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Doctors endorsing elective C-section for first-time moms

The number of women seeking elective primary C-sections here is small compared to other cities

Thursday, March 06, 2003

By Christopher Snowbeck, Post-Gazette Staff Writer

More women are scheduling Caesarean sections for the delivery of a first child, a trend that doctors writing in today's New England Journal of Medicine say is ethically defensible.

The controversial idea of an elective primary C-section -- scheduling a surgical delivery for a first-time mother before she goes into labor -- has long been discouraged by doctors who believe the risks of surgery outweigh the risks of vaginal delivery.

But for a variety of reasons, ranging from the convenience of scheduling the delivery to the perception that C-sections reduce the risk of incontinence, more patients are asking about the option, according to doctors in Pittsburgh and across the country.

Dr. Howard Minkoff, an obstetrician at Maimonides Medical Center in New York and one of the authors of today's article, contends that the evolving picture of the risks and benefits of C-section and vaginal deliveries is making it increasingly appropriate for doctors to discuss the possibility of elective primary C-sections with a first-time mother.

Improvements in technique, anesthesia, infection control and blood banking have made surgery safer, Minkoff argues. At the same time, both law and ethics increasingly reinforce a woman's right to autonomy in making medical decisions.

The autonomy argument isn't reasonable in the case of a patient who requests gall-bladder surgery just because he wants it removed, Minkoff said. But doctors shouldn't treat a woman's request for elective primary C-section the same way.

"The weight of evidence still favors a vaginal delivery, but I don't think the weight is so heavy now that the physician should refuse," said Minkoff, whose article describes the pros and cons that he believes doctors should discuss with patients.

"A mother has her own unique experience, and if she can understand what we're discussing, and she balances these things in another way, I don't think it's unethical to accede to her request," he said.

Scheduled C-sections for women who have previously had surgical deliveries are common and have become even more so in recent years, as obstetricians have become more concerned about the risks of attempting a vaginal birth after a cesarean delivery. That's part of the reason why, after declining for years, the overall C-section rate is increasing. It's unclear what if any part of the increase could be attributable to elective primary C-sections.

Concerns about incontinence are one reason cited by women who want to schedule a primary C-section, Minkoff said.

Minkoff pointed to a separate article in today's journal, which reports the results from a study of more than 15,000 Norwegian mothers. The prevalence of incontinence was 10.1 percent among women who hadn't had children, 15.9 percent among those who had had C-sections and 21 percent of those who had vaginal deliveries.

But the author of the Norwegian report strongly argued against using those results as a justification for more C-sections.

"From our figures, it can be calculated that three out of 13 women who have vaginal deliveries will become incontinent," said Dr. Guri Rortveit of the University of Bergen. "If all women deliver all of their children by C-sections, the number of incontinent women will be reduced to two out of 13. This implies that C-sections is not a very effective prevention strategy."

Dr. Dennis English, the medical director of health management at Magee-Womens Hospital, said he has heard more colleagues in recent years describe local patients asking about elective primary C-sections.

"On some occasions, patients are being insistent about this," English said. "I think you're beginning to see doctors locally who will say, yes, we'll do that."

But Dr. Halina Zyczynski, a researcher in pelvic floor disorders at Magee, said the number of women seeking elective primary C-sections here is small compared to other cities, just as the number of local women interested in midwife-attended births is lower here.

Anecdotal reports suggest that large percentages of women in some South American countries pay out-of-pocket to have a C-section out of fears about weakening of pelvic floor muscles, which can cause urinary incontinence as well as changes in sexual function. But such fears are overblown, Zyczynski said.

"They're completely focusing on the emotional fears. The truth is, women who've had C-sections also have incontinence and pelvic floor [problems]," she said. "Maybe we are blaming the trauma of childbirth too much for these problems. ... Maybe it's pregnancy and not the mode of delivery that plays the bigger role."

If elective primary C-sections really catch on, it could be yet another factor driving up health-care costs, said Dr. Carey Vinson, medical director for quality management at Highmark Blue Cross Blue Shield. And it could be a difficult trend for insurance companies to police, Vinson said, because the New England Journal of Medicine article begins to give the practice credibility.

"Anecdotally, we have not heard much from physicians about this and I believe that's because, until this article, there was not that much in the way of data to support doing the elective primary C-section," Vinson said. "This article changes that situation."

Christopher Snowbeck can be reached at csnowbeck@post-gazette.com or 412-263-2625.

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