Long before she even met her husband, and well before she decided to become pregnant, Euna Chung made a firm decision about how she would deliver her children. "I knew for years that I wanted a caesarean section," the 31-year-old Los Angeles--based child psychiatrist says.
She isn't a diabetic, doesn't have hypertension or, for that matter, any of the other risk factors that might indicate the need for a C-section. But a combination of having watched traumatic vaginal deliveries in medical school and hearing about her mother's difficult emergency caesarean experience after trying to deliver vaginally helped make up her mind. "I had a fear of going through labor and ending up with an emergency C-section anyway. I know that's rare, but I didn't want to deal with it," she says.
So six weeks ago, when she was ready to deliver her first child, Chung checked herself into the hospital on a day she had already scheduled, underwent local anesthesia, and several hours later had her baby by caesarean, without any complications. Pretty tidy way to conduct the often messy business of childbirth. Yet Chung sometimes feels defensive about her decision. "There is an admiration of women who are able to do a vaginal birth without pain medications, then breast-feed, and do everything else perfectly," she says. "So I didn't go around advertising that I had chosen to have a C-section."
Chung has unwittingly stumbled upon the latest battleground in maternity care. Just as moms and even doctors once clashed about the importance of breast-feeding, they now debate the benefits and risks of vaginal births and caesarean sections. Rates of C-sections have been climbing each year in the past decade in the U.S., reaching a record high of 31% of all live births in 2006. That's a 50% increase since 1996. Around the world, the procedure is becoming even more common: in certain hospitals in Brazil, fully 80% of babies are delivered by caesarean. How did a procedure originally intended as an emergency measure become so popular? And is the trend a bad thing?
Some of the rise in C-sections can certainly be attributed to women with routine pregnancies, like Chung, who make a pragmatic decision to keep their deliveries just as uneventful. Preliminary data suggest that such cases account for anywhere from 4% to 18% of the total number of caesareans. On the medical side, better anesthesia and antibiotics are making the procedure safer. Add to that the growing number of women delaying childbirth, those having twins or triplets as a result of in vitro fertilization and America's exploding obesity epidemic--all of which increase the risks of vaginal delivery. Doctors are also becoming better at picking up the slightest signs of distress in the baby or mother and are quicker to recommend caesareans in such cases.
But even taken together, all these factors don't explain the steep rise in caesareans over such a short time. Instead, says Eugene Declercq, a professor of maternal and child health at Boston University School of Public Health, the biggest change may simply be in the way we think about labor and delivery. In an increasingly technological and medicalized society, maybe even childbirth is losing some of its magic and becoming less about the miracle of life and more about simply getting a baby out safely and without incident. "We put a lot of emotional, psychological and spiritual value around birthing," says Dr. William Callaghan, an obstetrician at the Centers for Disease Control and Prevention. "But perhaps we are coming up with different cultural norms."
Shaping those norms are some powerful fiscal forces as well, such as soaring malpractice rates for obstetricians. Since doctors are sued more frequently after vaginal births than caesareans, surgery is often the prudent choice when there is even the slightest indication of a difficult vaginal birth. Combine this with the increasing willingness of moms like Chung to talk more openly about their C-sections, and we may be headed for a time when mothers make the vaginal-or-caesarean decision in the same way many now make the breast-or-bottle decision.
That does carry perils, however. A panel of experts convened by the National Institute on Child Health and Development in 2006 stresses that moms-to-be need more scientific data that directly weigh the benefits and risks of both delivery methods. Vaginal delivery can, for example, lead to future incontinence and pelvic damage, while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process. It will take more studies comparing the two methods for individual women to be able to determine how likely these risks are for them.
Chung remains convinced that she made the right decision for herself and son Nathan. As our ideas about birth evolve, perhaps more women will feel less defensive about making the same choice.