Published September 19, 2006
One look at People Magazine or Entertainment Tonight, and you might think the old-fashioned labor and delivery way to birth a baby has gone the route of the horse and buggy.
In its place: The mother-requested Caesarean, or C-section, delivery -- the fast, high-tech, hip celebrity way to have a child.
Or so, a popular theory goes.
"There's no doubt in my mind that the current interest in elective cesarean births has been ignited by the fact that in our pop culture many celebrity deliveries have been elected cesareans," says Manuel Porto, MD, chairman of the department of obstetrics and gynecology at the University of California, Irvine.
Indeed, from media reports on the pregnancies of rock stars like Madonna, Victoria Beckham, and Britney Spears, to actresses like Gwyneth Paltrow, Kate Hudson, Patricia Heaton, and Elizabeth Hurley -- not to mention a gaggle of super models in between -- the C-section appears to be the "it" activity of the decade.
Despite health risks for both baby and mom -- including a life-threatening uterine rupture for women and a greater risk of stillbirth for baby -- C-section deliveries are rising. According to the National Institutes of Health, the current rate is 29.1 percent -- up some 40 percent between 1996 and 2004.
But who is really responsible for the rise? Not everyone is ready to blame the woman giving birth.
Some suspect the doctors. After all, the word “elective” simply means there is no medical justification -- it doesn’t specify who made the request.
True, in celebrity-conscious New York City, some doctors say women are at least partly to blame.
"I have definitely seen an increase in C-section requests, even when there is no real medical justification behind it," says Ashley Roman, MD, a maternal fetal medicine specialist at NYU Medical Center in New York.
Her patients don't necessarily want to mimic celebrity life. They frequently cite other reasons -- particularly a reduced risk of incontinence and an easier, less painful birth, though she says medical literature is scant in support of either.
But organizations like Childbirth Connection argue this doesn't reflect the attitudes of women nationwide. Their surveys show less than 0.08 percent of pregnant women request a C-section.
"From our research we can say for sure that it is not mothers who are causing the elective C-section rate to rise," says Maureen Corry, executive director of ChildbirthConnection.org.
What Mothers Say
Indeed, when you look beyond the glitter of the Hollywood delivery and into the nurseries of working class America, a very different picture emerges.
"Some of the increase in elective cesareans is due to mother request, but I personally believe that group is a very small, very affluent subset of women and does not represent the desires or needs of most mothers," says Peter Bernstein, MD, MPH, a maternal-fetal medicine specialist at Montefiore Medical Center in the Bronx.
In fact, in two surveys aptly titled, "Listening to Mothers," Childbirth Connection says they found that the numbers prove this is so.
Referring to the group’s latest survey, released in March 2006, Corry says, "Despite some professional and mass media discourse about 'maternal request' or 'patient demand' Caesarean … just one woman (0.08 percent) among 1,315 survey participants who might have initiated a planned primary cesarean … did so."
According to the report, of 252 survey participants who had a primary, or first birth, Caesarean, only one woman (0.4 percent) initiated it.
Applying these numbers to the most recent figure for annual births, Corry estimates a scant 2,600 out of 4.1 million pregnant women actually requested a C-section.
Moreover, while in March 2006, the National Institutes of Health held a state-of-the-science conference entitled "Caesarean Delivery on Maternal Request" to address the issue of rising C-section births, officials were not able to pin the rise on moms, according to Corry.
"They failed to report a single study citing the extent to which American women are initiating C-sections and revealed only ‘limited evidence’ suggesting that mother-requested cesarean deliveries are what are spiking the rise," says Corry.
She says many women are curious enough about a C-section to question their doctors, but, she adds, "being curious and requesting a C-section are two very different things."
So if mothers aren't responsible for the burgeoning C-section trend, who is?
An alternative answer, Bernstein says, can be found in the medical-legal climate pervading every labor and delivery floor.
The Labor Room: Who's Really Pushing?
In the not so distant past, the drive to reduce Caesarean deliveries caused hospitals in many states to require the signature of two obstetricians before this surgery could be performed.
"There was this notion out there for awhile that doctors were doing C-sections for their own convenience … for financial reasons, for social reasons … and so the push was on to lower the rates," says Porto.
Even though the general birthing rule had long been that once a woman delivered by cesarean, her future pregnancies would have to be delivered by Caesarean also, by the 1980s the drive to push rates down was so great that doctors developed the VBAC -- vaginal birth after cesarean. It soon became the default procedure for the next birth after every Caesarean delivery.
Unfortunately, studies began to show that women undergoing VBACs had the highest rate of complications, including uterine rupture, hemorrhaging, and sometimes the need for a total hysterectomy. Moreover, babies didn't do so well either, frequently landing in neonatal intensive care immediately after birth.
It wasn't long before hospitals and insurance companies began refusing to back a doctor doing a VBAC. The end result: The idea of performing a Caesarean delivery went from a medical decision to a legal one -- and the VBAC died.
"The medical-legal climate on labor floors became such that many doctors no longer went out of their way to convince a woman to have a vaginal delivery, particularly if she had a C-section in the past," says Bernstein.
The “Listening to Mothers” survey seems to second this opinion, finding that "9 percent of mothers reported experiencing pressure to have a Caesarean -- far outweighing the number of mothers who voluntarily chose this procedure."
Perhaps even more telling are the observances of the mothers themselves. The survey found some 42 percent believe the current system leads maternity care providers to perform a C-section simply to avoid being sued.
Where Do We Go From Here
Doctors say that while advances in C-section delivery have increased its safety profile considerably, risks still remain higher than for a vaginal delivery, and rise still higher with every C-section a woman has.
"By the time a woman gets to her third cesarean, she's at serious risk for life-changing and even life-threatening complications," says Bernstein.
In the September 2006 issue of Obstetrics and Gynecology, a group of French researchers found that the rate of maternal death from C-section was three times that of vaginal delivery, due mostly to increased risk of blood clots, infections, and complications from anesthesia.
Moreover, the first study to examine risks to babies born via elective cesarean, published in this month's edition of Birth, reported that in 6 million births, the risk of death to newborns delivered vaginally was 0.62 per thousand live births versus 1.77 for those delivered by elective C-section.
Recent news statements by Stanley Zinberg, MD, deputy executive vice president of the American College of Obstetricians and Gynecologists, show that while ACOG continues to review maternal-request cesarean, "At this time, our position is that cesareans should be performed for medical reasons."
Still, all the experts interviewed by WebMD said individual patient need -- and choice -- should remain the prime considerations when deciding how to give birth.
For example, Bernstein says that for a woman who is 40 and having her one and only child, a C-section isn't a bad choice, while for a young fertile woman having her first child it could be a mistake.
Explains Bernstein: "Essentially the first delivery lays down the risks for all subsequent deliveries -- so if you can have your first and hopefully your second baby delivered vaginally, it's better for you, and better for your baby."
Hollywood … are you listening? Stay tuned.
By Colette Bouchez, reviewed by Louise Chang, MD
SOURCES: Madorman, M, Birth, September 2006; Vol 33: pp 175. “Listening to Mothers Survey,” ChildbirthConnection.org. Deneux-Tharaux, C. Obstetrics and Gynecology, September 2006; vol 108: pp 541-548. Manuel Porto, MD, chairman, obstetrics and gynecology, University of California, Irvine. Ashley Roman, MD, maternal-fetal medicine expert, NYU Medical Center; assistant professor, NYU School of Medicine, New York City. Peter Bernstein, MD, MPH, maternal-fetal medicine expert, Montefiore Medical Center, New York City; and associate professor, Clinical Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, New York City. Maureen Corry, executive director, Childbirth Connection, New York City. Stanley Zinberg, MD, MS, ACOG, deputy executive vice president and vice president, ACOG Practice Activities Division, news release, May 9, 2006. MacDorman, M. Birth, September 2006; vol 33: pp 175-182.