Answers prove elusive as C-section rate rises
But in childbirth, as in life in general, there are no guarantees.
"The problem is we don't know who's going to have an uncomplicated vaginal delivery," says Spong, chief of the pregnancy and perinatology branch of the National Institute for Child Health and Human Development.
If a woman has delivered one baby vaginally without much trouble, chances are good she'll be able to deliver another baby the same way.
But what if the woman is a first-time mother with no childbirth track record? Is scheduling a cesarean section a safer bet than planning to deliver vaginally?
Apparently, some pregnant women think so, and they're reportedly asking for C-sections even though there is no medical reason for one.
How much so-called maternal request cesareans have contributed to the soaring C-section rate isn't known, but growing numbers of women are delivering their first babies via surgery, researchers say. And for virtually all of them, once a C-section, always a C-section. Last month, the government announced the U.S. rate hit another all-time high in 2006.
As the rate has risen, so has the rate of pregnancy-associated deaths in 2003 and 2004. Data on the maternal mortality rate for 2005 and 2006 aren't yet available. The rate hit 13 per 100,000 live births in 2003, the first time it had topped 10 per 100,000 since 1977. The rate rose to 14 per 100,000 in 2004, or 540 reported pregnancy-related deaths.
National Center for Health Statistics researchers, who reported the maternal mortality trend in August, attribute the increase mainly to better reporting of pregnancy-related deaths, not greater actual numbers. But activists opposed to the growing use of C-sections and some doctors say the increase is probably the result, at least partly, of the increase in surgical deliveries. In 2006, 31.1% of U.S. births were by C-section, a 50% increase over the previous decade.
Lines are being drawn
Some leading obstetrician/gynecologists believe only a trial in which women are randomly assigned to deliver their first babies by planned C-section or planned vaginal delivery can determine whether either is safer.
Other doctors, as well as activists, question the need for and the feasibility of such a trial. They cite several recent studies that examined rates of pregnancy-related deaths and illness in women who opted for a vaginal delivery compared with those who scheduled a C-section. Mothers who delivered vaginally generally fared better, although complications were rare even among C-section mothers.
Whether first-time mothers increasingly are requesting C-sections when they don't need them isn't clear. Eugene Declercq, professor of maternal and child health at Boston University, says he suspects more doctors are recommending them, and their patients are reluctant to disagree. For example, Declercq says, a doctor might say, "The baby is looking kind of big. We could do a cesarean."
OB/GYN Peter Bernstein of Montefiore Medical Center in New York says some doctors encourage patients to schedule C-sections because they think they're less likely to be sued than if they perform a vaginal delivery. And "women are more ambivalent about what they want."
Not Pam Luddy of South Weber, Utah, who is president of the International Cesarean Awareness Network. "It may be true that (C-section) surgery is safer than ever, but it's still not safer than a vaginal birth," Luddy says.
Berna Diehl, the group's communications director, points to headline-making cases of young, apparently healthy women who died shortly after planned C-sections, which are thought to be safer than C-sections performed after a woman has gone into labor and tried to deliver vaginally.
Valerie Scythes, 35, and Melissa Farah, 28, were friends who taught at the same grade school in Avon, N.J., and died two weeks apart last spring after delivering their firstborns, both healthy girls, via planned C-sections at Underwood Memorial Hospital in Woodbury, N.J. Whether Scythes and Farah died solely as a result of their C-sections isn't clear. John Baldante, the Scytheses' attorney, and Todd Miller, the Farahs' attorney, did not return phone calls. The Philadelphia Inquirer reported that Farah's death certificate said she died of "shock due to bleeding and anemia."
"It's a tragedy when a young woman goes in for a baby and dies," says David Birnbach, an obstetrical anesthesia specialist who directs the Center for Patient Safety at the University of Miami. "Unfortunately, it can be due to misadventure or an error, but more often than not, it's an act of God."
Of course, not all women who died of pregnancy-related causes last year had C-sections.
"I don't think there's evidence to say that (a planned C-section) is at the present time riskier than a vaginal delivery," says Columbia University OB/GYN Mary D'Alton, chairwoman of a 2006 National Institutes of Health conference on maternal request C-sections. "There are risks and benefits to both. You need to know more about the individual woman to be able to assess the risks."
D'Alton's panel recommended that women who know they want "several" children should not get a C-section solely because they want one, because the risk of placenta complications rises with each C-section.
Always risk with surgery
OB/GYN Elliott Main doesn't rule out a connection between increased maternal illness and death and C-sections. Major abdominal surgery does carry risks, says Main, OB/GYN chair at California Pacific Medical Center in San Francisco and head of the California Maternal Quality of Care Collaborative.
"Blood clots can lead to sudden deaths," he says. "There can be anesthesia complications, hemorrhage complications."
On the other hand, some argue that the underlying reasons for a C-section and not the procedure itself are to blame for complications, he says.
To try to get around that potential confounder, some researchers have compared vaginal deliveries only with C-sections planned because a fetus is breech (not in the optimal head-down position for delivery). Virtually all breech babies are delivered via C-section.
"I think common sense tells us that they (women whose fetuses are breech) aren't more likely to have underlying medical conditions," says Robert Liston, OB/GYN chair at the University of British Columbia and co-author of a recent study comparing planned C-sections for breech babies with vaginal deliveries. "There may be something about the anatomy of their pelvis or the uterus, but it's not because they have heart disease that the baby's a breech."
Using hospital discharge records, Liston's study in February's Canadian Medical Association Journal compared nearly 47,000 Canadian women who had had scheduled C-sections for breech babies with nearly 2.3 million who'd planned to deliver vaginally.
The C-section group had higher rates of cardiac arrest, blood clots, infection and hysterectomy. They had a lower rate of transfusions, which might be because doctors are quicker to perform a hysterectomy in a bleeding C-section patient. The difference in death rates between the two groups was not statistically significant.
The next month, Declercq co-wrote a similar study in Obstetrics & Gynecology, the journal of the American College of Obstetrics and Gynecology. His team used birth certificates, fetal death records and birth-related hospital discharge records to compare 3,334 first-time mothers who had a planned C-section (not necessarily because of a breech fetus) with 240,754 mothers who had planned to deliver vaginally.
The women who had planned C-sections were more than twice as likely to be hospitalized again in the first month after birth than the women who had a planned vaginal delivery. In addition, the average initial hospital cost of a planned C-section for a first-time mother was 76% higher than that for a planned vaginal birth.
Cost is one reason D'Alton and Kenneth Leveno, chairman of obstetrics and gynecology at the University of Texas Southwestern Medical Center at Dallas, want to conduct a randomized trial of first-time mothers comparing planned C-sections with planned vaginal deliveries.
They say they would need to enroll 10,000 women and, because C-sections can affect subsequent pregnancies, would have to follow them for at least five years — although, D'Alton says, a much longer study would be needed to answer such questions as to whether a planned C-section protects against urinary incontinence and other problems not usually seen until middle age. The cost: an estimated $75 million.
"That sounds like a lot of money, but it really is not in the grand scheme of things," Leveno says. "The problem is to get the national will necessary to do this."
No easy answers
A study so large and costly would have to be conducted by the Maternal-Fetal Medicine Units Network, which conducts research funded by the National Institute of Child Health and Human Development, Leveno says. Last year, he says, the proposed trial fell one vote short of the two-thirds majority of network members needed to proceed.
"The next question is: Will women agree to this?" Leveno says. "I think they will."
Focus groups have suggested one out of 10 women pregnant for the first time would allow the equivalent of a coin toss to determine how they should deliver, he says.
Spong seems skeptical. For example, "when do you randomize them? You can't wait until they go into labor," because some doctors say avoiding labor is what might make planned C-sections less risky.
"The issues are going to be difficult to really figure out."
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