Can We Please Stop Blaming Women for C-Sections?

Jennifer Block

Women are not "electing" to put their babies at risk by choosing c-section. Women being backed into a corner and told what's best, then publicly shamed for "asking for it."

Most of us learn the word "elective"
in high school, when we find ourselves with the newfound freedom to
take a course like AP music theory, or advanced sculpture, or yoga.
Elective implies freely chosen, life-enhancing. Laser eye surgery is
elective. Tattoos are elective. But the vast majority of so-called
"elective" cesarean sections are not, and it is inappropriate and
disingenuous to call them so in the medical literature, as did the
recent study in this month’s New England Journal of Medicine,
"Timing of Elective Repeat Cesarean Delivery at Term and Neonatal
Outcomes."

The large study made headlines last
week in papers large and small, was mentioned on NPR, went viral on
the web, and even made national TV news. It found that when babies
are extracted prior to 39 full weeks in the womb, they are less
likely be born breathing on their own, more likely to start life in a
neonatal intensive care unit, and more apt to have infections and
lingering health problems.

We already knew this from previous,
smaller studies, and the American College of Obstetricians and
Gynecologists’ recommendation is to wait until the 39-week mark. But
the study, which culled subjects from the National Institute of Child
Health and Human Development network—presumably those hospitals
most likely to follow best practices—found that a whopping 36
percent of scheduled, repeat cesarean sections were booked before
39 weeks.

Ah, but these are "elective" repeat
cesareans, so women must be requesting them early! That’s what the
study’s authors tell us: lead researcher Alan Tita, MD, said that
women "usually" want to deliver "as soon as they hit" week
37. "Women should wait to have an elective cesarean until 39
weeks," he told Time magazine. Study coauthor Catherine
Spong, MD, elaborated for the Washington Post: "Sometimes
a patient is bonded to their physician…and says, ‘Can we schedule
it when you’re in town?’…Sometimes her in-laws are coming at a
certain time."

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And the media dutifully followed the
physicians’ pointed fingers—toward mothers: "Thousands of
women put their babies at needless risk of respiratory problems,
hypoglycemia and other medical ailments by scheduling C-section
deliveries too early…" began an L.A. Times story. "The
findings could help diminish a widely popular practice…in which
mothers choose to schedule c-sections, or surgical removal of the
baby," reported the Wall Street Journal. "Some women
opt to deliver a little earlier for a variety of reasons, including
being eager to see their baby, being tired of pregnancy or for
convenience," explained the Washington Post. Time
magazine castigated those mothers: "Today, a trend toward elective
cesareans is presenting doctors with another problem—women who
insist on delivering earlier than they should, with potential
risks to the newborn" (emphasis added).

To be clear, the researchers did not
survey the women in this study—they were looking strictly at the
health outcomes of newborns. And previous surveys of women have found
no evidence of a "trend toward elective cesareans." But in
classifying the deliveries as "elective," they imply
patient-choice. "These are all elective repeat Caesareans
without a medical indication and without labor," Spong told
reporters.

It’s true: scheduled, repeat cesareans
are not "medically indicated," at least not according to the
research evidence. After a cesarean birth, a woman is left with a
scar on her uterus, and there’s a small risk of that scar rupturing
in subsequent deliveries, which has led to concerns about vaginal
birth after cesarean (VBAC). But a VBAC baby has excellent odds—the
risk of severe harm or death is 1 in 2000—the same odds as for a
baby born vaginally to a first-time mother.

However, in spite of the true risk,
VBACs are often vehemently discouraged. In fact, many obstetricians
now refuse to attend them, and hundreds of hospitals have officially
banned them. And malpractice liability fears are a strong motivation
to schedule the surgery early, so as to avoid the possibility of
labor—and vaginal birth. The fact is that VBAC is inaccessible to
most women.

So, if a woman with a scar from a
previous cesarean goes to her OB and is recommended to schedule a
repeat cesarean—and is told that a vaginal birth would be risky,
and that anyway it won’t be done by this doctor, this practice, or
this hospital—can the surgery possibly be called "elective?"

There are risks to VBAC and risks to
repeat C-section—even those done after 39 weeks—and women should
be weighing the risks and benefits with objective care providers who
will support their decision. But this is not what’s happening. In a
survey conducted in 2005, more than half of women seeking VBAC could
not find a willing provider or hospital.

This is not about women "electing"
to put their babies at risk. This is about women being backed into a
corner and told what’s best, then publicly shamed for "asking for
it."

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