The C-Section Controversy
Date: July 1, 2007
Veronica Agostino of Raleigh was ready for the birth of her first child. She had hired a doula to provide support, attended childbirth classes and read a wide variety of books. But, she was not prepared to have a Cesarean delivery of her son in April.
During a long and difficult labor, Agostino's blood pressure dropped and the baby's heart rate increased. With concern mounting about their health, doctors performed an emergency C-section. The umbilical cord had wrapped three times around the baby's neck, but he was healthy, weighing 8 pounds, 10 ounces. Agostino was relieved her son was safe but disappointed with the surgical delivery.
"After my son was safe and the birth was over, I was very upset I had not had a natural childbirth," she says. "I had done everything right, even hiring a doula. But I was really disappointed to end up having a Cesarean."
C-sections are more common
Agostino is certainly not alone in having a C-section. Almost one in every four women who gave birth in 2006 had a Cesarean section, the highest rate in 13 years. C-sections accounted for 24.4 percent of the U.S. births that year, according to the Centers for Disease Control and Prevention. The nation's high was 25 percent in 1988.
In North Carolina, 23.1 percent of the births were C-sections. The rate at local hospitals was even higher, topping the national average in some cases.
* At Rex Hospital in Raleigh, 29 percent of the births in 2002 were C-sections, and 30 percent have been Cesarean deliveries during the first quarter of 2003. This compares with 23 percent five years ago at Rex.
* At WakeMed in Raleigh, 23.2 percent of the births in the first quarter of 2003 were C-sections. This compares with 22.9 percent for the same period five years ago.
* At Western Wake Medical Center in Cary, 29.7 percent of the births during the first quarter of 2003 were Cesareans.
* UNC Hospitals in Chapel Hill reported 29 percent of its births in 2002 were Cesarean deliveries. This compares with 27 percent of the births in 1998.
Why the increase?
Reasons for the increase in Cesareans are varied and often controversial. Some women are requesting Cesarean deliveries, even for their first child. Fear of pain, desire for convenience, lack of detailed childbirthing information and concern over pelvic relaxation problems later in life are some of the major reasons experts list for the surgical delivery.
Some place the blame for the increase on the overall health care system, particularly on physicians and insurance companies. New mothers today often experience a great deal of fear surrounding the vaginal birthing process, says Dr. Robert Littleton, a Raleigh physician and president of the North Carolina Society of Obstetricians and Gynecologists.
"We actually have women that come in with their first baby and request a Cesarean," he says. "Ten years ago, you would never have had that happen."
Ann Tumblin, a Triangle childbirth educator and doula, has also noticed that women today want their labors to be medically induced or have a Cesarean delivery. The desire to be in control and a fear of pain are often driving these decisions.
"Many young women today are more in tune to the calendar and have very little patience," she says. "Also, everything they see and hear helps to instill fear over the childbirthing process. They lack confidence, and many are seeking what they see as the quickest way out with a Cesarean."
Cesareans can be life- or health-saving for many mothers and babies. But a C-section is major abdominal surgery. Women's risk of death, although small, is three to seven times higher than during vaginal delivery, according to the American College of Obstetricians and Gynecologists.
Women also have longer hospital stays, a higher risk of post-delivery infection and increased recovery time. In the majority of cases, it is impossible to say who will medically need a C-section without going through a trial labor, Littleton says.
"If a doctor just looks at a patient and announces she will need a C-section, the doctor is blowing smoke," he says. "There are medical reasons in the beginning that you have to keep tucked in the back of your mind and discuss these with the woman."
These can include a multiple birth, an older woman having a first baby or a mother who has diabetes and runs the risk of having a larger baby.
C-section vs. vaginal birth
Also controversial is the fact that the majority of C-sections are repeats. Women who had one C-section are very likely to give birth that way again. A vaginal birth after Cesarean, or VBAC, is more common today, but in 2006 the number of prior-Cesarean mothers who succeeded in giving birth vaginally fell by 20 percent.
The questionable safety of a VBAC due to the risk of a uterine rupture is at the center of the controversy. Some studies have suggested that planning a VBAC may not be as safe as scheduling a repeat Cesarean. Other reports state that the risk of a uterine rupture is small and a VBAC should be preferred over more abdominal surgery. Still others believe that not allowing a woman to make such a decision for herself is violating her rights.
Gaining education about the entire childbirthing process and all of its procedures, including C-sections, is important for all women, Triangle experts agree.
After moving to the Triangle about a year ago, Kandace Dole of Morrisville formed the first International Cesarean Network of Raleigh. While living in Chicago, she had her son by Cesarean delivery after a long and difficult labor. Her daughter was born in Raleigh with a vaginal delivery. Dole is now working toward her certification as a doula and childbirth educator.
"When a Cesarean is necessary, it is an important and often a life-saving procedure," Dole says. "But far too many Cesareans are done unnecessarily, or when they become necessary because of medical intervention."
Dole says she has talked with many women who feel like failures after not experiencing a vaginal delivery. Too many women and couples just take a typical childbirth class and then they are left on their own. She encourages women to educate themselves in addition to childbirth classes and to develop confidence in their ability to give birth.
Education Is vital
Tumblin agrees that too few women take the time to properly prepare for the birth experience. Today, childbirth classes often are scheduled in one-day sessions on the weekends. Not enough time and study are being invested to prepare women for all aspects of the birthing experience, she says.
Women should spend time reading and learning about the risks and benefits associated with a Cesarean delivery and a VBAC, says Littleton. It is also important that women and couples discuss their thoughts and feelings on delivery procedures when selecting an obstetrician.
Agostino, the mother who delivered her son by C-section, wishes she had learned more about the surgery. She hopes to have a VBAC when she has a second child.
"I was totally not prepared for it at all," she says of her Cesarean delivery. "I guess no one wants to think they will have a C-section after they have worked so hard to prepare for a natural childbirth. But I wish I had learned more and knew exactly what to expect."
Want to Know More?
A wide variety of books and Web sites are available on Cesarean delivery.
* A Good Birth, A Safe Birth by Roberta Scaer
* The Thinking Woman's Guide to a Better Birth by Henci Goer
* International Cesarean Network: www.ican-online.org
* American College of Obstetricians and Gynecologists: www.acog.org
Note: This article is reprinted from Carolina Parent magazine in March 2003.