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Health: The C-Section Question

Just a few years ago the repeat C-section was medical dogma. Now hospitals and insurers are closely questioning cesarean births, and doctors are slowly learning that many are unnecessary.



In 1916 Edwin Craigin, an obstetrician addressing a medical meeting, pronounced, "Once a cesarean section, always a cesarean section."

After a woman had delivered one baby surgically, he contended, the procedure should be scheduled for all of her subsequent births. This statement stood as medical dogma until the mid-70s. Craigin's opinion was based on the fact that the vertical uterine incision, known as the "classical incision," is liable to rupture during a subsequent labor with catastrophic results, often requiring a hysterectomy.

Nowadays, however, the vast majority of cesarean incisions are horizontal and can hold during a later labor. According to current medical studies, about three-fourths of women who have had a cesarean will succeed in delivering their next child vaginally. In other words, the chances of needing an operation are no different the second time around than the first, despite earlier surgery.

As the costs of health care continue rising toward the stratosphere, experts have focused on increasing the percentage of vaginal births after cesareans (VBACs) as a way to save a great deal of money. "Medical experts estimate that at least half the 900,000 Cesarean sections performed in 1986 were unnecessary," former secretary of Health, Education, and Welfare Joseph A. Califano Jr. wrote a few years ago. "The cost of those excess operations came to $728 million--for poor quality medicine. American doctors perform the highest rate of Cesarean sections in the world, yet the United States ranks seventeenth in infant mortality." He noted that the percentage of babies delivered surgically had risen from 5.5 in 1970 to 24 in 1986.

The issue of reducing the number of first, or primary, cesarean sections is murky, since whether to do one is basically a judgment call in an emergency. So health planners have focused on secondary, elective operations as a more obvious target in reducing spending. A February 1990 article in the Journal of the American Medical Association noted that less than 10 percent of women with previous C-sections subsequently deliver vaginally and 35 percent of all C-sections performed in the U.S. are nonemergency previously scheduled repeat surgeries. The overall mortality rate for C-sections is one in 2,500, so it is a very safe operation. Yet there is no question that a surgical delivery is riskier for the mother than a vaginal one.

The more militant VBAC advocates contend that doctors, particularly male doctors, perform the operation for their own convenience and financial gain as much as in response to fetal distress. Financial incentives for cesarean delivery in the United States are high--both for physicians, who collect the operative and anesthetic professional fees, and hospitals, which charge for the operating time and the extra days of hospitalization for baby and mother. In fact, when Mount Sinai Hospital managed to decrease the rate of cesarean surgery from 17.5 percent to 11.5 percent over a two-year period (by intensive physician and patient education as well as peer review), it lost a million dollars in revenue.

There is ample evidence that medical necessity is not the only reason physicians decide to cut. An amazing study, "The Physician Factor in Cesarean Section Birth Rates," published last year in the New England Journal of Medicine, looked at 1,533 affluent, low-risk women without previous surgery. Their doctors' rates for cesarean delivery ranged from 9.6 to 31.8 percent and did not correlate with birth weight, prematurity, or maternal age. In 1986 the cesarean-section rate in California for women on one health-insurance plan was 19.7 percent; for women on a different plan it was 29.1 percent--with no difference in outcome. In all studies, poor women delivering in county hospitals have the lowest rate of surgery.

In the early 1980s some women outside the medical profession were taking matters into their own hands. In 1983 Nancy Cohen and Lois J. Estner wrote a book called Silent Knife and founded the Cesarean Prevention Movement. Citing the experiences of women like themselves, these authors claimed that almost every woman could achieve a VBAC, regardless of what her doctor recommended. More important, they said, every woman should "be allowed a trial of labor," as the doctors put it. The women of the CPM object to such language, since as far as they're concerned women do not need to ask permission to labor--it's their right. The book, considered the bible of the CPM, is a powerful and well-researched treatise documenting the success of VBAC at a time when most obstetricians were reluctant to consider that option for their patients.

Ironically, only seven years later the medical establishment has moved from tentatively accepting to strongly advocating VBAC. Among younger physicians the practice is considered routine. Older physicians have been slower to change, but increasingly hospitals require justification for any cesarean births.

The issue is addressed in quality-assurance committees as well as financial circles. There are even some doctors who agree with the CPM and will not consider scheduling a repeat cesarean. They don't feel it is a woman's choice to request an unnecessary operation. Since 25 percent of women will need a cesarean delivery whether or not they have had a previous operation, these doctors argue that if we don't allow a woman to request surgery in her first pregnancy, it makes no sense to allow it with subsequent pregnancies.

Not everyone agrees. "If I had to go through labor again, I would not get pregnant," said a mother who had a cesarean section after a long labor. Her baby weighed 12 pounds and had pneumonia. She is convinced that an earlier cesarean would have delivered a healthier baby, and she couldn't care less about confirming her identity as a woman by delivering vaginally. "Men are the ones who have to constantly assert their masculinity. We women just are." When I tell her that some people believe that women should not be allowed to choose a second cesarean, she is incredulous. "How can they tell me it won't happen again? What reason do they have to think the next one will be any smaller?"

Of course, each labor is different. Assuming a woman does not have diabetes or another ongoing condition, it is not possible to predict the size of siblings from the size of the first. A sonogram at term is accurate plus or minus one pound. So a nine-pound baby might actually be only eight pounds--or ten. And as Cohen and Estner emphasize, the size of the pelvis changes so much in labor due to hormone release and stretching of ligaments that there is just no way to predict whether a baby will fit.

The women Cohen and Estner quote in a chapter entitled "Voices of the Victims" feel different about their surgery. "The times I try to explain to others the depths of my disappointment and heartache over my C-section, the words just won't come out right. After months of trying to push these feelings aside, I no longer can. I always felt guilty thinking I was just feeling sorry for myself, that I was ungrateful for my healthy child." Part of the difference can be explained by circumstances surrounding the operation. Women whose children were whisked away, women whose husbands were banned from the operating room, have legitimate concerns beyond the actual surgery. As Cohen and Estner themselves admit, "If a woman believes that the operation saved her baby's life, or her own, it may be easier for her to accept the experience and move on through it. Or it may not. If she believes that she was victimized and cheated out of the experience of giving birth, she may be angry for a long while and find it difficult to work through her feelings."

Women approach pregnancy and childbirth with very different expectations. Each woman's path from the moment of conception is unique. The woman who vomits for five months has little in common with the woman who never felt better in her life. Cohen and Estner advocate something they call "pure-birth"--no medical intervention whatsoever, even for pain relief during labor. And they freely admit labor involves pain, not "discomfort or pressure." They welcome the challenge of that pain and suggest that everyone else should as well. They feel control of their bodies lies in rejecting technology. They also eschew sonograms, episiotomies, circumcision, and amniocentesis. They speak admiringly of a tribe where women either give birth or kill themselves.

Other women don't want to prove themselves or return to the pretechnological era. Some feel their bodies are beyond their control from the first nausea to the last contraction, that the essence of pregnancy is feeling out of control. A friend who had a tubal ligation (without consulting her husband) after her second child said she just couldn't face being that crazy again. An obstetrician I spoke to who strongly advocates VBACs tries to persuade women who are reluctant to face the pain of labor again by pointing out that in the last five years new and better epidural anesthesia has been developed that provides pain relief without stopping the contractions. "Women who request repeat cesareans aren't afraid of having a baby vaginally--they're afraid of pain. Assure them the pain can be controlled, and they are willing to try." Not in the spirit of Silent Knife, but nevertheless a strategy to avoid unnecessary operations.

It's worth noting that the rate of cesarean sections for women physicians is higher than that for women in general. Is this, as some authors suggest, because these women are socialized to expect intervention? Are these women more afraid of fetal distress because they see the sick babies in the nursery? Are their physicians more afraid of a lawsuit from an insider?

One of the incontestable advantages of a vaginal delivery is much easier recovery. The mother is able to be up and around immediately, caring for baby and siblings. She does not run the 20 percent risk of infection the cesarean mother faces. But to the woman who regarded her first surgery as deliverance from the pain of labor, postpartum pain, controlled with medication and free of anxiety about the welfare of the baby, may not be much of a deterrent. After all, it's the only birth she knows.

Imagine embarking upon an arduous backpacking trip to a remote, spectacular mountain lake. A camper in good shape, with adequate equipment and the luck of good weather, would return raving about the trip, recommending it to all her friends. Another camper attempting the same journey might encounter rain the whole week and develop blisters on the trail. If someone proposed trying again, she might be able to appreciate intellectually that with better boots and good weather she would enjoy herself as much as the first camper did. But it is hard for her to get past the gut feeling that it just isn't going to work out. Of course if she were offered a helicopter ride to the lake, she might well be tempted, despite the risk of flying.

It comes down to an issue of choice. There are women who would prefer to avoid the experience of labor, even recognizing the greater risk to themselves. They feel their position also deserves the feminist halo, since they are deciding. This point of view should not be surprising, since men and women sign up for the risk of anesthesia by the thousands in order to have plastic surgery. As one obstetrician put it, "If women are allowed to choose an elective breast augmentation, I think they should be allowed to choose a repeat cesarean." A woman who had a cesarean after 48 hours of labor and has chosen a VBAC commented, "I don't think women who had a baby after 12 hours of labor [the average quoted in many books and classes] should be allowed to discuss this question."

We are not likely to see a Movement to Save Cesareans. The women who want another operation may not advertise their decision, but they choose doctors by their willingness to perform the operation. I spoke to three younger obstetricians and received three different estimates of how many women requested repeat cesareans: 60, 30, and 10 percent. Yet as VBACs become the norm, insurance carriers may refuse to pay for scheduled repeat cesareans, as they now do for plastic surgery.

Once labor begins, of course, the obstetrician or nurse-midwife must still consider a C-section in cases of fetal distress. The U.S. has a sizable high-risk pool of mothers: teenagers, drug addicts, alcoholics, diabetics. And in our litigious society, perfection is the only acceptable outcome. "No one notices the obstetrician when everything goes well," says a high-risk obstetrical specialist, "although he may have saved the baby in a very difficult delivery. It is only when something goes wrong that attention is focused on the doctor." He admits that our current methods of assessing fetal distress are more sensitive than specific. But, he says, "the monitors are supposed to warn us of impending trouble, so that we can deliver healthy babies. If the babies are already blue, we've waited too long."

The obstetrician and nurse-midwife have a responsibility unique among health professionals. They have two patients to attend simultaneously. One of their patients is laboring, often screaming for relief, but their job is to stand by and let it happen. Not only is that unusual for Western medicine, that is unusual for our culture. We are not accustomed to letting nature take its course. We do not make a virtue of bearing pain. The first stage of labor can last for days, without any problem for the fetus. There is no need to do anything, but we want something done.

The VBAC movement reminds us that just because technology exists, we don't have to use it. It cautions us that medical dogma can be false. And it demonstrates how emotionally charged and how complicated individual decisions regarding health care can be. Every woman deserves a positive birth experience. The more we examine the realities of labor and delivery, our options and our expectations, the closer we will come to that goal.

Art accompanying story in printed newspaper (not available in this archive): illustration/Tom Herzberg.

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