When Debbie Cargile became pregnant with her first child in 1999, she very much wanted a natural childbirth. After seeing a Seattle obstetrician for the first few months, she decided to switch to a midwife for the rest of her prenatal care to help ensure she got her wish.
She considered a home birth but ultimately opted for a birthing center. After three hard days in labor with her cervix still not fully dilated, though, Cargile wound up in the hospital and her daughter was delivered in a sterile operating room via Caesarean section. “I had a real, real hard time with that, the fact that I ended up with a C-section,” Cargile says. “It was so far away from what I wanted. I wanted something more warm and natural.”
So when she became pregnant with her son a couple years later, she decided to try again for a vaginal delivery. Doctors call it a VBAC, for vaginal birth after Caesarean, and it’s one of the most controversial issues in obstetrics. For years, the mantra was “Once a C-section, always a C-section." Then in the 1990s doctors pushed to lower the escalating C-section rate by encouraging more VBACs. Now, the pendulum seems to have swung the other way, with many doctors — and insurers — saying the safest approach, to avoid the risk of uterine rupture or other complications, is to do the repeat Caesarean.
Recent research in The New England Journal of Medicine shows the risks of a VBAC are only slightly higher than those of a repeat C-section. But the outcome can be very bad, including the death of the baby. Cargile studied up on VBACs and decided she could live with the small chance of problems. “Yes, there’s risk, but there’s risk with any childbirth,” she says. The medical community, in her opinion, is “a bit pro C-section. It’s the easy thing to do and there’s less liability on everyone’s part.”
Although she wanted to try for a VBAC at a birthing center, she says, her insurance company refused to cover her unless she delivered at a hospital. In the end, Cargile attempted a VBAC at a hospital but her placenta ruptured, likely a complication of her previous Caesarean, and she needed an emergency C-section.
Even though most women won't face this problem, it is experiences like this that have prompted some insurers to insist on repeat C-sections and hospital births. Still, Cargile bristled at being told where to have her baby.
Confusion all around
Cargile's case highlights some of the controversies, issues and frustrations that many pregnant women now face. Though women have been having babies for millennia, there's still no consensus on the best way to go about it. If anything, it seems to be getting more complicated.
"The doctors are confused and so are the women," says Dr. Sharon Phelan, an obstetrician at the University of New Mexico and a spokesperson for the American College of Obstetricians and Gynecologists.
Laura Fields, an Atlanta mother who gave birth a year ago, says she was overwhelmed with medical information when she became pregnant. She remembers thinking, "Wow, there's so many decisions and so many different opinions. There's a lot of controversy out there."
One of the most confusing issues for her was choosing which of the many prenatal tests to undergo.
There's also disagreement on a range of other issues, including whether to use pain drugs in labor and which ones, when to perform episiotomies (incisions to widen the birth canal), whether elective inductions or C-sections are a good idea, where women should have their babies (hospital, birthing center or at home), and what to do when a woman is overdue.
Doctors, midwives, nurses, insurers, hospital administrators and patients can all have different opinions on the best way to go about having a baby.
Take elective C-sections, for instance, which are gaining in popularity as busy women want to schedule their births rather than wait for nature to take its course. Aside from the convenience (for both patients and doctors), proponents claim that C-sections are better than vaginal births because they don't cause damage to pelvic tissue that may lead to urinary incontinence or sexual problems later in life.
Others, like many midwives and physicians such as Dr. Ann Honebrink of the University of Pennsylvania, point out that a C-section is major surgery that carries risks of bleeding and infection, and requires a longer recovery period. Honebrink also says there's no proof that elective C-sections help women avoid incontinence or sexual woes.
"I think we'll look back [on elective C-sections] in 10 years and think that maybe this wasn't so good," Honebrink says. She notes that C-sections leave scar tissue and adhesions that may make it more difficult for a woman to get a proper colonoscopy or make it more likely she'll have complications if she needs additional surgery later in life, such as a hysterectomy.
Honebrink says there are lessons to be learned about making assumptions in medicine, as evidenced by hormone replacement therapy. Doctors and patients thought HRT must be good because it seemed intuitive that replacing lost hormones would be a good thing, but it actually turned out to be harmful.
Of course, hindsight is 20/20. And when medical research is confusing and health-care practitioners disagree, a woman often must painstakingly weigh the pros and cons and decide for herself.
Consider the source
Betsy Van Etten, a labor and delivery nurse in Chicago and a mother of three, says she empathizes with women grappling with these issues. "It's a jungle out there," she says. "It seems like the more we know, the murkier the issues get."
She recommends that women educate themselves well about birthing issues and carefully consider the source of their information when making decisions.
Practitioners generally mean well, she says, but they often have strong biases. Obstetricians are typically opposed to home births, for example, while many midwives advocate them.
And various other factors, like time and liability issues, may come into play. It doesn't take a cynic to realize, for instance, that performing a C-section on a woman is generally a faster way for a doctor to deliver a baby (and get back to the office or home) than waiting around all day and night for a vaginal delivery. Nurses, too, can benefit. Long labors are labor-intensive for them as well, particularly when a woman doesn't opt for epidural pain relief, Van Etten points out. "It's much much harder, because they need support," she says.
Phelan says fear of being sued may prompt physicians to recommend C-sections for women with breech babies or those who've previously had the surgery for other reasons. "The doctors say, 'Why should I stick my neck out?'"
Doing the right thing
Many times, though, people who deliver babies disagree simply because they "truly believe they're doing the right thing," Van Etten says.
And whatever the "right thing" is, childbirth in the United States has never been safer, emphasizes Phelan. At the turn of the last century, one in five women died in childbirth (as did many babies), she notes, but maternal deaths in this country are now rare and babies are much more likely to survive, too.
Fields, the Atlanta mother, who ultimately opted for a water birth with a midwife at a hospital, says there doesn't seem to be a one-size-fits-all approach to childbirth.
"I think all woman should do research," she says, "and figure out what's best for them in their individual situation."