Fascinating! FYI, warmly, Carolyn Hastie
Vogue
Moms who are "too posh to push" are one factor regularly cited as
contributing to record high C-Section rates. Commentators Judy Norsigian and
Gene Declercq say this drastically distorts the story.
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Here's today's update:
COMMENTARY
Don't Blame Mothers for C-Section Vogue
By Declercq and Norsigian - WeNews commentators
Editor's Note: The following is a commentary. The opinions expressed are
those of the author and not necessarily the views of Women's Enews.
BOSTON (WOMENSENEWS)--"Too posh to push."
That catchy phrase originated in 2001 headlines of British tabloids and has
been echoing through the news media ever since. It suggests a trend toward
an increasing number of medically elective Caesarean sections requested by
upper-class mothers.
In late March, the National Institutes of Health held a meeting called
"Maternal Request Caesareans."
While dropping the emphasis on "posh," the title of the conference and its
draft report seem to reinforce the general impression that mothers are
fueling the trend toward elective Caesareans, which are at record levels in
the United States.
Problem: No systematic evidence of this is available. In addition, focusing
on maternal request obscures a more complex story concerning changes in
obstetrical practice.
Although some studies do describe an increase in Caesareans without any
medical indication, this may not represent real "maternal requests" at all.
These studies, based on birth certificates or hospital billing records, have
no way of documenting whether the surgery was sought by the mother or based
on physician advice.
Childbirth Connection, a New York-based national nonprofit with whom we have
each separately collaborated in the past, has conducted the only
representative national studies, "Listening to Mothers," that directly
survey mothers about their birth experience, including those who had a
Caesarean section. The first study was published in 2002, initial findings
of the second were completed in March.
In the most recent survey carried out in January and February 2006 among 18-
to 45-year-old women who gave birth in U.S. hospitals to a single infant
last year, only 1 in 252 women (0.4 percent) who had a primary Caesarean
section without a medical reason actually chose this option herself.
Although there are undoubtedly some women who do seek elective Caesareans,
they are hardly enough to increase the number of Caesareans by 400,000
nationally since 1996.
Great News Story
With Caesarean rates at an all-time high--accounting for 1.2 million
surgeries and 29 percent of all births in 2004--reporters and editors are
naturally interested in seeking explanations and "patient choice" makes an
attractive news story.
Such stories often include human interest elements, such as following one
woman's decision to elect a Caesarean. They also involve broader ethical
issues, such as whether individuals should have the right to choose elective
surgery and, if so, who should pay for it.
The news coverage, however, too often gives a skewed impression of who is
electing to have a Caesarean. Many stories on maternal request, for
instance, feature suburban white professional women, often obstetricians
themselves.
These stories may be interesting, but they feed an inaccurate stereotype.
Mothers with the highest Caesarean rates in the United States--African
American women over 35--are rarely featured in such coverage.
So if it's not maternal requests, what then is causing the increase in
Caesareans?
Answer: Primarily changes in obstetrical practice.
Long gone are the days when a single obstetrician handled a caseload of
women to whom he or she made the extraordinary commitment to attend her
birth no matter when that woman went into labor.
Now, the overwhelming majority of obstetrical practices are group-based,
substantially reducing that individual bond with a mother.
In Childbirth Connections' 2002 survey, 19 percent of mothers reported they
had never met the person who delivered their babies and another 10 percent
indicated they had only briefly met their birth attendants.
Reality of Lawsuits
Another factor is the increasing concern about malpractice and the reality
of lawsuits that may be brought even in instances when an obstetrician is
not really to blame for a bad outcome.
It is not surprising that in the gray area of clinical decision-making
during labor, many obstetricians have substantially lowered the threshold
for when they would perform a Caesarean.
In cases involving maternal or fetal health risks, a Caesarean can be safer
than vaginal delivery. But the core question in elective C-sections is
whether they are safer when no medical risk is involved. That answer depends
on many variables.
Are we are talking about the baby or the mother? Are we talking about this
birth or the risks associated with future births (the more Caesareans a
woman has the greater her risk of future delivery complications). Are we
talking about short or long-term morbidity for the mother? Are we
considering postpartum pain as part of the equation?
Caesareans, especially those that are scheduled and not matters of
emergency, allow obstetricians to exercise their surgical skills, appear to
decrease the likelihood of malpractice suits and provide more control over
the scheduling of hospital and office hours.
Lack of Evidence
Advocates of medically elective Caesareans will also cite an array of health
benefits for mothers and infants from Caesareans, although the National
Institutes of Health conference made clear that solid evidence of such
benefits is not available.
Nonetheless, as we know from survey findings, many women do hold erroneous
assumptions about elective Caesareans.
For example, they may think of Caesareans as reducing the pain that they
will experience. However, while regional anesthesia such as epidurals can
reduce the experience of pain during vaginal deliveries, this pain often
pales in comparison to the substantial long-term pain after birth
experienced by women who have undergone Caesareans.
There is much we still don't know about the impact of Caesarean or vaginal
birth on health outcomes, either for the mother or the baby or both.
We do know, however, that Caesareans cause more respiratory-lung problems in
the infant, even with technology to avoid births before 39 weeks when this
risk is higher. At the NIH meeting one pediatrician described a rapid rise
in the occupancy rates of neonatal intensive care units in Brazil, where
some city hospitals are said to have 90 percent Caesarean section rates.
Thus, the information now available makes clear that the growth in
Caesareans--which includes mothers of all ages, races and across all medical
conditions--is the result of a complicated shift in professional practice
that deserves careful scrutiny. It is not primarily about mothers pressuring
doctors to take what they perceive to be the "easy" way out, as contemporary
media coverage would have us believe.
Gene Declercq is professor of maternal and child health at the Boston
University School of Public Health. Judy Norsigian is executive director of
Our Bodies Ourselves.
Women's eNews welcomes your comments. E-mail us at [EMAIL PROTECTED] .
For more information:
Childbirth Connection-- - NIH Cesarean Conference: Interpreting Meeting and
Media Reports: -
http://www.childbirthconnection.org/article.asp?ClickedLink=743&ck=10375&area=2
NIH Medline Plus: Caesarean Section: -
http://www.nlm.nih.gov/medlineplus/cesareansection.html
Our Bodies, Ourselves: - http://www.ourbodiesourselves.org/
Note: Women's eNews is not responsible for the content of external Internet
sites and the contents of Web pages we link to may change without notice.
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