It is known as elective C-section or C-section on demand, and now new research suggests that the once highly controversial practice of choosing surgical delivery when there is no compelling medical reason to do so is gaining acceptance among American women.

A review of U.S. birth certificates between 1991 and 2001 showed a steep rise in cesarean deliveries among women with no reported medical risk. Rates were steady until the mid-1990s, but they rose sharply after that.

“This really does appear to represent a new phenomenon in American obstetrics,” lead researcher Eugene Declercq, PhD, tells WebMD. “These figures were certainly higher than we expected to see, both in terms of percentages and raw numbers. We are talking about around 80,000 births in 2001 alone.”

Downward Trend Reversed in ‘96

The late 1980s and early 1990s saw an overall decline in cesarean deliveries in the United States, prompted by a move by leading professional organizations to reduce rising surgical birth rates. The downward trend reversed in 1996, however, and rates began to increase rapidly.

In their review of roughly 4 million births per year between 1991 and 2001, Declercq and colleagues were able to identify mothers who had the lowest risk of delivery complications. Twenty-eight specific labor and delivery complications are recorded on birth certificates, and the authors included only deliveries with none of them. Women who gave birth to twins, triplets, etc. were also excluded from the analysis.

The birth records showed that cesarean deliveries increased by 67 percent among these low-risk women in the decade prior to 2002. Older, first-time mothers were the most likely to have a cesarean without an obvious medical reason. Low-risk, first-time moms who were 40 and older were more than five times more likely to have surgical deliveries than first-time moms between the ages of 20 and 24.

The rate of C-section deliveries among low-risk, first-time moms between the ages of 35 and 39 increased to 18 percent in 2001 from 12 percent in 1991, while the rate among women aged 40 and over increased to just under 26 percent from 18 percent during the same period. The study is published in the Nov. 20 issue of the British Medical Journal.

Sea Change in Attitudes

The findings suggest a sea change in attitudes and practices regarding elective surgical delivery around 1996, but Declercq says this is just speculation.

“We can’t say for sure that these figures absolutely show a rise in elective cesareans, and that is why we avoided that term,” he says. “Having said that, we do think that a significant proportion of this increase is patient and doctor driven.”

Declercq adds that the increase in surgical births among low-risk women corresponds with a decline in so-called vaginal birth after cesarean (VBAC) deliveries. Women who have had previous surgical deliveries are less likely than they were a decade ago to attempt a subsequent vaginal birth.

“It could be that the waning popularity of VBACs has led to a rethinking of cesarean delivery for (first-time) births,” he says.

New York obg-yn Howard Minkoff, MD, says doctors are struggling with how to best counsel their patients about elective C-sections. In an effort to help them do this, a government-sponsored conference is planned for sometime next year, he says, to “try to come up with some sort of consensus about the appropriateness of this trend.”

Those who favor choice say C-sections are far less risky than they were even a decade ago and that the evidence suggests women who have them have a lower risk of urinary incontinence and other pelvic issues as they age. Minkoff counters that there is growing evidence that surgical delivery increases the risk of stillbirth and other problems in later pregnancies.

In a New England Journal of Medicine editorial published last year, Minkoff wrote that the evidence still favors vaginal deliveries over elective C-sections for uncomplicated labor. But he added that women who are informed about both procedures should be allowed to make up their own minds about their method of delivery.

“Elective C-section certainly shouldn’t be routinely recommended,” he tells WebMD. “But it also wouldn’t be unethical to accede to the wishes of a woman who wants one if she has educated herself on the issue.”

By Salynn Boyles, reviewed by Brunilda Nazario, MD

SOURCES: Declercq, E. British Medical Journal, Nov. 20, 2004; online edition. Eugene Declercq, PhD, professor of maternal and child health, Boston University School of Public Health. Howard Minkoff, MD, chief of obstetrics-gynecology, Maimonides Medical Center, New York.