Once a Cesarean, Always a Cesarean: The Sorry State of Birth Choices in America

By Nicette Jukelevics
Issue 123, March-April 2004

“No evidence supports the idea that cesareans are as safe as vaginal birth for mother or baby. In fact, the increase in cesarean births risks the health and well-being of childbearing women and their babies.”1

Years ago, I attended a childbirth educators’ conference session on elective repeat cesarean delivery and vaginal birth after cesarean (VBAC). The speaker was a published expert on the subject and a practicing obstetrician-gynecologist affiliated with a highly ranked medical school. At the beginning of his presentation, as he adjusted his microphone, he asked, half joking, “Are there any physicians in the audience?” When no hands went up, he took a deep breath. “Alright, I can speak freely now.”

Recently, a physician contacted me to ask if I knew of an attorney who represented women who were denied medical care for a planned VBAC. He said that his wife, an obstetrician-gynecologist, was planning to labor for a fourth VBAC but, due to the no-VBACs policies of local hospitals, the closest VBAC-friendly provider she could find was 70 miles away. His was not the first request for legal representation in this matter.

The controversy over cesareans and VBACs is not new. However, unprecedented are: the current promotion by the media and some physicians of elective primary cesarean delivery as a low-risk procedure, inappropriate use of medical interventions that increase the odds for cesarean (see sidebar, “Care Practices That Increase the Odds for a Cesarean Delivery”), the denial of medical care for women who want to labor for a VBAC, and the grab bag of current justifications for performing a cesarean section.

In 2002, 26.1 percent of US women gave birth by cesarean. The majority of these were elective repeat operations and first cesareans for dystocia, or failure of labor to progress, a highly variable diagnosis. The cesarean rate is the highest ever for this country. Eighteen percent of women had a primary cesarean, a rate also unprecedented.2 Of concern is the fact that young women between the ages of 18 and 24 have the highest number of first cesareans.3 A cesarean rate of no more than 15 percent is recommended by the World Health Organization,4 and a goal of the US National Health Service is a cesarean rate of 15 percent for first-time mothers by the year 2010.5

In the US, a woman is likely to have a cesarean, says Diony Young, editor of Birth: Issues in Perinatal Care, if “she’s too big or too small; too early or too late; too old or too fearful; too tired of being pregnant or too tired of being in labor; if she’s having twins, if she’s breech, if she’s previously had a cesarean; or if she’s due and so is the weekend, Christmas, Thanksgiving, or New Year’s Eve. Then again, she’s also at risk if her doctor is in doubt, scared of a lawsuit, too busy, going out of town, or convinced that a cesarean is always safer . . . the reasons go on.”6

Cesarean Section is Major Abdominal Surgery
Dangers for the Mother: Although cesarean section is safer than ever before, it is still major abdominal surgery with inherent risks. A woman who has one cesarean will always be at risk for a uterine rupture in a subsequent pregnancy, whether she labors for a VBAC or has an elective repeat cesarean delivery.

With one prior uterine scar, the risk of a uterine rupture is 1 in 500, compared to 1 in 10,000 for a woman without a cesarean scar. Each additional cesarean increases that risk. Postoperative complications include risk of injury to other organs (2 percent), hemorrhage (1 to 6 percent of women will need a blood transfusion), blood clots in the legs (0.06 to 2 percent), pulmonary embolism (0.01 to 2 percent), infection (up to 50 times higher), and complications from anesthesia. A woman is four times as likely to have a placenta previa (low-lying placenta) in her next pregnancy, putting her at risk for miscarriage, bleeding during pregnancy and labor, placental abruption, and premature delivery. One birth by cesarean puts a mother at 10 times the risk for placenta accreta (placenta grows into or through the uterus), for which women often require a hysterectomy to stop the hemorrhaging. The incidence of placenta accreta has increased tenfold in the last 50 years.7

A US study found that mothers are four times more likely to die from a cesarean unrelated to health problems, compared with women who have vaginal births.8

Emotional Scars of Cesareans: Personal accounts from women who have had a cesarean, as well as emerging research, suggest that despite a healthy baby and a timely physical recovery, some women experience cesarean birth as a traumatic event. An unanticipated cesarean is more likely to increase the risk for postpartum depression and post-traumatic stress disorder (PTSD). As in other traumatic human experiences, the symptoms of birth-related PTSD may emerge weeks, months, or years after the event.9–11 Women re-experience the birth and the emotions associated with it in dreams or thought intrusions. They avoid places or people that remind them of the event. Some mothers have difficulty relating to their infants, and some will avoid sexual contact that may result in pregnancy. They will also exhibit symptoms of hyperarousal, such as difficulty sleeping or concentrating, irritability, and an excessive startle response. Untreated post-traumatic stress often leads to clinical depression.12