Obstetrics

Monday, Apr. 19, 2004

Actress Elizabeth Hurley had one. So did supermodel Claudia Schiffer. Ex-Spice Girl Victoria Beckham and singer Toni Braxton had two each. TV mom Patricia Heaton had four. They're so popular among the upper class in Brazil that the only way you won't get one in Rio de Janeiro, as the joke goes, is if your doctor gets stuck in traffic.

What all these women had are C-sections. Not the emergency caesareans that have been performed for hundreds of years to rescue babies from women in medical crisis. (Legend has it that Julius Caesar was born this way.) Rather, they had an increasingly popular modern-day variation: planned, scheduled operations for all sorts of less-than-critical reasons. One young college student arranged her baby's birth to avoid conflict with her final exams. Another woman was convinced a C-section would ensure that her child's head had a nice round shape. Others are terrified of labor pains and complicated deliveries or want to avoid the wear and tear on their bodies. Some, as the British tabloids have put it, are simply "too posh to push."

Whether or not the label fits, more and more women — and not just celebrities like Madonna, actress Kate Hudson and Live with Regis & Kelly co-host Kelly Ripa — are taking charge of their childbearing these days and avoiding the vagaries of natural births. Around the world, rates of caesarean sections are soaring, far surpassing the recommendation by the World Health Organization (WHO) that C-sections make up less than 15% of all births and less than 9.5% in wealthy, Westernized nations. In England, 22% of all babies are born by C-section. In Italy, the rate has climbed from 21% a decade ago to 33% today. In some private clinics in Brazil, C-section rates are as high as 90%.

In the U.S., according to the Centers for Disease Control and Prevention, at least 1 in 4 babies is born by C-section — the highest rate since the government officially began keeping track — up from 10.4% in 1975. According to Dr. Samantha Collier, vice president of medical affairs at HealthGrades, a company that rates the quality of health care in the U.S., about 22% of those C-sections — or 63,000 births per year — are purely by patient choice, a 20% increase since 1999. "In the next couple of years," says Collier, "we're going to see this go through the roof."

All of which puts the obstetrics community in an uneasy ethical position. While C-sections are safer than ever — thanks to improvements in anesthetics, antibiotics and operating techniques over the past few decades — they still introduce real risks. In 1% to 2% of cases, C-sections lead to infection, damage to other organs during surgery or severe bleeding in the mother. They can also endanger the baby if the infant's gestational age has been miscalculated and the child is removed from the womb too soon. Risks to the mother increase with each successive C-section, and the procedure isn't recommended for women who plan to have more than two children.

So the question for doctors is this: Should women be allowed to have C-sections just because they can?

"I personally like to practice under 'Do no harm,'" says Dr. Kimberly Gregory, director of maternal-fetal medicine and women's health services at Cedars-Sinai Hospital in Los Angeles. "Surgery is a major procedure." Gregory says most women ask for C-sections because they're afraid of complicated deliveries or long, painful labor. Though she has performed a few elective procedures, she doesn't do them routinely and says good doctors should be able to allay women's fears by discussing the use of drugs and breathing techniques, which can ease pain.

On the other hand, many doctors believe just as strongly that a woman should have the right to choose for herself how she wants to have her child, as long as she is fully informed of the risks and benefits.

Of course, there are risks associated with natural childbirth too. During difficult deliveries, in which the mother is pushing for three or more hours, a baby can suffocate or sustain brain damage in the birth canal. Moreover, up to 5% of vaginal deliveries result in severe tearing of the mother's perineum, which can lead to incontinence and an excruciating recovery.

According to Dr. Benjamin Sachs, a professor of obstetrics and gynecology at Harvard Medical School, a careful study of the risks of both forms of delivery suggests that one is generally as safe as the other. That's one of the reasons doctors have become quicker to cut, says Sachs, even in nonemergency situations. With malpractice premiums hovering at $150,000 to $200,000 per year, obstetricians can no longer afford to take even the slimmest risk associated with natural childbirth. And if patients want to have a caesarean section, says Sachs, why deny them without a compelling reason to do so? "The opportunity for a woman to elect to have a caesarean section should be as available as the opportunity to have a safe, natural childbirth," he says. "Our responsibility as physicians is to counsel at both ends of that spectrum, explain the issues and try to provide support for women."

Officially, the American College of Obstetricians and Gynecologists (ACOG) agrees. Last November, an ACOG ethics committee issued its opinion on the debate, finding it ethical for doctors to perform elective C-sections so long as the procedure doesn't imperil the health of the mother or child. But the committee fell short of offering guidelines, citing lack of evidence. Dr. Laura Riley, of Boston's Massachusetts General Hospital and the current chair of the ACOG obstetrics practice committee, says studies haven't fully explored the issues many women fear most: pelvic-floor damage and incontinence. "The studies are still out," says Riley, but in reference to her personal practice, she adds, "My thought is, a vaginal delivery is safer for the mother."

A Gallup poll published in February suggests that female obstetricians are sharply divided on the issue. Thirty-six percent say they would not perform a caesarean at a woman's request if it wasn't medically necessary, 32% say they would, and 28% say it would depend on the circumstances. Tellingly, 27% of the polled doctors who had been pregnant had had at least one C-section themselves, and 22% of those procedures were elective.

A case in point is Dr. Kim Warner, 36, chair of the obstetrics and gynecology department at St. Joseph Hospital in Denver. When her first child was due last year, she scheduled her own C-section. Warner had spent the past five years surgically reconstructing pelvic-floor muscles and repairing leaky bladders in women who had experienced difficult natural deliveries. She didn't want to risk a hard labor herself.

On Aug. 22, 2003, Warner and her husband arrived at St. Joseph, where about 15 of their closest friends and family members were waiting. Within half an hour, Warner was in recovery holding a baby girl named Kiah; the next day mother and child were home. "Everything was just smooth as silk," says Warner. "I wouldn't think twice about having another C-section." But, she adds, "I'd think twice about having another baby. It's hard work."

With reporting by Andrew Downie/Rio de Janeiro, Helen Gibson/London, Kristin Kloberdanz/Chicago and Jeanne McDowell/Los Angeles

Copyright © 2004 Time Inc.