Nearly three in 10 U.S. mothers are giving birth by Caesarean section — a record number — and more and more of them seem to be choosing a surgical birth even when there's no clear medical need.
No one knows exactly how many C-sections are purely elective. It's an intense controversy: Some estimates suggest there could be tens of thousands annually, and critics say many of those women were pressured into surgery or didn't know the risks.
Amid the uncertainty, the National Institutes of Health opened a three-day meeting Monday to determine just how much is known about the risks and benefits of a pre-planned Caesarean — and how to ensure that mothers-to-be get all the facts.
"We all have noticed that women are asking for Caesareans more often. I don't think they always have the best information in making that decision," said Dr. Cathy Spong, pregnancy chief at NIH's National Institute of Child Health and Human Development.
A Caesarean can be life- or health-saving for many mothers and babies. Fetal distress, twins or more, or diseases that make labor risky for the mother are important reasons to have one.
At the same time, it is major abdominal surgery that poses some rare but serious, and occasionally life-threatening, side effects, such as hemorrhage, infection, blood clots. In addition, a prior C-section increases the risk of complications in future pregnancies, such as stillbirth or problems with the placenta, Spong says.
What's the appeal?
So what's the lure if it's not medically necessary?
Convenience plays a role for busy women. Maybe mothers need to schedule delivery so relatives can visit to take care of older children, or they live far from a hospital and worry about arriving in time. Or they fear something will go wrong and they'll wind up with an emergency Caesarean, considered far riskier than a planned one, especially if performed by a tired physician.
Others worry that vaginal deliveries can cause incontinence, although some studies dispute that the method of childbirth plays any role.
"Women deserve to know that. Whatever their decision, they need to know what the data is," said NIH's Spong.
In 2004, the latest data available, 29.1 percent of the nation's 4 million births were by Caesarean. That's the highest rate ever recorded, a 40 percent rise since 1996.
The rise is partly due to repeat surgeries: Some hospitals fearful of lawsuits refuse to let women who had a prior C-section attempt vaginal delivery with future babies, because about 1 percent may suffer a ruptured uterus, a potentially lethal complication.
But even among first-time mothers considered at very low risk for childbirth problems, the Caesarean rate is rising among every age group — from 21 percent of low-risk women under age 30, to 47 percent of those over age 40.
Questions over what's elective
How many were pre-planned solely at the mother's request? The government figures can't say. A handful of recent studies that examined birth certificates and insurance claims estimate that roughly 80,000 women a year have elective C-sections.
Complicating the issue is the definition of elective, says Dr. Wendy Wilcox of New York's Montefiore Medical Center: More pregnant women are obese, for example, something that can increase childbirth complications but that medical records don't traditionally record as a Caesarean factor.
"I think the American pregnant woman is becoming a lot more high risk," says Wilcox.
There's little good data comparing mothers and babies who have elective Caesareans with healthy women who choose a vaginal delivery — as opposed to a C-section planned because of medical problems or an emergency one.
But proponents of elective C-sections say the worst risks are extremely rare, especially for a healthy, rested woman, and that vaginal birth has its own problems, such as vaginal tears or the use of forceps.
"At the end of the day it should be the mother's decision," said Linda Dyson, a New York public relations executive whose first baby was born by a medically necessary C-section but chose to have her second child the same way. "Honestly for me, I thought a C-section was safer."
On the other side is Barbara Stratton of Baltimore, who says a preventable Caesarean — required after her doctor induced early labor that stalled — left her in pain for months.
"I don't believe that any women should go through this major surgery unnecessarily," Stratton told a news conference organized by midwives who say women aren't adequately warned of Caesarean risks.