For millennia, cesarean sections were performed
for only one purpose - to deliver a baby just before or just after its
mother died. Only 500 years ago was the first reported case of a woman
who survived the ripping open of her abdomen and uterus and sewing them
closed. But today, a growing number of healthy women around the world
request a cesarean rather than a vaginal delivery because they fear the
pain or want to be "in control." And many physicians go along to avoid
can be a lifesaver for women and their babies if labor does not
proceed, the fetus remains in a feet-down or horizontal position or is
suffering from distress. But cesarean delivery on maternal request
(CDMR) has become a medical, ethical, financial and legal dilemma in
both the developed and developing worlds.
THE WORLD Health Organization
has recommended that the cesarean
rate be no higher than 15% of all deliveries. While the rates are very
low - under 5% - in countries like Haiti
Uzbekistan, 20-30% is today considered "moderate" in the United
One-fifth of deliveries in Israel
and nearly one-third in the US are
cesareans, while high rates are found in Italy (36%), Mexico
China (40%) and Brazil
(where it is an astonishing 80%).
As the rates among countries vary so wildly, it is clear that
there are cultural, psychological, legal, medical, technological and
other reasons for why some societies have many CDMRs and others have
A cesarean section - which was not
named after Julius Caesar
but may come from the Roman
legal code Lex Caesarea
on delivery of a fetus when its mother dies, or derive from the Latin verb caedere
"to cut" - is major abdominal surgery. It requires longer
hospitalization and poses possible complications such as bleeding,
infections and problems from anesthesia in the mother and premature
birth and respiratory distress in the baby. Cesareans may also postpone
the psychological/hormonal bonding between newborn and mother, and have
harmful psychological effects. Although hospitals are compensated well
for deliveries by the National Insurance Institute (NII), cesarean
deliveries take up operating room space and require a larger staff than
Although some doctors try to perform a vaginal delivery after a
cesarean (VBAC), the trend is to do yet another cesarean to prevent
uterine rupture and lawsuits, so if it's one cesarean, very often all
subsequent deliveries are by surgery as well. The VBAC rate after all
cesareans used to be 80% in Israel, but it has dropped to between 30%
and 50%, compared to 10% in the US.
who plan to have a large family thus obviously try to do without
cesareans, while women in China - where official government policy
allows only one child (except if couples pay hefty fines) tend to have
that one delivery by cesarean.
A FEW months ago, at an Eilat
conference on medical malpractice
organized in Eilat by the Israel Bar and attended by hundreds of
lawyers and physicians, a mock trial was held about cesarean section.
Jerusalem District Court president Hila Gerstel convened the "trial"
and heard lawyers advocate each side of the issue. Ironically, Tel Aviv
lawyer Dori Caspi (of the Caspi-Sror law firm), who has represented
plaintiffs in medical malpractice suits for 25 years, was asked to
represent a fictitious doctor for a change. Dafna Rosen-Singer, who
usually represents the other side, was invited to speak on behalf of
"I've dealt with hundreds of cases of births that ended in cesarean or did not but should have," Caspi told The Jerusalem Post
"The question was if in Israel one can force a doctor to perform CDMR
and give him the legal responsibility for any complications if he did.
The autonomic rights of an individual come into conflict with the right
of a doctor to act according to his conscience. The right to autonomy
over one's body is very important here, but sometimes it can be pushed
aside." Caspi has noted a steady trend among his clients to have a
cesarean even when there are no medical reasons to do so. "It's become
fashionable," he added.
The American College of Obstetrics and Gynecology has
guidelines for obstetricians asked to perform CDMR. They may do it only
if the fetus is 39 weeks old, the woman is not in active labor, and
does not want more than one or two more children.
Caspi said he won the case by defending the fictitious
physician. "He (or she) can't be forced to perform a cesarean that is
not medically justified. The Israel Medical Association has a rule that
a doctor can refuse to give a specific treatment that violates his
personal religious views," said Caspi, and the physicians' oath written
by the great sage Maimonides requires him to be "true to himself."
The Tel Avi lawyer said he doesn't recall a lawsuit against any
physician who refused to do a cesarean and thereby caused a woman harm,
but there have been hundreds of cases against doctors who didn't
do a cesarean or did one too late even though there allegedly were
medical reasons for it. The plaintiff has almost always won in such a
situation, and the compensation can go into the millions of shekels if
the woman or her child suffered permanent damage.
At the Israel Bar conference, the participating lawyers were
asked to vote electronically after the facts were presented; then,
after all the "testimony" was heard, the lawyers voted again before the
judge ruled. The second time, recalled Caspi, "many more of them were
on the doctor's side."
Although the Israeli average of cesarean deliveries is around
20%, that figure represents significant variation among the medical
centers. Hospitals with religious ownership or a large number of
religiously observant patients, such as Jerusalem's Shaare Zedek
Medical Center or Bikur Holim Hospital, Bnei Brak's
Hospital and Netanya's
Laniado Medical Center naturally perform CDMR
much more rarely, both because it is requested less and because women
intend to have large families - a fact not suited to repeated
cesareans. Prof. Arnon Samueloff, Shaare Zedek's director of obstetrics
and high-risk pregnancy care, says a quarter of his department's
deliveries are of a woman's sixth or beyond children.
For a long time, Shaare Zedek refused to perform
CDMRs, but "four or five years ago we realized that if we didn't do
them, women would just go elsewhere. So we agreed, but today they
constitute only about 5% of deliveries. It's so clear to the vast
majority of our patients that a vaginal delivery is usually best for
though the World Health Organization discourages cesareans in general
(except for clear and urgent medical reasons), neither the Health
Ministry nor the NII (which pays for childbirth) has an official policy
encouraging or discouraging CDMRs - though the ministry strongly
discourages intentional home births because of medical risks.
"When a pregnant woman comes in and says she wants a cesarean
because she is fearful or wants to be in control, we voice our position
against it," said Samueloff. "We have protocols. The woman meets with a
senior obstetrician, and he tries to persuade her not to do it. But if
she really insists, we agree. If there are psychiatric or psychological
reasons such as past sexual trauma, we try to discourage a CDMR and
provide counselling. Maybe we have a dozen CDMR cases out of 12,000
annual deliveries. But in the center of the country, most of the
obstetricians won't even argue."
The likely CDMR patient is a secular woman with a white-color
job. "She is calm and determined," said Samueloff. They regard even
epidural anesthesia as insufficient to relieve their fears. They are
mostly Jews, but we have had some Arab women making the request as
well," said the Shaare Zedek physician. Unlike two days of
hospitalization after vaginal birth, cesareans involve three or four
days of recovery.
Prof. Drorith Hochner-Celnikier, head of the maternity unit in
obstetrics and gynecology at Hadassah
University Hospital on
Jerusalem's Mount Scopus
, has quite a different patient profile and a
more liberal personal view. In fact, on a panel a few years ago on
CDMR, Samueloff faced off against Hochner-Celnikier, with him being
more conservative and her being an advocate of women's choice.
As pregnant women and their fetuses cannot easily or morally be
turned into subjects of prospective clinical trials, there has been
almost no research on the consequences of CMDR vs. vaginal birth.
"Whatever a doctor thinks and decides to do, we at least need
retrospective epidemiological studies to see short- and long-term
outcomes and complications," said the Hadassah obstetrician.
women who are pregnant often get cesareans because they are recognized
as having a "precious pregnancy," and surgery gives obstetricians more
certainty and control. Not everything regarded as "natural," noted
Hochner-Celnikier, who herself has had three vaginal deliveries, is
best. "For example, if you drink unpasteurized milk from a cow, you can
get a brucellosis infection."
But she agrees that a vaginal birth routinely leads to a
speedier recovery, without a scar. "If one wants a lot of children,
vaginal delivery is much better." She noted that in Germany, for
example, where the average woman has only one baby, cesareans are very
popular as women feel they are in control of their delivery.
High-income women on the Upper West Side
of Manhattan often give birth
on schedule by cesarean on a Thursday and get back to work the
following Monday. "The profile of women who want to give birth at home
and those who want a CDMR is very similar.
The Mount Scopus hospital delivers about 450 babies a month,
and the maternity director has not noticed a dramatic increase in
cesareans in recent years. As it has a large catchment area for
patients from eastern Jerusalem, there are numerous Arab women, and a
surprising number prefer CDMR. "They want large families, but they are
tired and feel that if they're in the hospital longer they'll get a
rest and more attention from their families," suggested
Vaginal births often involve a higher risk for damage to the
muscles of the pelvic floor. There are women with collagen [connective
tissue] that is not very elastic, so regular delivery is hard for them
and they want a cesarean, she said. "I don't suggest cesareans without
medical reasons, but if they are determined and they are not diabetic
or very overweight, I don't deny it to them."
The Mount Scopus maternity director concluded: "I think we have
to reduce the importance given to how a woman gives birth. It is a
means to the end of bringing a healthy baby into the world, and not an
end in itself. I wouldn't want to give birth by myself in a jacuzzi or
in my bed at home. Some women have even done this while their husband
and children watched TV."