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Exposing the
Cesarean Myth
“It is dangerous to be right on a subject
on which the established authorities
are wrong”
Voltaire
The
maternal mortality from cesarean section is 10 to 20 times greater than from a
vaginal delivery. Despite all of the
recent scientific evidence, showing that the c-section rate is too high [25-30%
in United
States
hospitals versus less than 5% by home birth physicians], the rate continues to
climb. The countries which have the
lowest cesarean section rates, (i.e. Norway, Denmark, Sweden, Holland, Japan, etc.) also have the lowest infant and maternal mortality
rates in the world.
The
mantra “once a cesarean always a cesarean” is being used by doctors today
despite all the lip service that they give to vaginal birth after
cesarean. In 1987, less than 2% of women
in this country who had previous cesareans actually delivered their next babies
vaginally. We, at Homefirst®
Health Services, have been privileged to successfully deliver over 1,000 HBAC
(home birth after cesarean) babies since 1988, with a vaginal success rate of
90%. Success cannot only be measured by
vaginal birth, the other 10% were just as successful, even though delivered by
cesarean. The success of our HBAC
program rests with the skills of our physicians and nurses, as well as a
philosophy that unnecessary medical interventions, (i.e. electronic fetal
monitoring, epidural medication, routine cesarean section for breech and twin
deliveries, etc.) at the time of delivery are some of the major causes of
unnecessary cesarean sections.
We
have reached a time when women must become educated about cesarean section
prevention long before the birth of their first child. In the new millennium unnecessary cesarean
sections are analogous to environmental hazards. In order to be protected from radon gas in
your home, for example, you must be informed of the dangers and take the
appropriate action to protect your family.
The same is true of c-section surgery.
Education is the best prevention method families have from this
hazardous surgery.
I
use the term hazardous because it is. In
1987, a 14-state survey from the Center for Disease Control indicated that
babies over 1500 grams (3.1 pounds) are more likely to die if born by cesarean
section than if born vaginally. The risk
to the mother is many times greater when surgery is performed. Recovery from c-section surgery is painful
and slow, leaving the mother with psychological, as well as abdominal scars.
Our
goal as doctors must be to deliver healthy babies to healthy mothers. Doctors must aim to make America the safest country in the world in which to have a
baby. We now rank 20th among the top 20
industrialized nations for infant and maternal mortality. It is unethical and unthinkable that any
doctor would be performing unnecessary c-sections, but it is happening with too
great frequency today.
TEN
years ago doctors were delivering babies by cesarean section at a 6% rate,
eight years ago at a 10% rate, five years ago at a 15% rate and three years ago
at a 20% rate. In 1987, a jump in the
rate to between 25% and 30% occurred, translating into one million plus
Americans having c-section deliveries in that year. Doctors, supposedly, have increased their
c-section rates in the U.S. as one means of decreasing our infant mortality, but the
infant mortality rate has risen dramatically.
Why So Many
Cesarean Sections?
About
one in four women is now having this surgery for the delivery of her
child. In Illinois, according to a Chicago Sun Times report of March 16, 1988, there was a 10% increase in cesarean sections. Blue Cross/Blue Shield of Illinois is urging
hospitals to slow the growing rate of surgical deliveries. The National
Institutes of Health (N.I.H.), a neutral body, likewise says that there are too
many cesareans being performed. N.I.H.
believes that obstetricians aren't willing to make changes to improve this statistic.
These
findings really hit home for my staff and myself when our practice had a booth
at a baby fair in Chicago a few years ago. We
were at the fair to explain the home birth option to those who didn't realize
that babies could be safely born at home.
However, over the course of the fair, about 1,000 women who had
previously had cesarean section deliveries stopped by our booth to talk.
Many
of them were pregnant again and returning to their same obstetricians for planned,
repeat c-section deliveries. They were
feeling their bodies had failed them and were wondering if surgery would really
be necessary the second time. We were
shocked and realized we had to do something to help these women. With the c-section rate rising as it is, by
the turn of the century all women will be having c-sections, a ridiculous but
plausible thought. We felt we had to
intervene to change this statistic.
Since our own c-section rate was about 4% we felt there must be
something we could do to provide safer deliveries for so many women fearing
unnecessary repeat surgery for the births of their next infants. Our research led us to some very positive
conclusions. Statistics collected by my
Homefirst® medical staff revealed that 90-92% of all pregnant women should be
able to deliver their babies without any medical intervention at all. It was puzzling to me why so many doctors
were choosing a measure so drastic as surgery for the delivery of so many
babies.
According
to the March
16, 1988, Sun Times article quoted
above “. . .doctors in major teaching hospitals tend to have lower c-section
rates because doctors there have a heightened awareness of the overuse of
c-sections.” This implies that with
doctor awareness the rate could be lowered.
This article was clearly saying that doctors are the cause of so many
c-sections.
Everyone
knows why Blue Cross/Blue Shield is mentioned in the article as being
interested in lowering the c-section rate.
Theirs is the financial interest of an insurer who has to pay out much
more per birth on a c-section delivery.
Currently c-sections average about $3,000 more per birth than a Natural
delivery. Blue Cross/Blue Shield's
research was saying the same thing to hospitals — there are too many
unnecessary c-sections. Dr. Norbert
Gleicher, former Director of Maternal-Fetal Medicine at Mount Sinai
Medical Center in Chicago is quoted in the article as being concerned that
unnecessary c-sections expose women to risks of infection and other problems. He believes the bottom line is going to have
to be financial. “Scientific data and
education haven't been enough to get doctors to lower the rates. . . . If
insurers want to reduce the c-section rate, they will have to give doctors and
hospitals a financial incentive for vaginal deliveries.” This certainly implies that doctors are
doing c-sections for the added income which this surgery generates.
So
here too, with the high c-section rate
we see unscientific medicine being practiced in yet another area. Doctors continue to disregard the scientific
literature. Why? A misguided sense of security from
malpractice lawsuits, additional income, and a false assumption that their
patients have had a safer delivery.
These are powerful obstacles to hurdle if you are an uninformed
patient. The less informed patient, the
greater the chances of a cesarean section.
It has become imperative to be an educated pregnant woman in order to
have the safe delivery of a baby today.
Doctors’ Myths About
Cesarean Section
The
doctors in my practice did further research.
The reasons for most c-sections were not grounded in good scientific
practice, but rather in doctor myths such as, “Once a c-section, always a
c-section.” A whole body of medical
phrases has been invented to justify the surgical delivery of infants. Mothers are being told that: they “failed to
progress” in labor; the baby's head was too large for the pelvis; they had a “cephalo-pelvic
disproportion”; twins and breech babies must be delivered by c-section, and
that vaginal delivery after a previous c-section is dangerous due to the
likelihood of “uterine rupture.”
These
reasons for c-section and repeat c-section surgery are unfounded in most
cases. In 1997, c-section surgery was
the number one surgical procedure performed in the United States. Over 1,000,000
women had this surgery for delivery of their babies. If an acceptable rate of c-section surgery is
5%, then 850,000 women had unnecessary and dangerous operations.
Women
are being deprived of vaginally delivering their babies for reasons other than
those stated to them by doctors. Could
doctors actually believe that c-sections are safer and easier than natural
delivery? This is absurd. It is impossible to comprehend that an
ethical practitioner would choose a procedure “safer” for himself and more
dangerous for the mother and her baby.
Various studies have indicated that c-section delivery is from 8 to 26
times more dangerous than natural delivery.
Today’s mothers and babies are suffering unnecessarily, and even dying,
from cesarean deliveries.
A
1986 publication of the Public Citizen Health Research Group entitled Unnecessary
Cesarean Sections: A Rapidly Growing National Epidemic states that:
The three most important medical causes contributing to the
rapid national increase in c-section rates are:
1) the continued use
of the outdated policy of automatic repeat c-section for women who have already
had a c-section.
2) the over diagnosis
and overuse of c-section for dystocia (or abnormal labor), and
3) the over diagnosis
of fetal distress.
These three categories contributed to 93.4% of the increase
in national c-section rates from 1980 to 1985.
C-section surgery does have a few benefits for an insecure,
fearful or inexperienced doctor. Surgery
is quicker than waiting for labor and delivery to happen on its own. It seems safer to the doctor because he/she
doesn't have to watch the mother progress through the pains of labor which can
be a tremendously lengthy and anxious experience for everyone. Obstetricians who don't understand the
scientific principles of labor and delivery might actually believe they are
saving mothers from a lot of pain by performing a c-section. We know they believe they are saving
themselves from potential lawsuits.
But these are
incorrect and unethical reasons for performing surgery on any pregnant
woman. As one of the new doctors on my
staff put it, “We were trained in medical school that a pregnant woman is
something to be feared. She is
considered ill until she delivers, and the sooner the better.”
My staff and I
did much investigating of the explanations given to families for their c-section
deliveries. We discovered fallacies in
all the explanations.
The doctor’s
myth, “Once a c-section, always a c-section,” has never been proven. This statement, first made by an intoxicated
physician at a medical meeting, is only espoused by doctors with no understanding
of the contractility of the uterus. The
uterus is a tremendously strong muscle.
It contracts as other muscles do in order to function. Much as the heart muscle contracts to pump
blood, the uterine muscle contracts and expands in labor to deliver the
baby. A scar on the uterus from a
previous c-section negligibly lowers its ability to contract properly. So you might say that for most women the
opposite of this myth is true, “Once a c-section, next time a VBAC.” Each labor is unique and a doctor is suspect
who prejudges the outcome of the next labor after a c-section.
Exposing the Myths
Many women whose
obstetricians have scared them with the threat of a repeat c-section ask me how
any woman who has had a previous c-section could be a low risk patient in my
practice. They have all been labeled by
their obstetricians as high risk due to their last deliveries. In reality, provided the woman is in good
health, she should be treated no differently from any other pregnant
woman. She will become high risk only if
doctors use interventionist measures at the time of delivery.
Another doctor’s
myth, about which women are so frequently warned, is the feared “uterine
rupture” which occurs rarely in births subsequent to c-sections. Contrary to the doctor’s myth, scientific
literature supports the fact that the uterus does not rupture from and has not
been weakened by a previous c-section delivery.
Two investigators reported, in separate presentations to the American
College of Obstetricians and Gynecologists, that they “have been
unable to find a single report of a maternal death due to rupture of a low
transverse uterine incision in the more than 11,000 trials of labor.” This statement was made after reviewing data
collected at the University of California, Los Angeles, School of Medicine;
Kaiser Permanente Medical Centers and the University of California, Irvine,
School of Medicine (as reported in Family Practice News; Volume 18, No.
14, July 15--31, 1988). Uterine rupture
is just another well-propagated myth.
Then there is the
often-used expression, “failure to progress,” which leads to surgery. Doctors use this phrase at hospital births
for several reasons. They have placed
women flat on their backs and on the hospital's timetable for delivery. If progress isn't made in a given amount of
time, they prepare for surgical delivery.
But “failure to progress” is predictable if a woman is on her back for
eight or nine hours and pushing in this very unnatural position.
It becomes a
different matter if someone at home, who is not confined to bed during labor,
has “failure to progress.” The laboring
woman has then done everything in her power to deliver in a reasonable amount
of time. However, as I have discussed
in a previous chapter, timetables for labor get distorted in the hospital. Labor time in the hospital doubles because
doctors don't make the best use of that time.
Dr. Emanual Friedman of Boston's Beth Israel Hospital and Harvard
Medical School has stated that 70% of cesareans for prolonged labor are
unnecessary.
Hand in hand with
“failure to progress” goes another classical mythical reason for c-section
deliveries — CPD — “cephalo-pelvic disproportion.” This first myth leads doctors to suspect the
second. “Cephalo-pelvic disproportion”
means that the baby's head is too large for delivery through the mother's “too
small” pelvis. It is easy for doctors to
incorrectly conclude that if a woman has “failure to progress,” it is because
the baby's head is too large for delivery.
In reality, this
doesn't happen very often. Nature allows
women to grow babies to a size proper for delivery by that individual
mother. If this were really a problem
occurring frequently in nature all babies born to small women such as Chinese,
Thai, and Japanese would be c-section babies.
However, in these countries c-sections are rarely performed.
Babies, born at
home, to mothers who have had previous c-sections are usually larger than
older cesarean-born siblings. These
later, natural born babies disprove the disproportion problem, by being larger
than their older siblings at birth.
Generally, it is improperly used labor time or an unwarranted fear of
birth accidents which prompts doctors to write CPD on the mother's chart and
prepare her for surgery.
The myth that
twins and breech babies must be delivered by surgery is a ridiculous notion
also. Doctors have been intervening in
these types of births for so long that the skills necessary to deliver
multiples have been lost. It is actually
a five-year program to train doctors properly to deliver twins and breech
babies. However, a new doctor can learn to do a c-section in
about 90 days. Preference for the
shorter training time and fear of lawsuits, has virtually eradicated all knowledge
of natural delivery of these babies from U.S. hospital
s.
The Birth of
HBAC
In the past, my
staff and I had assisted women in hospitals who were trying to have vaginal
births after cesarean (VBAC). We noticed
that they succeeded only about 50 to 60% of the time in the hospital. We felt sure that this was due to the foreign
environment and that a higher success rate could be achieved at home because
women have an easier time delivering at home.
It would seem unnecessary to hospitalize these women at all if the
scientific literature were correct. All
reputable obstetrical literature states that VBAC women are no different from
anyone else in labor if they have no other medical complications.
So a plan evolved
within my practice during the summer of 1987 to let VBAC women labor at home in
the comfort of their own surroundings, with the support of their families and
the careful monitoring of the Homefirst® medical staff. The plan was initiated
by Dr. Peter S.L. Rosi, one of the Homefirst® senior staff physicians. Dr. Rosi, in addition to being a home birth
specialist, is a board certified surgeon. This project became known as HBAC,
Home Birth After Cesarean.
We chuckle to
ourselves when we look back to those first HBAC births. In the name of safety, two doctors and two
nurses from the practice were sent to these laboring women's homes. Of course it soon became apparent, due to
careful prenatal screening, that there was no need to provide more medical
support than any other home birth mother receives. Eighty-seven percent of this pilot group had
their babies at home with no complications or need for intervention.
This program has
been a tremendous success. Now potential
HBAC mothers attend our childbirth classes alongside those who have had
successful home births in the past. There is no reason to treat HBAC women
differently from other pregnant women, unless new indications point to a
possible problem.
We do have a few
additional recommendations for HBAC mothers.
We tell them not to return to the
doctor who performed the first c-section
surgery. That doctor will view
the returning woman as trouble. That
doctor will, chances are, have his or her mind made up in advance that there
will be complications.
We also suggest
that HBAC couples connect with a VBAC Support Group to increase their chances of having a vaginal birth. Jane, leader of a VBAC Support Group in
Chicago says, “If women attend our sessions, they increase their chances of
having a vaginal birth. We help them lay
to rest the fear of uterine rupture and try to connect them with doctors who
will give them a fair chance at a
vaginal delivery. C-section mothers have
been stripped of all confidence in their bodies' ability to give birth and
they need the support of other women who
have “been there” to regain their confidence.
It is a lack of education and
the feeling that the doctor is always right that leads to many c-sections. This is what we work on. Being at home for the next birth and knowing
how to give birth helps so much!”
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