NEW YORK, NY September 05, 2003 —

Why c-sections are coming back strong after years of declining.

About one in four American women deliver babies by cesarean section. Many care-givers, health officials and patient advocates think that's too many. Through much of the 1990s, c-section rates were declining, but in recent years they have started to increase again. WNYC's Fred Mogul looks at why.

Total and primary cesarean rate and vaginal birth after previous cesarean rate(source: CDC)

Michele Bouniol is juggling her two young daughters in their Hoboken apartment. Celeste is blowing bubbles on her baby sister Margo. Two and a half years ago, Celeste was born by c-section, because she was a breach baby. But 14-month-old Margo came into the world in a way that's become quite rare.

Bouniol: When I was pregnant with Margo, my doctor informed me I could do a vaginal delivery or a repeat c-section I didn't realize that that was really an option, and the more we discussed it, the more I was for it.

For decades, obstetricians followed the saying, once a c-section, always a c-section. They felt the powerful contractions during labor could rupture earlier surgical scar tissue - and the uterus. In the 1980s and 90s, doctors gave women with previous c-sections more leeway, and almost a third of them chose the procedure called Vaginal Birth After Cesarean - or simply VBAC. The new popularity of VBAC's led to fewer women getting c-sections but only briefly. Since 1996, the VBAC rate has plummeted and c-sections are up again. Last year, only about one in ten women with a prior c-section gave birth vaginally. Melissa Weinstein is Michele's obstetrician.

Weinstein: There are many practices in Bergen County that still are doing VBACs, of course, but there are a lot of people that aren't. Every day, I have a colleague who says, Oh no. I would never do a VBAC. I offer them a repeat c-section, and if they don't want it, they can find another practice.

What changed? In 1996, the New England Journal of Medicine published a study citing higher complication rates for VBAC's. Another report in 2001, quantified the risk of rupture from VBAC. Those studies have been challenged by many researchers, clinicians and advocates, but, together with revised guidelines by the American College of Gynecologists, they have discouraged doctors from taking a chance on VBAC. Dr. Howard Minkoff chairs the OB-GYN department at Maimonides Medical Center in Brooklyn.

Minkoff: There are risks. About one in a 100 are going to uterus, and some of those are going to be catastrophic. It'll rupture in a very vascular part of the uterus. There'll be a lot of blood loss, and there'll be some fetal deaths. So we try to do it more safely. We try to get records where the scar was from the previous surgery, we wanted to make sure that they're in the hospital early in labor, that they hadn't had 3-4 previous sections and that they understood the risks.

Dr. Minkoff and others who still perform VBAC's believe the chance of complication is low, if mother and fetus are both healthy and the pregnancy has gone smoothly. Much of the debate over c-sections-versus-vaginal-delivery hinges on the tolerance for even very low risks. C-sections, of course, also have complications. But obstetricians feel that when the surgery is scheduled - as opposed to being performed under emergency circumstances - it is the best way to reduce medical risk - and malpractice suits.

Minkoff: It's hard to discuss any obstetrical issue in the 21st century without discussing the issue of liability concern. And physicians, rightly or wrongly, sometimes think if they have the same bad outcome but they had a cesarean section, at least they can't say, If you had only done a cesarean section, this baby wouldn't be impaired.

TRACK6: About 40 percent of women nationwide were denied the option of a VBAC last year, according to a survey by the Maternity Center Association. Program Director Carol Sakala says doctors are defining too many patients as high risk, and then under-selling vaginal delivery, while over-selling c-sections.

Sakala: This is major abdominal surgery and it's getting totally out of hand and out of control. Cesareans are associated with pain, and prolonged pain, with increased chances of infection, with increased risk of having an emergency hysterectomy, of re-hospitalization - all kinds of things that you don't want to be doing in any case, let alone during the time you have responsibility for a newborn baby.

And yet it's not just doctors and their fear of malpractice suits or medical complications. Some mothers want c-sections. Take Nino Beridze, an immigrant from the former Soviet Republic of Georgia. Ten months ago, her first baby was stillborn. Last week, she was at full term in her second pregnancy, eager for a c-section as soon as possible.

Beridze: Until I know the baby's normal, until I know that everything it's okay -- I just want to have a c-section before something happens. For me, it's important to have a baby as soon as I can.

It's still very rare for women who have never had a c-section choose to deliver that way. Dr. Minkoff, who has written about elective c-sections for the New England Journal, estimates that fewer than one percent make this choice. In recent years, doctors have debated the ethics of letting women choose to go under the knife. The International Federation of Gynecology and Obstetrics says doctors simply shouldn't give them this choice. Dr. Minkoff disagrees. He doesn't volunteer information about c-sections to women who've never had one, but if they ask, he will tell them about the risks and benefits of c-sections and give them have a role in the decision.

Minkoff: I think it's clearly in the best interests of the mother and the child, unless there's a particular issue at hand, to go through labor and have a baby the old-fashioned way. However, if despite my obvious eloquence in trying to discourage a woman, she understands what I'm saying and still says, I've heard the information. I interpret it subtly, differently than you do. I want a primary cesarean section. I don't think it would be unethical for a physician to accede to her requests.

Dr. Minkoff says that's what happened with Nino Beridze, the Georgian immigrant. He was called in for a second opinion by her primary doctor, and the two physicians tried to talk her out of it. But Beridze wouldn't budge.

Beridze: When I asked them for c-section, they doesn't look really happy they say it's a lot of risk, there has to be some reason, otherwise they cannot do. But I think it's my right to make this decision, because it's my body and I'm responsible for it.

The day after we spoke, Beridze gave birth by c-section to a six-pound, 15-ounce girl named Maria, after the Saints Day on which she was born. When we talked this week, she said the recovery has been much more painful than she imagined. She hopes to deliver future children vaginally - if her doctors will let her.

Links

http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_13.pdf -- Childbirth Trends from the 1990s

http://www.cdc.gov/nchs/data/nvsr/nvsr51/nvsr51_11.pdf -- The Most Recent Birth Figures from the CDC

http://www.acog.org -- American College of Gynecology

http://www.acog.org/ -- Debating Elective Cesarean sections

http://www.maternity.org/listeningtomothers/index.html -- Survey Results on Women's Childbearing Experiences

http://www.ican-online.org/ -- International Cesarean Awareness Network

http://www.motherfriendly.org/ -- Coalition for Improving Maternity Services

http://www.ahcpr.gov/clinic/epcsums/vbacsum.htm#Summary -- Research on VBAC by the U.S. Health and Human Services Department.