Do Women Really Want On-Demand C-Sections?
The question of whether maternal requests for c-sections could be contributing to rising rates of the procedure is a hot topic - the National Institutes of Health held a conference on the issue, ACOG has issued statements guiding its member OB/GYNs, and there has been no shortage of media coverage. In general, there does not appear to be any consensus that there is significant demand from women for c-sections that are not medically indicated, with the NIH calling requests “difficult to quantify.”
Previous results from the Listening to Mothers II national survey of childbearing women found that “Of the 1573 women surveyed, just one mother said that she had had a planned initial cesarean by her own choice with the understanding that there was no medical reason,” and suggested that the NIH panel’s estimate of maternal demand for c-sections may not be accurate:
“…working with a leading polling firm to ask mothers themselves results in an estimate of just 0.2% of all cesareans (1/480) by maternal request in 2005, and suggests that the panel’s reported estimate of 4 to 18% of all cesareans grossly overestimates this phenomenon.”
A small study in the new issue of the American Journal of Obstetrics and Gynecology also attempts to address the question of whether women are truly clamoring for c-sections. Researchers surveyed 314 pregnant women in the Bronx, and 95% of women responded that they did not believe cesarean delivery on maternal request was “a good idea,” and 93% said they preferred to deliver vaginally. Although the authors note that their sample is small and may not be representative of all American women, it’s an interesting start in trying to quantify this supposed trend.
For further reading on this issue, see OBOS’s Maternal Request for Cesarean Delivery: Myth or Reality? pages.
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January 23, 2008 at 5:28 pm
Rachel, as I’ve mentioned this before on my blog, there isn’t any data to suggest that there is a great demand for maternal requested c-sections. My (non-published) paper suggests that this is all media driven and deflection of the more relevent reasons behind the rising rate of surgical births.
One such problem with this is that the “experts” can not come up with a universally accepted definition. Non-medically necessary surgery apparently isn’t enough clarification for some; the other argument includes that some women who request such deliveries don’t see themselves as requesting it for non-medical reasons. In other words there are women who might be requesting it because of their own perceptions of what constitutes medical necessity. ACOGs statement allows for a lot of interpretations as far as what is a reasonable “non-medical” request. Either way, this still doesn’t support that such surgical births, however perceived by the mother or physician, are the cause of the numbers of surgical births in this country.
One position on this matter is the issue of choice; that a woman should be able to choose surgical birth if she pleases. And I support choice, if the woman is given full disclosure and informed consent of all of her birthing options. As far as I’m concerned, I don’t believe this happens. Many who support maternal requested non-medical surgical birth won’t “allow” VBAC and some areas have legislation in place to restrict access to midwifery care; so how is this giving the woman full choice?
I should stop before I make this comment a post of it’s own!
January 23, 2008 at 6:44 pm
Labor Nurse, I really don’t believe maternal requests are really happening at a level that explains the c-section rate, either, but I’m glad to see people are starting to study it (and in this small population, debunk it). I think you raise an important point for future research on this topic - namely, what is truly maternal request, and what is maternal agreement based on how risks were communicated?
If you’re interested in reading the study I mentioned, the citation is: Pevzner L, Goffman D, Freda MC, Dayal AK. Patients’ attitudes associated with cesarean delivery on maternal request in an urban population. Am J Obstet Gynecol. 2008 Jan 14; [Epub ahead of print] PMID: 18199421
January 24, 2008 at 10:55 am
I work as a maternity nurse and see up close what happens and people’s attitudes. Very few women would choose major surgery as a birth option but our culture has normalized surgical birth and when your family members and friends end up with C/S, the bar is lowered. Please read the book Pushed that talks about birth politics. The author exposes interesting info about the “consensus” conference. Who was in charge? Urogynecologists!!! She also says and this makes such good sense to me: when we call it maternal request C/S, we are saying women are asking for it and so so much easier for doctors to convince all of us how this C/S was necessary! Less scrutiny for Doctor request C/S when women can request it! I personally know of primips who at term at their appt were told that their baby is too big, their pelvis too small and that they would need a C/S. these women of course trust their doctors and go ahead. It is infuriating!
January 26, 2008 at 12:09 pm
I have been a doula for many years and I have never experienced a woman requesting a c-section. I don’t know if I believe women should have the right to request them w/o medical necessity. It increases her and her baby’s risk for complication. Why should it be a choice?
January 26, 2008 at 1:50 pm
Outside of medical school, I only know of one person who requested a cesarean from the beginning of her pregnancy. I think it is a small small percentage of the cesarean rate. Much of it may be due to suggestion by the OB. I know the OB who teaches for the school suggests elective cesarean several times to all of his mothers, and totally violates, IMO, the ACOG position statement on adequately explaining the risk and benefits and trying to allay the mom’s fears. He has interpreted that to mean that ACOG supports elective cesarean if that’s what the mom and OB decide on.
Unfortunately, an obnoxious number of my classmates say they will have an elective cesarean if they ever get pregnant. There have been studies on OBs and their attitudes toward elective cesarean for themselves and/or their partners, and the numbers choosing it were about 50%. I would be curious to see that extended to all doctors and/or med students.
I think it is for a combination of reasons. A lot of them have parents who are doctors, and many of them have a good understanding and respect for medical procedures and the practice of modern medicine, but know little to nothing about childbirth or pregnancy.
January 27, 2008 at 3:38 pm
Good comments….may I offer another POV? My OB, who tries at all costs to avoid c-sections, did indeed allow me to proceed with a vaginal birth to a boy far, far too big for my body. I ended up with a level 4 pereneal tear which resulted in permanent fecal incontinence for the rest of my life. Had I known that this was a possibility and been offered a choice, I may indeed have opted for a c-section. But no such choice was even offered.
My current pregnancy is due is March and my same OB has informed me this one is breech. This time, I was offered a choice which has allowed me to do the research and make my own informed decision. My body…my choice.
Are there some who will make choices in ignorance? Sure. But that’s the price of a society with the freedom to choose.
January 27, 2008 at 5:56 pm
When I was pregnant, my due date was close to Christmas. At one of my final OB visits, my doctor came right out and asked me if I wanted to be induced early because she was going out of town for Christmas. I refused, and frankly I was shocked that she would suggest induction for such a frivolous reason. Being a doctor, she should know better.
January 27, 2008 at 6:22 pm
Michelle, I am sorry that happened to you, but cesarean section has 4 times the risk of maternal mortality, and risks to the baby, including more admissions to NICU. Those risks should be weighed against risks of vaginal delivery.
Any vaginal delivery does have a risk of tears and pelvic floor dysfunction. 4th degree tears are extremely uncommon. I would hope any health care practitioner that delivered your baby would have told you that, and it is in most information sources about birth.
An episiotomy increases that risk, as does use of instruments to aid delivery. Research on weight estimates of larger babies does not indicate that the mother or baby is safer with cesarean delivery. I am sorry you suffered from a vaginal delivery, but that does not mean you took the path of least risk.
There are doctors that specialize in pelvic floor reconstruction, including one who just spoke at my med school who does trips to Africa to do fistula repairs. I hope a 4th degree tear does not mean you have to suffer with life long incontinence.
April 1, 2008 at 3:36 pm
I am 7 mo. pregnant and have been informed that I have HPV. According to my doctor it is not vital that I have a C-section as this virus can only cause symptoms in a small percent of infants. I do not want my child to be exposed to anything that could possibly cause her harm. Should I ask that I be allowed to have a C-section to avoid any risks?
June 16, 2008 at 5:51 pm
I can relate. I was induced when I had my second child a year ago. My doctors said that there must have been a dictation error in the readings of my first ultrasound and that I needed to be induced, because they couldn’t tell if I was 40 weeks or more. My first delivery was a piece of cake and I pushed just as hard this time around and I knew something wasn’t right. I asked the doctor if the baby was in the right position. She said he was and wouldn’t do a quick ultrasound. Well, he wasn’t. He was face up. She proceeded to yell at me to push and said the baby was in distress and that we had to get the baby out. I knew something wasn’t right. She ended up using forceps and snipping me 3 times which resulted in a level 4 tear. Luckily my body healed pretty well, although I have a few mild symptoms that hopefully kegels will eventually change. Now, I’m pregnant with my third and she wants me to plan on having a c-section. Both make me really nervous. But, I can sympathize with Michele, both for her condition and for feeling like her practioner didn’t respond to her requests. I work with all medical professionals and I know it’s not easy, but I think any physician would admit that even the best misjudge and miscommunicate from time to time like the rest of us!
June 23, 2008 at 7:42 pm
Hi. Whether or not women are requesting cesareans, isn;t it a woman’s perrogative to choose what she feels is best for her and her delivery? I know moms, nurses, doctors and other health care professionals. Many MDs and DOs have no problem performing cesareans as they are seen as less of a risk (citing the recent rise in lawsuits against physicians). Cesareans were perfromed beginning in the 1500’s (when the first successful one was performed by a Pig gelder for his wife who was having a long and difficult delivery). Thank God for this option. Many women have serious issues such as a narrow and unaccomodating pelvis, the do not dilate appropriately and this can caus serious tears and injuries, and there are emergency situations when the baby is in distress, one such incidence I know of personally was monitored closely by a doctor and the heartbeat was showing signs of irregularity. The doctor saved the baby and the mom, with an emergency c section during the flood of 1993 in Illinois. The baby’s cord had been wrapped around his neck and ankles. If it had not been for the excellent doc and his team, this could have resulted in tragedy. Now, as for “elective” cesareans, I do not know if “elective” is the word. Even if the mother fears natural birth or the destruction of her female parts. It is her right to protect her own body. If she feels a cesarean is safer for her, who are we to judge or dictate how she gives birth to her child? Furthermore, I think this “VBAC” push is irresponsible. There are women who have had repeat cesareans, I know of one who had eight. I cannot believe it when she told me a NP was trying to push her towards a VBAC. The muscles are weakened with each cesarean and this will make things all the more complicated and difficult for a woman believing a VBAC is safe after several cesareans.
As for the drugs used in cesareans making it all more dangerous? Well, most women having a vaginal birth also have epidurals and other drugs administered. Let’s have an honest conversation here.
June 24, 2008 at 7:33 am
All For Choice, I think an important thing to remember is that nobody is really suggesting that all women must have a VBAC, or nobody can ever have a c-section, or anything else that is an absolute extreme rather than subject to variations based on individual risk and choice. However, (and especially at the time of this post) there had been some speculation that the c-section rate had been rising at least in part because women were demanding the surgery - think about coverage including the phrase “too posh to push.” It helps to understand whether or not that is actually the case in order to understand what is or is not a real factor in the current c-section rate.