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 lawsuits. Cesareans 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, Nigeria, Uganda, Eritrea and Uzbekistan, 20-30% is today considered "moderate" in the United Kingdom, Canada, Ireland, Germany, Switzerland, Cuba and Portugal. One-fifth of deliveries in Israel and nearly one-third in the US are cesareans, while high rates are found in Italy (36%), Mexico (39%), 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 few. 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 for "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 vaginal deliveries. 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. Women 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 the women. "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 Ma'ayanei Hayeshua 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 them." Even 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. Older 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 Hochner-Celnikier. 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."