WASHINGTON- Jenny Haley never wants to be cut again
The Mount Airy mother of three has had two cesareans and a vaginal delivery, and found the cesarean births more frightening and more tiring, taking up to six weeks for recovery.
“With a vaginal birth after 10 days I felt like dynamite,” Haley said. “I would never opt to have a c-section again unless it was medically necessary.”
But Haley said she has many friends who are having cesareans, mirroring a steady growth in the number of such procedures in the state and nation.
In 2001, about a quarter of all births in Maryland — or about 18,500 births — were cesareans, according to the National Vital Statistics Report released by the National Center for Health Statistics. In Wicomico and Worcester counties, cesarean deliveries accounted for nearly 30 percent of total deliveries in 2000, the highest rate in the state, according to the Maryland Vital Statistics Annual Report.
The state rate was slightly higher than the national average and well above a World Health Organization recommendation that no region in the world is justified in having a cesarean rate greater than 10-15 percent.
Physicians and health officials are not entirely certain why cesareans are rising again after a steady decline from 1990 to 1996.
Critics of the procedure say it can be attributed to women who like the convenience of an elective cesarean, which can be fit into a busy schedule. Others point to changing medical beliefs, or the fact that there are more deliveries by women with high-risk factors — like hypertension and older age.
“Do one quarter of women need to have a baby surgically? I think not,” said Nancy Zelnik, a certified nurse-midwife at the Maternity Center Associates in Bethesda. Zelnik believes that most cesareans are avoidable.
But Dr. Fred Guckes, an obstetrician in Annapolis, said he does not know of any doctors who are performing elective primary cesareans, and he has only had two or three patients request the procedure in the last few years. Each time, he was able to persuade the women to have a vaginal birth.
Guckes said that a blanket policy on cesareans is unwise, because every case should be examined on an individual basis. But he agreed that they should not be done as a matter of convenience — they are major abdominal operations, and present patients with the same dangers as any other operations, no matter how routine they may have become.
Elective cesareans increase the risk of premature birth and respiratory distress syndrome in infants, and can cause infections and hemorrhaging. They also have a maternal mortality rate two to four times higher than vaginal birth, according to the International Childbirth Education Association.
Many nurse-midwives attribute the increase in the procedure to the belief among some women that a cesarean delivery is more convenient, and to a belief among some doctors that risks associated with cesareans are the same, or less than, the risks associated with natural childbirth.
“It’s very enticing and attractive (for doctors) to be able to tell a woman ‘this is your day’,” said Deanne Williams, executive director of the American College of Nurse-Midwives.
In today’s competitive healthcare environment, she said, many doctors are agreeing when a woman says she wants to be able to go into the hospital and point to the exact day for her child’s birth.
She said that these women do not understand that one cesarean delivery can lead to another, as doctors swing back to the theory that vaginal birth after a cesarean may not be safe. Those women could be trapped in a cycle of surgery, where each successive cesarean is more dangerous than the previous one, Williams said.
“You have to when you’re looking at that first c-section look down the road at the second, the third and the fourth,” she said. “She’s (the mother) making a decision with her first baby she’s going to have to live with for the rest of her childbearing years.”
In the United States and Canada, over one-third of all cesareans are repeat c-sections, according to the International Childbirth Education Association.
Guckes agreed that the high rate in Maryland could be because of a return to the opinion that women who have had cesarean deliveries have c-sections for all subsequent births.
Once a c-section, always a c-section was the standard for years among doctors, who believed that a scarred uterus could not tolerate the strain of a natural birth. That changed when doctors discovered that the risks were the same for cesarean births and vaginal births, with vaginal births being less invasive and cheaper.
But the pendulum swung back the other way a few years ago, when another study recommended that doctors again advise patients to avoid vaginal birth after a cesarean.
Haley said she definitely felt pressured by her doctor to have her first cesarean. She said that her physician seemed rushed and ready to get things over with.
“Doctors are on a schedule,” she said. “They like to be in control of things.”