Quick Fix Culture: The Cesarean‐Section‐on‐Demand Debate

… So frequent these bad effects [of labour] that I often wonder whether nature did not deliberately intend women to be used up in the process of reproduction, in a matter analogous to that of the salmon, which dies after spawning.” Joseph B. DeLee 1920 (1, pp 40–41) Dr. Joseph DeLee's 1920 musing about the negative effects of vaginal childbirth came as a preamble to his recommendation that prophylactic forceps and episiotomy be used routinely. Today, however, using similar justification, the issue has morphed into calls for cesarean section on demand. In some parts of Latin America, cesarean section by custom or demand is becoming the norm, but in North America and Europe the phenomenon is also growing, although the actual numbers of women requesting it in the absence of clear indications for themselves or for their fetus is unknown. Proponents claim that cesarean section protects the woman from pelvic floor damage attributed to vaginal birth and avoids trauma and injury to both mother and fetus (2,3). Opponents counter that the literature on which these assertions are made (4) is biased. Furthermore, they claim, although more difficult to measure, that little weight is given to the empowering aspects of vaginal birth or the impact of mode of birth on overall maternal health. The ethics of supporting cesarean on demand is being debated by FIGO, the international association of obstetricians and gynecologists, but at present this organization finds such a practice unethical (5). Nevertheless, the American College of Obstetricians and Gynecologists (ACOG) has determined that it is ethically permissible to accede to a request for an elective cesarean section from an informed woman—but it is also acceptable to refuse if the surgeon thinks it is not in the woman's interest (6). Stimulated by an opinion piece in the Canadian Medical Association Journal by Dr. Mary Hannah (3), claiming that Canadian obstetricians were following the ACOG position, the Society of Obstetricians and Gynecologists of Canada (SOGC) issued a press release stating that vaginal birth remains the “preferred” approach and the “safest option for most women and carries with it less risk of complications in pregnancy and subsequent pregnancies than cesarean births”(7). A follow-up press release stated: The Society is concerned that a natural process would be transformed into a surgical process … The SOGC will continue to promote natural childbirth and make strong representation to have adequate resources available for women in labor and during childbirth in Canada (8). Vancouver's British Columbia Women's Hospital, the largest maternity facility in Canada, had placed a moratorium on cesarean on demand for 2 years while an interdisciplinary committee deliberated on the issue. Arriving at a position similar to that of the SOGC, that preemptive cesarean section results in increased risks for mother and fetus, the committee directed that it will only be possible for a woman to obtain cesarean on demand after she receives structured counseling by a trained individual in the context of a research protocol. The most comprehensive review of the literature comparing cesarean with spontaneous and assisted vaginal birth was completed recently by the Maternity Center Association in New York. Using a systematic review, it concluded that in the absence of a clear, compelling, and well-supported rationale for cesarean section, vaginal birth is far safer for mothers and babies. The precautionary principle of non-maleficence (first do no harm) requires that potentially harmful actions or routines in the “management” of vaginal birth be eliminated before recommending a potentially harmful intrusion like cesarean on demand. In conjunction with the review, in April 2004, the Association published a booklet, What Every Pregnant Woman Needs To Know About Cesarean Section(9). What is so striking about the current debate is the parallel to a similar debate about episiotomy in 1920. This historical linkage illuminates a way of thinking or paradigm that is inherent in the nature and roots of the discipline of obstetrics and gynecology. Before DeLee's 1920 address to the 45th annual meeting of the American Gynecological Society, routine episiotomy was considered meddlesome and inappropriate. DeLee was advocating the “prophylactic forceps operation,” with associated episiotomy, to protect mother and baby from adverse vaginal birth outcomes. His rationale was strikingly reminiscent of the justification for cesarean on demand today. He said: The public is demanding…relief from the dangers to the childbearing woman…While we have decidedly improved the maternal mortality and morbidity and have reduced fetal deaths somewhat, labor is still a painful and terrifying experience, still retains much morbidity that leaves permanent invalidism. The latter statement is also applicable to the child…The prophylactic forceps operation is a technique…with the defined purpose of relieving pain, supplementing and anticipating the efforts of nature, reducing hemorrhage and preventing and repairing damage…It is not a complete reversal of the watchful expectancy…but I cannot deny that it interferes much with nature's process. Were not the results I have achieved so gratifying, I myself would call it meddlesome midwifery. For unskilled hands, it is unjustifiable (1, p 34). In 1920, attended by midwives and general practitioners, most births occurred at home and serious complications and death from childbirth were common. Those who attended DeLee's talk were seeking an area of expertise not shared by others. The challenge could hardly be ignored: “We must not bring the ideals of obstetrics down to the level of the general and occasional practitioner … for the one, watchful expectancy, for the other prophylactic forceps,”(1, p 44). He promoted his approach on the following grounds: It “saves the women the debilitating effects of suffering in the first stage and the physical labor of a prolonged second stage.” It “undoubtedly preserves the integrity of the pelvic floor and the introitus vulvae and forestalls uterine prolapse, rupture of the vessicovaginal septum .… Virginal conditions are often restored.”[Italics by Klein] It saves the baby's brain from injuries and from the immediate and remote effects of prolonged compression”(1, p 43). On examination, the language and justification of his new approach to protect the fetus and women from pelvic floor consequences of vaginal birth are almost identical to the justification for cesarean on demand. The modern version of this claim occurred in a 2002 article, subtitled: “Protecting the Pelvic Floor and Ourselves”(10). Notable is the emphasis on single, short-term outcomes and legal issues and omission of consideration of the effect of mode of birth on overall maternal health. The beginning of focused research on cesarean on demand can be dated to a 1993 publication from the United Kingdom by Sultan et al (11) Striking rectal ultrasound images demonstrated disruption of perirectal collagen fibers, especially with forceps use, but these images were usually unassociated with maternal symptoms. Their argument was convincing: since forceps was an issue, and episiotomy did not prevent complications as previously thought (12–14), the problem was vaginal childbirth itself. A renewed discussion of the dangers of vaginal childbirth followed, each group of researchers studying one or several biophysical outcomes. A consensus was emerging at least among some specialists: practitioners ought not to employ episiotomy, and now since forceps was also in disrepute, the only solution was cesarean section—and why not on demand? The debate was further fueled in 1997 by a survey showing that 17 percent of United Kingdom consultant obstetricians (33% among women consultants) would choose elective cesarean for themselves or their partner, rather than have a baby vaginally (15). Overall, 88 percent of those so choosing decided based on fear of perineal damage. Forgotten in the debate was the reality that in the United Kingdom, normal childbirth is in the hands of midwives, and consultant obstetrician/gynecologists are consulted only for difficult and complicated cases, thereby distorting their view of vaginal birth. Absent from the conventional obstetrical literature on birth, perhaps considered “soft” or “unscientific,” were the personal and spiritual issues of power, control, depression and other psychological trauma, self-esteem, feelings of confidence and competence, breastfeeding, or the maturational and growth-promoting features of vaginal birth. Discussing these issues had even become unfashionable: the domain of the social and behavioral scientist, midwifery, nursing, doulas, and family practice. A full discussion of the nuances between vaginal birth and cesarean section is complex and difficult. Research data are often ambiguous and dense. Women rarely receive the time (which should be at least an hour) that a full discussion of the complexities of birth alternatives deserves. Moreover, the person providing the counseling is often in a conflict of interest. Structured, elective cesarean section is easier for the surgeon. Although certainly not a unified position of the specialty, why do some leaders of obstetrics and gynecology find it easy to support cesarean on demand? To state the obvious, this is a surgical specialty, and most medical students who choose it do so because they are attracted to the surgery or the discipline's complicated and highly specialized aspects—infertility, reproductive endocrinology, oncology, maternal-fetal medicine. Many who select the birth or “delivery” side of the specialty are, as one resident told me recently, attracted to the task of rescuing the fetus from an unsafe environment. They do not usually enter the field to sit with women in labor. In contrast, the discipline devoted to supporting women in normal childbirth is midwifery. Our recent research demonstrates that obstetricians, family physicians, and midwives see birth very differently. Looking at the same research data or phenomena, obstetricians—whether looking at birth plans, prolonged pregnancy, induction, out-of-hospital birth, epidural analgesia, doulas, or labor support—emphasize what misadventures may happen. Midwives see birth as a natural event that needs to be facilitated. And, depending on the issue, we family physicians either think like obstetricians, or midwives, and some of us in between. Cesarean on demand is one of the defining issues that characterizes how very differently practitioners, and now women, can see this issue (16). Whereas midwifery's rebirth in Canada and the United States came from consumer demand for a more woman-centered birth process and the avoidance of unnecessary medical intrusion, the evolving social acceptability of cesarean on demand may be driven by a new consumerism and changes in the cultural context of childbirth. For some the phenomenon is driven by pop culture and trivialized by the unfortunate expression “too posh to push.” But other more serious issues have developed. Professional women are having their first baby in their middle to late 30s, and some who have difficulty becoming pregnant may understandably see childbirth as another event to be controlled in their increasingly complex lives. Control over timing and return to work has entered the equation. The demand for a preemptive cesarean section is sometimes situated as a kind of new feminism in which childbearing is much less central in the lives of this generation. Although in the 1960s and 1970s women worked hard to improve the birth environment of hospitals, in the new millennium many women see the family-centered-childbirth battle as having been won, and are more concerned with other personal and professional issues. For many women in the childbearing years, and for their mothers, birth is no longer on women's health agenda. The generation that fought the battles for family-centered-childbirth is now worried about other health issues: breast and other cancers, osteoporosis, heart disease. Their professionally successful daughters may believe that the exercising of “choice” in their mode of birth is the essence of achieving autonomy and control in their stressful lives. And for some women and some obstetricians the word “choice” has been transplanted from the debate on abortion rights. The debate is further confused by the uncritical use of the word “freedom.” Who can be against such concepts? Although a woman's choice needs to be respected, for her to make a truly informed decision, she needs to receive detailed, accurate, and complete information. Fear of childbirth is a central issue in informed consent. Fear is often based on painful, frightening images as portrayed in popular TV programming. And birth, as a normal family-supported event, has been lost in the increasingly isolated nature of modern life. A preemptive cesarean section can be based on unexplored fear: of pain, of being alone and unsupported, of damage to the pelvic floor—including future urinary and sexual functioning. A well-conducted informed consent session (or, if needed, more than one) provides time for detailed exploration of fears and anxieties. Misconceptions can be rectified. A history of sexual abuse may be uncovered (17), and assistance obtained. A pain management plan can be created, and anesthetic consultation, if necessary, can be arranged. A Swedish study suggested that, largely by dispelling misconceptions about the relative safety of vaginal birth compared with cesarean section, a counseling program will increase women's satisfaction with the outcome of their pregnancies and decrease the proportion of those requesting this procedure (18). What ought not to be accepted is cesarean section as a quick and easy solution to such complex issues. Uninformed, and even misinformed, consent is clearly an issue that belongs on women's health agenda. Cesarean on demand is not a solution. It is a symptom of a problem. Women are not biologically defective or broken. Rather than spending precious community dollars on a surgical fix for a basic human and deeply personal experience, health professionals need to recognize the central importance of support and the contribution of doulas to improved maternal and newborn outcomes (19). We physicians and midwives need to show appreciation for our nurses, and work with women and all health care providers to improve the staffing and attitudinal environment for birth. Then women will know that they will be looked after by people who appreciate them and have the skills, time, and commitment to help make their birth experience as positive, memorable, and life affirming as it can be.

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