesarean surgery.
• According to a study just published by the British medical journal, The Lancet (December 2003), women who’ve had a baby by cesarean surgery have approximately double the risk of losing a baby to an unexplained stillbirth in a subsequent pregnancy.

What other factors are contributing to the steady rise in the cesarean birth rate? Fear of pain is a motivating factor for elective cesareans, and also contributes to overuse of epidurals—which in turn contributes to the rising cesarean rate. Parents fear the unknown and being out of control as much as they fear pain. Requesting (or accepting the offer of) an elective cesarean may appeal to some parents (and doctors) because surgery is scheduled and controlled.

We are concerned that the current increase in the cesarean birth rate may be further accelerated by the recent statement issued by the American College of Obstetricians and Gynecologists’ Ethics Committee. On October 31, 2003 the Ethics Committee sought to address issues related to “patient choice”cesareans. Part of their statement is excerpted below:

Where medical evidence is still limited, ACOG says there is no one answer on the right ethical response by a physician considering a patient request for surgery. Thus the decision on whether to perform an elective cesarean delivery (also known as "patient choice cesarean" or "cesarean on demand") will come down to a number of ethical factors including the patient's concerns and the physician's understanding of the procedure's risks and benefits.

In the case of an elective cesarean surgery if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean would be detrimental to the overall health of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.

Why has this seemingly mild and evenhanded excerpt from ACOG raised alarm among birth-related professional organizations throughout the world, including Albuquerque. Given the long list of risks to mothers and babies from cesarean surgery (only partially described above), their alarm becomes understandable. In addition, giving doctors more room to honor patient-request cesareans (in the absence of medical necessity) opens the door further to casual cesareans—and the rate of cesareans and their related complications will continue to rise.

When does a patient’s request for surgery need to be guided by ethical professional advice? Wouldn't an ethical divorce lawyer suggest counseling to an angry, distraught couple rather than agreeing to their request for a quick divorce? Or wouldn't a responsible orthopedic surgeon recommend physical therapy before prematurely performing surgery on a patient in search of quick relief? Similarly if a pregnant woman or couple requests a cesarean to avoid pain or fear of the unknown, an ethical birth attendant would refer them to classes or a counselor to address their fears and develop pain-coping skills before opting for a surgical solution.

Taking responsibility for health care choices is not always easy or quick. Expectant parents need guidance, support and training to learn how to ask the right questions, get a second opinion, and hire a doula (a woman specially trained to provide birth support). If after weighing all relevant issues, cesarean surgery is a wise decision, a couple should be encouraged to experience the cesarean not just as a surgical procedure, but as the birth of their child and themselves as parents.

For many complex reasons, birth practices are changing rapidly. While the trend toward cesarean on demand is a medical crisis, it is a spiritual and social crisis as well. Parents and professionals must share the responsibility to challenge trends that are not in the best interests of mothers, babies and birth attendants.

Pam England is a midwife, creator of the Birthing From Within childbirth preparation method, and international speaker and trainer. She also teaches childbirth classes in Albuquerque. Rob Horowitz is a psychologist in private practice in Albuquerque. England and Horowitz are the authors of Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation (1998).

This article is excerpted from an article by DAVID WEISS printed in the Times Leader, Jan 16, 2004
dweiss@leader.net

Court Delivers Controversy: Mom Rejects C-Sections; Gives Birth On Own Terms

A judge late Wednesday afternoon gave a local hospital permission to force a woman to deliver a baby via Caesarean section against her will. Her refusal came after warnings by doctors that a vaginal delivery could result in death for the fetus because it was expected to weigh 13 pounds.

The events began to unfold Tuesday when the Marlowes, of Academy Street in Plymouth, first went to Mercy Hospital in Wilkes-Barre to give birth. Drs. Lynne Coslett and Stephen Zeger repeatedly told the Marlowes a C-section was necessary. They warned the expectant other that not having a C-section could kill her and/or her child. The doctors held her at the hospital for 13 hours, telling her "horror stories" in trying to change her mind, he said. "They just kept telling me to do a Caesarean section," Amber Marlowe said. "They were forcing me in to it."

The couple refused, insisting the fetus be delivered vaginally, and left the hospital against doctor's orders. Hours later, Wilkes-Barre General Hospital received legal permission to become guardian of the fetus and perform the C-section if Marlowe returned to the hospital.

Marlowe never returned. The couple gave birth vaginally Thursday morning at Moses Taylor Hospital in Scranton to a baby girl, her and her husband's seventh child. The Marlowes said the mother and infant are healthy (and the baby weighed less than 13 pounds, but the Marlowes would not release the baby’s birth weight).

"Jane Doe and John Doe have made it clear that they are adamant that they will not consent to a C-section, regardless of the danger that a vaginal delivery presents to Baby Doe," Cummings wrote. "There exists the imminent threat of irreparable harm to Baby Doe in the absence of an immediate order."

John Marlowe said the hospital's request is full of "lies," and is considering taking legal action against General Hospital.

He said his wife wanted a vaginal delivery because all of her prior six births were done that way, including births of children larger than her newborn. A friend of Amber Marlowe also died from a C-section, making her wary of the procedure, the couple said.

Amber Marlowe said she had no religious concerns about the procedure. John Marlowe said his family practices typical Christianity, and he does not belong to any radical sect.

Conahan's court order gave the hospital permission to notify the Marlowes of the court order if they had returned to General Hospital. Cummings said the ruling was the first of its kind in Pennsylvania.