Vancouver Magazine Jan/Feb 2004

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The C-Word

It isn't just celebrities who are too posh to push. In B.C., more women are choosing to go the C-section route even when surgery isn't necessary.

This story appeared in Vancouver Magazine Jan/Feb 2004

You've heard the Hollywood pregnancy story: six months into the natural process, a skinny starlet opts to schedule the birth of a premature baby through a C-section. She's counting on less unsightly career-threatening stretching of the abdomen wall and zero guesswork about the birth's timing. It's disturbing. It's outrageous. And here's the part that might surprise you most: we may not be far behind.

C-sections are on the rise in Canada, as they are in other developed nations such as the U.K., the U.S. and Australia. The increase is a side effect of larger trends—i.e., first-time mothers are older, drug therapies are leading to multiple births—which have increased the risks connected with the natural birth method. The more widespread use of electronic fetal monitoring has also meant that many doctors tend to err on the safe side. If there's the suggestion of a problem, a doctor often chooses to use a surgical incision in the abdominal wall and uterus to deliver the baby. Over the past 20 years, the surgery has improved: the long, vertical incision has evolved into a discreet horizontal cut below the bikini line, while a regional anesthetic has replaced a general one, allowing mothers to stay awake during “delivery.” Despite the advancements, C-sections still end with a four-to-six week recovery time, versus the 24 hours needed after natural childbirth. And more important, some say, C-sections cheat mothers of a unique, life-altering experience.

But there is a quiet shift taking place in B.C., as more mothers ask for caesareans, also called the C-section-on-demand. And what's even more surprising is who is doing the asking: nurses, doctors and the wives of doctors—medical insiders who believe the C-section should be an option, even for healthy, “normal” pregnancies without any of the medical indications that would call for a C-section. The issue has become the centre of a raging global debate among obstetrician-gynecologists, midwives and urinologists.

Already in B.C., nearly one-third (27.9 percent) of all live babies born are delivered through C-sections, and the numbers indicate an upward trend of a few percentage points annually. The change can be partly explained by B.C.'s similarly rising age of new mothers: last year the average age of a new mom jumped a full year to 29.6 years; 20 percent of new moms were over the age of 36.

The exact number of Vancouver women currently requesting C-sections every year is not an easy figure to pin down. At B.C. Women's Hospital, anecdotal talk of elective C-sections triggered a 15-member task force to review the medical, legal, ethical and cost implications, and then draw up guidelines should requests go up. They did. Last year 12 births were listed in the hospital's books as C-sections-on-demand, but administrators believe that 10 times that number occurred.

Why the shift? The reasons do not appear to be as connected with vanity or convenience as the Hollywood births. Most women say they want to avoid any uncommon, but often gory, vaginal birth complications—a nebulous phrase assigned to various possibilities of damage to the pelvic floor. The problems vary but include (note to squeamish: brace yourselves) urinary incontinence, fecal incontinence, sexual dysfunction and hernias from pelvic organ prolapse. Such problems occur in about a quarter of women who deliver vaginally, explains Vancouver obstetrician-gynecologist Rob Anderson, though most women recover within a year. Of course there are also cases where the problems persist. And Anderson sees graphic cases of them in his office. Until now, most of the women who have asked him about elective C-sections have been women who work within medicine or have a physician in the family. But he now sees an increase in demand for C-sections among the general public, albeit “well-read women,”says Anderson. “Women who have been reading the medical literature.” He adds, “I had two women requesting them today.”

Every cause has its champion. Canada's most vocal advocate of elective surgical childbirth is Calgary obstetrician-gynecologist Dr. Magnus Murphy, author of Choosing Caesarean Births, a contentious book about pelvic health and childbirth. Murphy is direct: “I feel strongly that a woman should have the right to an elective C-section. I feel strongly that you could make a case healthwise for doing that. And it should at least be the patient's right to consider and discuss it in a nonbiased manner.” In a debate fought in shades of grey, he says the elective C-section is a more valid option for women who've already suffered pelvic floor damage. A scan through the recent medical literature will turn up plenty of preliminary studies showing vaginal births do increase the risk of incontinence, as well as studies suggesting that elective C-sections could provide a protective effect against that damage. While such journal studies are not conclusive, they do hint at a future where the C-section may become more accepted.

Financially, there could be benefits to more scheduled C-sections, too. Some claim that planned surgeries could end up being cheaper than unscheduled, unpredictable deliveries, which require high levels of staffing at all times. Then there's the argument that requested but not medically necessary C-sections could be offered on a user-pay basis, as with circumcisions.

“Appalling,” was the word that came to mind for professional ethicist Margaret Somerville when she was first confronted with the idea of elective C-sections. As the director of McGill's Centre for Medicine, Ethics and Law, she was asked to take the issue and peel back the layers. After investigating the ethics and law surrounding obstetric decision-making, Somerville says it comes down to this: If a woman has the right to terminate a pregnancy, how can you argue that she doesn't have the right to choose how that baby is born? Besides, she adds, as more evidence is gathered naming the benefits of surgery—and as more female obstetrician-gynecologists say they would choose it for themselves—the more obligated doctors are to at least discuss the option with their patients. (Right now obstetricians don't raise the topic. They blame a lack of time, a lack of knowledge—too many unknowns. Besides, there's still the perfectly good, old-fashioned way of giving birth.)

In some parts of the world, the swing to elective C-sections is far more pronounced. In places like Hong Kong and Brazil, the numbers of babies delivered through requested surgery is said to be in the 80 percent range, and the C-section has become the choice of delivery for women with private health care. By comparison, it's estimated that less than one percent of Canadian births are by elective C-section. (In the U.S., it's about double that number, at 1.9 percent.) It's worth noting that Canada also has one of the world's lowest perinatal mortality and morbidity rates whatever the delivery method (and B.C.'s record is among the best), and that our excellent record is mostly due to medical intervention. Which leads some doctors to ask: exactly what is natural? “There's more natural, and there's less natural,” Murphy points out. So where do you draw the line? As it is, 40 percent of women who deliver vaginally need some sort of intervention, ranging from drugs to make the uterus contract to forceps and epidurals. Is it possible that raising alarm bells based on “natural” arguments essentially takes away a choice that legally and ethically belongs to each individual woman?

Time to hear from the other side. The elective C-section trend is opposed by many who see it as the dangerous remedicalization of childbirth. Dr. Jan Christilaw, an obstetrician-gynecologist and head of all outpatient programs at BC Women's Hospital and Health Centre, says she is concerned about the high use of C-sections, requested or not, in Vancouver. “We're worried that some people are more liberal than they should be,” says Christilaw, noting that the vast majority of the C-sections are performed on women partway through labour. “I think we need to take a step back and look at these decisions…Birth is a natural process that we should be learning from, not imposing our surgical agenda on.”

At the Society of Obstetricians and Gynecologists of Canada, the policy is open to interpretation. The society's associate executive vice-president, Dr. Vyta Senikas, says she believes most women ask for surgery out of concern for the safety of the fetus, even considering the increased risk for the mother. (Don't forget, the C-section is major surgery; risks to the patient include post-surgical infection, bleeding of the womb and injury to the bowel or bladder.) “Putting aside high-risk women in pregnancy, what we like to promote is a best practice that results in the best outcome for the patient and the baby. Many times it comes to a judgement call.”

Translation: Vaginal births are recommended, but if a woman asks about a C-section and knows the risks, obstetricians would be hard-pressed to say no. Says Senikas, “It's a question of informed consent.”

Ironically it's that same patient-oriented philosophy—the idea that women should have a say in what's best for them—that pulled midwifery from the fringes to legitimacy. Modern midwifery arose out of a strong consumer movement against the medicalization of birth in the '60s and '70s, when doctors called all the shots. Now, empowered mothers also tend to believe in preventive medicine—and voilà, the elective C-section is in demand. What happens when a patient asks for a C-section depends on the politics of the obstetrician and the institution. In B.C., there's nothing in the current guidelines that forbids the surgeries.

“C-sections are being presented to women as something that can prevent them from having unwanted changes in their bodies later on,” says Christilaw. “But it's a very murky area.” For anyone to make the decision, she adds, “we have to make sure women understand all the pros and cons.” She believes that what's missing from the medical debate are all the anthropological and psychological studies. “For the vast majority of women [natural childbirth] is a very positive experience.”

In Christilaw's corner is Kim Campbell, a Vancouver midwife and president of the Canadian Association of Midwives. Campbell suspects the increase in surgery requests comes from an exaggerated fear of pain and labour, which, most everyone agrees, would not be a valid reason to avoid a significant human experience. “We're losing perspective,” says Campbell. “Birth is not just a surgical event. It's more than being pregnant and then holding a baby in your arms. It can be inspiring and fulfilling. It's a gift.” If it vanished, she adds, “it would be a huge loss to our culture.”

New mother Marilyn Bell felt the friction of acting against the mainstream birth culture when she opted for a C-section: “There's huge stigma about not giving birth vaginally. There's this idea that if you don't, you've somehow failed as a mother.”

The evening before her planned C-section—scheduled a week before the due date for minimal risk—Bell's water broke. She rushed to St. Paul's Hospital. Since there were staff on hand, she had the C-section done at 2 a.m. instead of her allotted 10 a.m. time-slot. The curve ball? Physical indications showed the baby was probably a week overdue. Earlier ultrasound readings had been off. The lesson: there are no guarantees.

After the surgery, Bell holds her 8.7-pound baby boy in her arms and welcomes visitors. She looks rested. “I feel great,” she confirms. She's on Tylenol 3 for the pain of the incision, and she faces several weeks of recovery. Asked if she feels like she missed out on what could have been an inspirational, uniquely female experience, she says, “I did wonder when my membranes ruptured and the labour started, what it would be like. But now, it's not an issue. It makes no difference to me….I just want him healthy.”