Elective C-sections continue to rise

Safety vs. vaginal delivery still debated

Women increasingly are electing to give birth by cesarean when there is no medical necessity to do so; meanwhile, the debate about the safety to the mother continues.

While there are some who insist the safety of elective cesareans in healthy mothers is comparable to birth via vaginal delivery, others say the risks of surgery should cause cesareans to be reserved for medical necessity. The American College of Obstetricians and Gynecologists (ACOG), is somewhere in between, advising member physicians that they are ethically obliged to "counsel" patients who ask about elective cesareans in otherwise healthy pregnancies, but has not come out with a guideline about when physicians should say "yes" or "no" (when the safest choice for the patient is not clearly indicated).

HealthGrades, a Lakewood, CO-based health care quality company (www.healthgrades.com) issued a report in 2004 analyzing 1,684 hospitals in 16 states, representing approximately 50% of all deliveries in the United States. The findings are that "patient choice" cesarean deliveries rose 25% in the United States from 2000 through 2002, representing 2.21% of all deliveries in the United States in 2002. HealthGrades released a similar study in 2003, examining data from 1999 through 2001, and found that the percent of elective cesareans grew from 1.56% to 1.88% — a 20% rise for those three years.

Questions about safety still debated

"When we conducted this study last year, we were able to show a clear trend toward an increasing number of women choosing cesareans over vaginal births," says Samantha Collier, MD, HealthGrades’ vice president of medical affairs. "Now we see that this increase is continuing, and that the overall in-hospital complication rates for patient choice’ cesareans may be lower than that of vaginal deliveries."

HealthGrades’ report states that women who choose a cesarean over vaginal delivery have reduced overall in-hospital complications. But the authors of a statistical review that appeared in the on-line version of the British Journal of Medicine (BMJ) in 2004 is not so confident.

"Although some recent editorials have suggested that vaginal births carry risks comparable to caesarean births, health problems associated with caesareans have been amply documented," wrote Eugene Declercq, MD, the author of the BMJ article and a professor of maternal and child health at Boston University School of Public Health.

The article, "Rise in no indicated risk’ primary caesareans in the United States, 1991-2001: Cross-sectional analysis," appears on-line at www.BMJ.com.

Declercq concludes that more research is necessary to determine whether the risks of elective surgical are outweighed by potential benefits.

Jeffrey Ecker, MD, a high-risk obstetrician at Massachusetts General Hospital in Boston and vice chairman of ACOG’s Committee on Ethics, says that even though patients will ask for elective cesareans, and ACOG has not issued an opinion, "absent compelling data and appropriately designed studies, I and many in ACOG believe that most pregnant women are best served by a trial of labor and vaginal delivery."

The authors of the HealthGrades report conclude that elective cesareans, as compared to traditional vaginal delivery, are not without real immediate-term risk, but describe those risks as "feasibly comparable." On average, HealthGrades states, about eight out of every 100 mothers who choose to have cesareans develop at least one major complication, likely related to bleeding, infection, or the surgical wound, while traditional vaginal delivery is associated with 12 out of every 100 mothers developing significant vaginal tears or lacerations, pelvic floor or organ injuries, or bleeding complications.

What to say to patients who ask

Whether because it is more convenient to schedule a cesarean delivery than to wait for the surprise of the onset of natural labor, or because mothers believe the long-term physical effects of giving birth will be lessened by surgical delivery, most researchers agree that the number of elective cesareans will continue to rise.

What, then, does an obstetrician say to his healthy patient, in whom neither surgery nor vaginal delivery is prescribed or contraindicated, who wants to schedule an elective cesareans?

In 2003, ACOG published Surgery and Patient Choice: The Ethics of Decision Making, a report on how physicians can help their patients make decisions on any surgeries when there is a lack of clear evidence for or against the surgery. In that report, the ACOG ethics committee used elective cesareans as an example of an elective surgery decision that doctors may be presented with. Ecker says this use of cesareans as an example has let some to erroneously conclude that ACOG supports elective surgical delivery.

"I, and many who practice, recognize that some patients will request elective cesarean delivery. The Ethics Committee statement offers guidance on how to appropriately approach such requests," he says. In the 2003 report, he continues, the Ethics Committee writers argue that in situations in which evidence is inconclusive or unavailable — as many would argue is the case with the issue of elective cesarean delivery — after informed discussion and careful consideration of alternatives, a patient may choose, and a practitioner appropriately offer, such elective surgical intervention.

"The obstetric community is split by this issue, with some believing that women who understand the risks should be able to choose," says Collier. "Others believe that it is malpractice to allow someone to choose major surgery when it is not necessary."

She points out that thus far, insurers and providers have largely stayed out of the debate; however, with some research indicating that cost might be a factor, Collier sees the debate widening.

"With C-sections costing more than vaginal deliveries, we can expect them to weigh in on this growing trend," she says.

Possibly adding to the debate are data from a study University of Texas researchers who concluded that elective cesareans may be the most cost-effective in terms of postpartum costs, when considering the expense of pelvic floor complications (urinary and fecal incontinence) that can result from vaginal delivery. In presenting a poster on the study, "Patient selection of mode of delivery: A cost-benefit analysis," (available at the University of Texas-Houston web site, www.research.uth.tmc.edu/researchforum/abstracts.pdf) author Nora M. Doyle, MD, told the Society for Maternal-Fetal Medicine in 2004 that while there might be long-term savings with elective cesarean in healthy women, "women need to be told this is surgery, and that any surgery is serious. It takes longer to recover from a cesarean than a vaginal birth, and there can be complications."

The University of Texas researchers recommend additional research into the long-term complications before adopting elective cesareans as a delivery strategy.