January 23, 2008

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.


20 Responses to “Do Women Really Want On-Demand C-Sections?”

  1. Labor Nurse Says:

    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!

  2. Rachel Says:

    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

  3. lienjud Says:

    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!

  4. Sally Brady Says:

    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?

  5. Hilary Says:

    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.

  6. Michele Says:

    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.

  7. tp Says:

    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.

  8. Hilary Says:

    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.

  9. Mary Says:

    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?

  10. jamie Says:

    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!

  11. All for Choice Says:

    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.

  12. Rachel Says:

    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.

  13. Kim Says:

    I think doctors these days are becoming very non-challant (sp) about cesaeans. From my first ultrasound I was told I had a 7 cm posterior fibroid in my cervix area. The doctor told me I might want to consider an elective c-section because I wouldn’t want to go thru hours of labor only to find out the baby could not get past the fibroid. I opted to wait and see.

    Well the fibroid has not grown and I am now 38 weeks. My son is not engaged and my cervix is still closed. My doctor brought up today “if you want to go ahead and schedule a c-section just let me know”. I told him I still want to wait and see. I really feel all I have to say is “schedule one” and I would be having a c-section. My question or comment is this – I’m not the medical professional – and I have to believe that because he isn’t saying I have to have a c-section that I have some sort of chance of a vaginal delivery. Am I crazy to try to give it a go? I hate to give in to an “elective” c-section if I can deliver vaginally but who wants to labor for hours only to have a c-section any way? Any thoughts or comments would be appreciated.

  14. mrs spock Says:

    Kim,

    I labored for 36 hours and ended up with a c-section. If I had to do it over again, I would. I feel really good about my birth, because we truly gave it a good try, and my feelings about what route we chose were honored and respected. My concern was my son’s safety, and if at any time that was jeopardized by the route we were taking, that plan could change. I went into my unplanned induction not knowing if it was going to work or not, since my body really wasn’t ready to labor yet, but my son had stopped moving and had obvious signs of distress, necessitating his exit. My thinking was, I had planned to do all the work to get him out anyway, it just might or might not end surgically. When it became obvious I would need a c/s, there was no disappointment.

    Who knows, you may you may surprise everyone with a short, easy labor.

  15. Jaza Says:

    On what basis are you claiming that women who demand c sections don’t exist? And on what basis are you assuming that the ones who do must be uninformed and require you to “educate” them? I’m a living breathing example if a woman who knows about the pros and cons of both modes of delivery and would still want a c section. Do I not have the right to make this informed choice about MY body? Even if women like me are in a monirity, does that mean our rights and choices shouldn’t be supported?

    This is a feminist website isn’t it? The feminist mantra for years has been “my body, my choice”. Does this only extend to abortions and home births? If it’s my body and my choice, I also have the right to demand (and get) an epidural or a c section. It boggles my mind to imagine how feminists can say that a woman who makes an informed decision to have a c section should not be “allowed”. Do you not see how patronising and paternalistic that sounds?

    To the people who insist that c sections are risky- yes, they are. But so is vaginal birth. If c sections can cause breathing difficulties in babies, vaginal births can cause brain injury due to hypoxia and asphyxia, or even birth injuries such as broken collar bones and brachial plexus nerve damage.
    If c sections can cause infections and blood clots for women, then vaginal births can cause severe perineal tears, pelvic floor disorders, sexual dysfunction, incontinence and pelvic organ prolapse.
    The statistics which show that c sections are associated with higher maternal mortality, are statistics that don’t differentiate between emergency and planned cesarean births. The recent research conducted by NICE in the UK shows that the mortality rates of PLANNED c section births is actually comparable to vaginal births. Once a woman has been through alk the information available, it is her choice and her’s alone to decide how she wants to give birth and which set of risks she wants to take.
    There are plenty of procedures that come with significant risks (abortions, liposuction, elective hysterectomies), and yet women request them all the time. Why the hysteria when it comes to c sections?
    My body, my baby, my choice. And I have the right to make this choice without judgement. If you can’t respect this choice, don’t call yourself a feminist.

  16. Rachel Says:

    Jaza, I think you’re making a leap in assuming this is about you and your personal choice. The point is not that they “don’t exist” – it’s that while the media have tried to frame this as some big trend, and maternal demand c-section has been kicked around as an explanation for rising cesarean levels, the existing data don’t really support that. There’s also evidence that often docs aren’t really discussing the potential risks with women. In your specific case this may have been different, but when focusing on the issue in general, there’s not much to support this as widespread or significant enough to drive the major US increases in cesarean rates.

  17. Jaza Says:

    Rachel, I am well aware that maternal request c sections cannot be the sole reason for an increase in the overall c section rates of any country, not just the US. But I have two points to make- the first being that you cannot deny the fact that the feminist community has often portrayed c sections in a very negative light. They simply aren’t willing to accept that there are women out there (like me) who are fully educated about the pros and cons of a c section and want to choose it anyway. It’s a bit silly to have a motto like “my body,my choice” and then use it selectively. So I can choose an abortion, a home birth and a VBAC because it’s my body and my choice, but I can’t choose a c section? How senseless is that?
    It’s absolutely fine to be concerned about women being forced into c sections but you must understand that women CHOOSING c sections is a separate issue, and confusing the two is not going to solve either problem.
    The second point I want to make is that perhaps we as a society need to rid ourselves of this bias we have against c sections and try to understand that they do have some benefits as well.
    Vaginal birth is not automatically risk free simply by virtue of being natural.
    People love to correlate c sections with high maternal mortality rates in the US, but if you analyse the data carefully you’ll see that one has nothing much to do with the other. Why? Because Australia has exactly the same c section rate but half the maternal mortality. Greece has a c section rate of close to 44% and the lowest maternal mortality rates in the world. Italy has a c section rate of 39% and a maternal mortality rate which is about 1/6 that of USA’s. So it’s clearly something other than just c sections that is driving up the maternal mortality rates in the US- could be obesity, could be lack of insurance, could be high immigrant population, the possibilities are endless. It would be far more productive if we would look at those other causes instead of focusing on one assumption which is not supported by global trends.
    You must also understand that studies which have shown c sections to be associated with higher maternal mortality have not distinguished between emergency and planned c sections or between medical and non medical c sections. And this is crucial. If a woman who died in childbirth had heart disease and was high risk in the first place and then ended up with a c section, can her death be blamed on the surgery alone? If a woman attempting a VBAC had a uterine rupture and haemorrhage in labour and then delivered by emergency c section, would you blame her death on the c section or uterine rupture caused by labour? Until these studies make a clear distinction between the various types of c section deaths, it is counterproductive and pointless to demonise and vilify the surgery.
    I’ll also point out that with a rise in c section rates, the perinatal mortality rates, the rates of sever perineal tears and the rates of maternal heamorrheage have all gone down int the USA.
    If you want to run a responsible website, you need to show both sides of the story and that requires extensive research.
    I’m not saying c sections are risk free – they honestly aren’t!! But I’m just saying that some modicum of balance is required while discussing this topic.
    Please don’t assume that every c section is unnecessary, and that they have no benefits and only risks. Please also don’t marginalise women who are making informed choices to opt for this surgery. In fact, it would be most helpful if you could show some support for women who are fighting to have the right to deliver their babies the way they feel is right- and that extends to elective c sections as well.

  18. Rachel Says:

    Interestingly, having not said anything like “every c section is unnecessary,” I don’t think there’s much here in your latest comment that we disagree on! Thanks for commenting.

  19. Jaza Says:

    I would like to clarify that I didn’t mean to say you have implied every c section is unnecessary. However, that is what an alarming percentage of people are thinking nowadays thanks to negative media hype and misleading information online.

    I’d just like to reiterate that I’m looking forward to support from feminist blogs and websites for a woman’s right to make an informed decision to choose a c section- just as they support her right to refuse it.

  20. Wendell Says:

    I am an Ob-Gyn physician in NY, one of the areas with the highest medical malpractice premiums in the country.
    I OFFER, every patient in my office an elective cesarean section. I go through in detail, the risks of a vaginal delivery, and the risks of a cesarean section.
    When medically indicated, I offer induction of labor.
    Throughout the process of pregnancy, and labor, I discuss the risks of continuing labor, vs cesarean section. I do this with ALL medical conditions.
    After that, I leave it in the hands of the patient.
    The rise in malpractice rates are due to our society demanding perfection. In countries with 2 percent cesarean rates, it is acceptable for adverse outcomes.
    If a patient wants to accept an adverse outcome, it is not within my scope to violate her body.
    As long as the physician adequately informs her, the job has been done.

    I have seen fetal distress due to low heartbeat turn into NO heartbeat right in front of my eyes. Patients sometimes decline treatment, citing “I dont want a c-section”
    I have seen HSV infected babies, because “I dont think that this tingling is an impending outbreak”

    Its a patient’s choice. It is our job as ob-gyn docs to educate and facilitate.

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