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Elective cesareans--recent controversy.

With the national cesarean section rate already over 26 percent (1) , it is very alarming that some physicians may now offer healthy women the option to choose birth by cesarean surgery. In a press release on October 31, 2003 (2) , The American College of Obstetricians and Gynecologists (ACOG) left it open to the physicians' discretion whether to offer their patients elective cesareans without any medical indication.

In the last several months there have been many articles used to support the option of elective cesarean surgery, as well as many articles supporting the view that cesarean section is major abdominal surgery carrying significant risk, and should only be performed when there is a clear medical indication.

In the following pages, we present short summaries of several of these articles with references to the complete article, as well as responses to the current controversy from several birth organizations, to help you effectively address this issue with your clients.

We have also included a fact sheet on the risks of cesarean delivery to mother and baby developed by the Coalition for Improving Maternity Services (CIMS). You are welcome to reproduce this fact sheet to use as a handout for your clients.

Cesareans Sections Increase Maternal Death Rate

In August of 2003, Harper et al., published an article titled "Pregnancy-Related Death and Health Care Services" (3) in Obstetrics & Gynecology, ACOG's journal. The focus of the study was to determine if there is an association between pregnancy-related death and health care service variables, such as use of nutritional services, source and use of prenatal care and method of birth. Women who gave birth by cesarean section had a four times greater risk of dying than women who birthed vaginally. This does not support the option of elective cesareans and women should be informed of this risk before choosing a cesarean birth.

Urinary Incontinence

ACOG refers to an increased risk of urinary incontinence as a reason to justify elective cesarean surgery. In the same issue of Obstetrics & Gynecology as the above referenced, Dietz et al., published an article titled "The Effect of Childbirth on Pelvic Organ Mobility" (4) that showed women who birth vaginally versus by cesarean section have increases in organ mobility at two to five months postpartum. This suggests, but does not prove, that vaginal birth could be a contributing factor to urinary incontinence and pelvic-organ prolapse.

Among vaginal births, use of vacuum or forceps showed the greatest increase in pelvic organ mobility, with forceps having a two-fold increase in pelvic organ mobility above normal vaginal birth. (Refer to the CIMS' press release on the following page for interesting information and references regarding this issue.)

An article published in the February 2003 issue of Obstetrics &Gynecology discussed the benefits of "Pelvic Floor Muscle Training During Pregnancy to Prevent Urinary Incontinence." (5) This article was not cited in ACOG's press release discussing the pros and cons of elective cesarean sections (6), although the above article suggesting that vaginal birth increased the chance of future urinary incontinence was referenced. Although ACOG does seem concerned by the problems some women have with urinary incontinence, it does not appear interested in prevention through education and exercise, only through major abdominal surgery.

The International Randomized Term Breech Trial (7), showed a relatively small absolute reduction in incontinence with a cesarean birth versus a vaginal birth (7.3 percent versus 4.5 percent). These results suggest that at least 35 cesarean surgeries would have to be performed to prevent one case of incontinence. The small benefit of reducing urinary incontinence seems far outweighed by the many risks of cesarean surgery to mothers and babies, particularly when a simple exercise also reduces urinary incontinence.

Cesarean Sections Double the Risk of Stillbirth in Future Pregnancies

A recent study published in The Lancet showed that women with one previous cesarean birth had double the risk of having a stillborn in the subsequent pregnancy than did women whose first birth was vaginal.

While the absolute risk is still low (1.1 per 1,000 for women who had a prior cesarean and 0.5 per 1,000 for women with a previous vaginal birth), women considering an elective cesarean should be informed of this increased risk.


(1.) National Vital Statistics Report. National Center for Health Statistics. Final Data for 2002. (

(2.) ACOG News Release. October 31, 2003. New ACOG Opinion Addresses Elective Cesarean Controversy. (

(3.) Margaret A. Harper, MD, et al. Pregnancy-Related Death and Health Care Services. Obstetrics & Gynecology. August 2003; Volume 102, Number 2, pages 273-278. (

(4.) H.P. Dietz, MD and M.J. Bennett, MD. The Effect of Childbirth on Pelvic Organ Mobility. Obstetrics & Gynecology. August 2003; Volume 102, Number 2, pages 223-228. ( /wrapper.cfm?document=2003/ong14512fla.htm.)

(5.) Siv Morkved, MD, et al. Pelvic Floor Muscle Training During Pregnancy to Prevent Urinary Incontinence: A Single-Blind Randomized Controlled Trial. Obstetrics & Gynecology. February 2003; Volume 101, Number 2; pages 313-319. ( /wrapper.cfm?document=2003/ong13957fla.htm.)

(6.) ACOG News Release. July 31, 2003. Weighing the Pros and Cons of Cesarean Delivery. (

(7.) Mary E. Hannah, MDCM, et al. Outcomes at Three Months After Planned Cesarean vs Planned Vaginal Delivery for Breech Presentation at Term. Journal of the American Medical Association. April 2002; Volume 287, Number 14, pages 1822-1831. (

(8.) Gordon Smith, et al. Caesarean Section and Risk of Unexplained Stillbirth in Subsequent Pregnancy. The Lancet. November 29, 2003; Volume 363; Issue 9398; pages 1779-1784. ( /query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14654315&dopt=Abstract.)
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Title Annotation:Pregnancy & Birth
Publication:Special Delivery
Date:Mar 22, 2004
Previous Article:Does race figure in maternal and infant death?
Next Article:The emotions of cesarean birth.

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