At the cutting edge of birth

For millennia, cesarean sections were performedfor only one purpose - to deliver a baby just before or just after itsmother died. Only 500 years ago was the first reported case of a womanwho survived the ripping open of her abdomen and uterus and sewing themclosed. But today, a growing number of healthy women around the worldrequest a cesarean rather than a vaginal delivery because they fear thepain or want to be "in control." And many physicians go along to avoidlawsuits.

Cesareanscan be a lifesaver for women and their babies if labor does notproceed, the fetus remains in a feet-down or horizontal position or issuffering from distress. But cesarean delivery on maternal request(CDMR) has become a medical, ethical, financial and legal dilemma inboth the developed and developing worlds.

THE WORLD Health Organization has recommended that the cesareanrate be no higher than 15% of all deliveries. While the rates are verylow - under 5% - in countries like Haiti, Nigeria, Uganda, Eritrea andUzbekistan, 20-30% is today considered "moderate" in the UnitedKingdom, Canada, Ireland, Germany, Switzerland, Cuba and Portugal.One-fifth of deliveries in Israel and nearly one-third in the US arecesareans, 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 thatthere are cultural, psychological, legal, medical, technological andother reasons for why some societies have many CDMRs and others havefew.

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 longerhospitalization and poses possible complications such as bleeding,infections and problems from anesthesia in the mother and prematurebirth and respiratory distress in the baby. Cesareans may also postponethe psychological/hormonal bonding between newborn and mother, and haveharmful psychological effects. Although hospitals are compensated wellfor deliveries by the National Insurance Institute (NII), cesareandeliveries take up operating room space and require a larger staff thanvaginal deliveries.

Although some doctors try to perform a vaginal delivery after acesarean (VBAC), the trend is to do yet another cesarean to preventuterine rupture and lawsuits, so if it's one cesarean, very often allsubsequent deliveries are by surgery as well. The VBAC rate after allcesareans used to be 80% in Israel, but it has dropped to between 30%and 50%, compared to 10% in the US.

Womenwho plan to have a large family thus obviously try to do withoutcesareans, while women in China - where official government policyallows only one child (except if couples pay hefty fines) tend to havethat one delivery by cesarean.

A FEW months ago, at an Eilat conference on medical malpracticeorganized in Eilat by the Israel Bar and attended by hundreds oflawyers 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 Avivlawyer Dori Caspi (of the Caspi-Sror law firm), who has representedplaintiffs in medical malpractice suits for 25 years, was asked torepresent a fictitious doctor for a change. Dafna Rosen-Singer, whousually represents the other side, was invited to speak on behalf ofthe 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 CDMRand give him the legal responsibility for any complications if he did.The autonomic rights of an individual come into conflict with the rightof a doctor to act according to his conscience. The right to autonomyover one's body is very important here, but sometimes it can be pushedaside." Caspi has noted a steady trend among his clients to have acesarean even when there are no medical reasons to do so. "It's becomefashionable," he added.

The American College of Obstetrics and Gynecology hasguidelines for obstetricians asked to perform CDMR. They may do it onlyif the fetus is 39 weeks old, the woman is not in active labor, anddoes not want more than one or two more children.

Caspi said he won the case by defending the fictitiousphysician. "He (or she) can't be forced to perform a cesarean that isnot medically justified. The Israel Medical Association has a rule thata doctor can refuse to give a specific treatment that violates hispersonal religious views," said Caspi, and the physicians' oath writtenby the great sage Maimonides requires him to be "true to himself."

The Tel Avi lawyer said he doesn't recall a lawsuit against anyphysician who refused to do a cesarean and thereby caused a woman harm,but there have been hundreds of cases against doctors who didn'tdo a cesarean or did one too late even though there allegedly weremedical reasons for it. The plaintiff has almost always won in such asituation, and the compensation can go into the millions of shekels ifthe woman or her child suffered permanent damage.

At the Israel Bar conference, the participating lawyers wereasked to vote electronically after the facts were presented; then,after all the "testimony" was heard, the lawyers voted again before thejudge ruled. The second time, recalled Caspi, "many more of them wereon the doctor's side."

Although the Israeli average of cesarean deliveries is around20%, that figure represents significant variation among the medicalcenters. Hospitals with religious ownership or a large number ofreligiously observant patients, such as Jerusalem's Shaare ZedekMedical Center or Bikur Holim Hospital, Bnei Brak's Ma'ayanei HayeshuaHospital and Netanya's Laniado Medical Center naturally perform CDMRmuch more rarely, both because it is requested less and because womenintend to have large families - a fact not suited to repeatedcesareans. Prof. Arnon Samueloff, Shaare Zedek's director of obstetricsand high-risk pregnancy care, says a quarter of his department'sdeliveries are of a woman's sixth or beyond children.

For a long time, Shaare Zedek refused to performCDMRs, but "four or five years ago we realized that if we didn't dothem, women would just go elsewhere. So we agreed, but today theyconstitute only about 5% of deliveries. It's so clear to the vastmajority of our patients that a vaginal delivery is usually best forthem."

Eventhough the World Health Organization discourages cesareans in general(except for clear and urgent medical reasons), neither the HealthMinistry nor the NII (which pays for childbirth) has an official policyencouraging or discouraging CDMRs - though the ministry stronglydiscourages intentional home births because of medical risks.

"When a pregnant woman comes in and says she wants a cesareanbecause she is fearful or wants to be in control, we voice our positionagainst it," said Samueloff. "We have protocols. The woman meets with asenior obstetrician, and he tries to persuade her not to do it. But ifshe really insists, we agree. If there are psychiatric or psychologicalreasons such as past sexual trauma, we try to discourage a CDMR andprovide counselling. Maybe we have a dozen CDMR cases out of 12,000annual deliveries. But in the center of the country, most of theobstetricians won't even argue."

The likely CDMR patient is a secular woman with a white-colorjob. "She is calm and determined," said Samueloff. They regard evenepidural anesthesia as insufficient to relieve their fears. They aremostly Jews, but we have had some Arab women making the request aswell," said the Shaare Zedek physician. Unlike two days ofhospitalization after vaginal birth, cesareans involve three or fourdays of recovery.

Prof. Drorith Hochner-Celnikier, head of the maternity unit inobstetrics and gynecology at Hadassah University Hospital onJerusalem's Mount Scopus, has quite a different patient profile and amore liberal personal view. In fact, on a panel a few years ago onCDMR, Samueloff faced off against Hochner-Celnikier, with him beingmore conservative and her being an advocate of women's choice.

As pregnant women and their fetuses cannot easily or morally beturned into subjects of prospective clinical trials, there has beenalmost no research on the consequences of CMDR vs. vaginal birth."Whatever a doctor thinks and decides to do, we at least needretrospective epidemiological studies to see short- and long-termoutcomes and complications," said the Hadassah obstetrician.

Olderwomen who are pregnant often get cesareans because they are recognizedas having a "precious pregnancy," and surgery gives obstetricians morecertainty and control. Not everything regarded as "natural," notedHochner-Celnikier, who herself has had three vaginal deliveries, isbest. "For example, if you drink unpasteurized milk from a cow, you canget a brucellosis infection."

But she agrees that a vaginal birth routinely leads to aspeedier recovery, without a scar. "If one wants a lot of children,vaginal delivery is much better." She noted that in Germany, forexample, where the average woman has only one baby, cesareans are verypopular as women feel they are in control of their delivery.High-income women on the Upper West Side of Manhattan often give birthon schedule by cesarean on a Thursday and get back to work thefollowing Monday. "The profile of women who want to give birth at homeand 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 incesareans in recent years. As it has a large catchment area forpatients from eastern Jerusalem, there are numerous Arab women, and asurprising number prefer CDMR. "They want large families, but they aretired and feel that if they're in the hospital longer they'll get arest and more attention from their families," suggestedHochner-Celnikier.

Vaginal births often involve a higher risk for damage to themuscles of the pelvic floor. There are women with collagen [connectivetissue] that is not very elastic, so regular delivery is hard for themand they want a cesarean, she said. "I don't suggest cesareans withoutmedical reasons, but if they are determined and they are not diabeticor very overweight, I don't deny it to them."

The Mount Scopus maternity director concluded: "I think we haveto reduce the importance given to how a woman gives birth. It is ameans to the end of bringing a healthy baby into the world, and not anend in itself. I wouldn't want to give birth by myself in a jacuzzi orin my bed at home. Some women have even done this while their husbandand children watched TV."