C-Sections are vastly overutilized.  They are much more expensive, cause the mother much greater overall pain, suffering, and disability, seriously damage the birthing process, and increase post-partum depression.  Women are almost never told the serious side-effects of C-sections.

C-sections have an especially disastrous effect on future fertility.  The less than 1% increase in neonatal mortality in breech babies from a natural delivery (breech birth is the most common reasons doctors use for C-section) is offset by an increase in stillbirths with C-sections and a 23% decrease in fertility for the chance of a second child with a still greater decrease in the chance of any later children.  There is no doubt that C-sections deprive many wanted children the chance of ever being born.  

Many doctors could care less about the loss in fertility.  It is a closely guarded secret and almost never mentioned when a woman is asked to sign a consent for a C-section.  C-sections are costly and much less satisfying for both the woman and the child.  One study found them even less satisfying to women who were planning to have a C-section and where some women had unplanned vaginal deliveries.  C-sections are associated with an increase in post-partum depression and a decrease in breast-feeding.  Of course, physicians favor C-sections because of increased convenience, increased income, and decreased risk of being sued.  

Many women have been frightened away from vaginal deliveries by false information.  Read below.

Maybe Less Post-Partum Depression with Natural Spontaneous Delivery: In the ALSPAC study of 14,663 women recruited before delivery, the odds of post-partum depression was lower for spontaneous vaginal delivery (11% lower the average) compared to planned vaginal delivery (6% higher than average) and emergency C-section (17% higher than average). The authors state that none of these differences are statistically significant. Operative delivery and postnatal depression: a cohort study. Roshni R Patel, et al. St. Michael's, Bristol, UK. BMJ  4/16/2005;330:879. Ed: I have a hard time accepting the authors' claim that the difference are not significant. Research from Brazil has found that the vast majority of women prefer vaginal deliveries if they experience them, even women who had planned C-sections in order to avoid vaginal deliveries, but the baby just wouldn't wait.  Other studies have also found higher rates of post-partum depressions with C-sections.

FirstIn a review of existing cohort type studies to compare subsequent reproduction after Caesarean section with a comparable control group, with exposure at the earliest in the 1960s, 8 studies were found. They suggested that a Caesarean section is a risk factor for lowered fertility, for uncompleted pregnancy (ectopic pregnancy and possibly miscarriage), for complications in the next pregnancy and birth (including placental complications) and for health problems in the next infant. Paediatr Perinat Epidemiol 1996 Oct;10(4):366-79. Scottish study: 22,948 women from a stable homogeneous population who gave birth for the first time between 1964 and 1983 were followed up prospectively. Analysis by mode of delivery showed that of those delivered by caesarean section 23.2% fewer had another pregnancy than those who had a spontaneous vaginal delivery. Women delivered by forceps were in an intermediate group. Miscarriage was more common in women who had been delivered by caesarean section. The relative infertility after caesarean section could not be accounted for by early sterilization, was not associated with maternal height or social status, and was only partly attributable to age. Br J Obstet Gynaecol 1989 Nov;96(11):1297-303. US Study: infertility after primary cesarean section (study group) was compared to an age- and parity-matched control group who underwent vaginal delivery during 1978 at The New York Hospital. Secondary infertility occurred in 17/291 (5.8%) of the study group and 5/279 (1.8%) of the control group (p less than 0.03). Am J Obstet Gynecol 1987 Aug;157(2):379-83. Swedish study: After a primary c-section, fewer second children, subsequent children and twin deliveries in the cesarean section groups than in the control groups. J Reprod Med 1986 Jul;31(7):620-4. U.S.: subsequent fertility of 406 women who had had their first delivery by cesarean section is compared with that of 406 matched control women. Using any of several measures, women who had had a cesarean section had lower fertility. The difference in fertility seemed to result largely from difficulties in having children after a cesarean section, rather than lessened desire for children. Fertil Steril 1985 Apr;43(4):520-8

Slower Recovery and More Ectopic Pregnancies: In a long-term follow-up study of 25,371 women, 67% of women went on to have another baby after C-section compared with 74% who gave birth completely naturally. The Royal College of Obstetricians and Gynaecologists has urged doctors to consider the impact of the procedure.  Natural birth results in less risk of complications and a quicker recovery. Ectopic pregnancies increased by 60% after a C-section. British Journal of Obstetrics and Gynaecology, 8/05.

C-sections Lower Fertility 33%: Deirdre Murphy, 14,500 women who wanted to become pregnant again. One in eight women who has a C-section take more than a year to become pregnant again, compared with 1 in 12 of those who deliver vaginally. C-sections are associated with increased risk of miscarriage, ectopic pregnancy, and an abnormally sited placenta. Human Reproduction 7/02.

C-sections Often Avoidable: Liverpool University found women whose wombs were not contracting properly had tired muscles, signified by high levels of lactic acid. Treatments aimed at speeding up labor may exacerbate this problem. Not giving oxytocin could allow the womb to rest and regain strength for a natural labor. 21.5% of births in the UK are by Caesarean. Up to a quarter of those take place because labor fails to progress properly. Blood samples from the wombs of 72 women who had undergone Caesarean sections found blood acidity levels were highest in women whose womb had failed to contract and for whom hormone therapy had not worked. These women also had a higher level of lactic acid and a lower level of oxygen in their bloodstream than any of the other groups. The researchers say if muscles are working hard but not getting as much oxygen as they need, they change their biochemical make-up so they can still perform. This change produces lactic acid. BBC 5/31/04.

C-Sections Skyrocketing in U.S.: In just six years from 1997 to 2003, the U.S. rate of C-section increased from 20.6% to 27.6% with the largest increases in the last three years.  This occurred despire more women getting prenatal care, fewer teen pregnancies, and less smoking during pregnancy.  Tonya Jamois of the Internaitonal Caesarean Awareness Network noted that doctors and hospitals make more money from C-sections and are less likely to be sued. In the U.S., 300 hospitals have banned vaginal birth after a first C-section. Washington AP 11/24/04.

C-Section Drawbacks: Cesarean mothers, compared with mothers who delivered vaginally, expressed less immediate and long-term satisfaction with the birth, were less likely ever to breast-feed, experienced a much longer time to first interaction with their infants, had less positive reactions to them after birth, and interacted less with them at home. Health Psychol 1996 Jul;15(4):303-14.

C-sections Doctors’ Choice in Brazil: C-sections are especially common in Brazil in private patients (72%) even though the vast majority of women prefer vaginal birth. BMJ 11/17/01

Companion Cuts C-Section 26%, Increases Satisfaction: reviewing 15 studies, women who received continuous labor support from a non-hospital care-giver were: 26% less likely to give birth by Caesarean section. 41% less likely to give birth with vacuum extraction or forceps., 28% less likely to use any analgesia or anesthesia. 36% less likely to be dissatisfied with or negatively rate their birth experience. Epidural analgesia, Caesarean section and birth by vacuum extraction or forceps are major interventions with the potential for adverse short- and long-term effects on mothers and babies. Continuous labor support is an important tool to help women avoid risks associated with these practices and to have a satisfying experience at this important time in their lives, Carol Sakala, Maternity Center Association, 9/19/03 The Cochrane Library

Vaginal After C-Sec OK: study of 313,238 births in Scotland found that for women with previous Caesareans, the delivery-related death rate for subsequent babies was about 11 times higher in vaginal births than in planned repeat Caesareans. Still, the overall infant death rate for vaginal-after-Caesarean births was about equal to the death rate in first-time vaginal births - about 1.2 per 1,000 babies, the study found. That compared with 0.1 per 1,000 for planned repeat Caesareans. Often-cited previous research suggested a death rate of 5.8 per 1,000 births for vaginal-after-Caesarean deliveries. JAMA 5/22/02

Little Difference Ceasarean vs. Vaginal for Breech Presentation: JAMA 4/10/02 in Term Breech Trial randomizing 1940 women. Only benefit of CS was less urinary incontinence at 3 months (4.5% vs. 7.3%). CS women actually had a minimally greater risk of serious morbidity. Vaginal group liked birth better and thought recovery better. Vaginally delivered were much more likely to like their method of delivery whether they had been originally in the planned CS group or in the planned vaginal group (80% vs. 47%). CS patients were much more likely to find recovering from the childbirth was difficult (25% vs. 4%). Severe pain was only slightly more common with vaginal (15% vs. 9%). CS women were much more likely to dislike their method of delivery and vaginally delivered were much more likely to dislike nothing about the birthing experience (55% vs. 32%). Lancet 4/10/02. CS did result in slight decrease in adverse perinatal outcomes (1.6% vs. 5%) (Lancet 356:1375 ’00).

C-Sections Cause Doubling of Later Stillbirths: Women who had had one C-section had an increase in stillbirths from 0.89/1000 to 1.77/1000 according to Scottish data on 120,000 births. Lancet 11/28/03 Univ. Cambridge. 7% of C-sections strictly at woman's request without indications. Risk of breech baby dying if vaginally delivered is 8.9/1000.

Breech Births Often as Safe as C-Section; Most Show Small Increase Neonatal Mortality: 3-4% births breech. Controlled prospective studies have shown that the outcome of breech fetuses weighing more than 1500 g was not dependent on the mode of delivery. A more recent review from the Cochrane database by Grant does not justify a policy of elective cesarean section for pre-term breech. Vaginal delivery is preferred if the following criteria are met: frank breech only, estimated fetal weight of 2500-3500 g, adequate pelvimetry without hyperextended head, normal progression of labor, no evidence of fetal hypoxia under continuous fetal monitoring, and maternal weight under 90 kg. Vaginal delivery of frank breech at term may be just as safe as cesarean section when careful selection criteria are used. J Perinat Med. 2003;31(5):415-9; Another Cochrane analysis disagrees and says much lower serious neonatal complications. Cochrane Database Syst Rev. 2003;(3):CD000166.; A Dutch report on 32,000 breech deliveries 1995-9 found vaginal doubled neonatal mortality. BJOG. 2003 Jun;110(6):604-9; C-section no advantage in most twins. Am J Obstet Gynecol. 2003 Jan;188(1):220-7

No Difference Breech vs. C-Section: In 711 breech presentations, retrospective study found no difference in outcome of 63% vaginally delivered and 37% C-section. All weighed 2000 g. or more. Lund Univ. Eur J Obstet Gynecol Reprod Biol. 2003 Dec 10;111(2):122-8

Vaginal Hysterectomies Much Less Suffering and Disability than Abdominal Ones: In a DB randomized study, 36 women with dysfunctional uterine bleeding, uterine fibroids or pelvic pain scheduled for hysterectomy were randomized to abdominal or vaginal hysterectomy. Vaginal hysterectomy had a shorter hospital stay (median stay 3 days vs. 5 days, p = 0.01), experienced less pain as measured by morphine consumption (mean 75.4 mg vs. 131.4 mg morphine equivalent, p = 0.002), shorter need for intravenous hydration (mean 25.3 h vs. 32.7 h, p = 0.05), and faster return of bowel action (median 3 days vs. 4 days, p = 0.002). They also returned to normal domestic activities (mean 4.6 weeks vs. 8.5 weeks, p = 0.01) and work (mean 7.0 weeks vs. 13.9 weeks, p = 0.005), and completed their recovery (mean 7.9 weeks vs. 16.9 weeks, p = 0.008) more quickly. Randomized, prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse. Miskry T, et al. Royal Free Hospital, London, UK. Acta Obstet Gynecol Scand. 2003 Apr;82(4):351-8. Ed: I included this study here because I haven't seen a similar study with C-sections. Many women get C-sections thinking that they are avoiding pain, while in fact they will experience much more pain and prolonged disability.

Indomethacin Suppositories Means No Need for Opiates: In a DB PC study of 30 women with spinal anaesthesia for elective caesarean in a standard manner using hyperbaric bupivacaine, fentanyl and morphine, two rectal suppositories, followed by 12-hourly suppositories for six doses (three days) of 100 mg indomethacin found median time to first analgesia (TTFA) was 9 hours for the placebo group v. 39.5 hours for indomethacin (P < 0.003). Additional analgesic requests throughout the postoperative period were less in women who received indomethacin: 4 v 11 (P < 0.001). Women who received indomethacin had significantly less pain on the first postoperative day, especially on movement: mean VAS 1.4 v 5.1 (P < 0.00001). There were no reported adverse neonatal or maternal effects from the use of indomethacin. Rectal indomethacin potentiates spinal morphine analgesia after caesarean delivery. Pavy TJ, et al. University of British Columbia, Vancouver, Canada. Anaesth Intensive Care. 1995 Oct;23(5):555-9.

Thomas E. Radecki, M.D., J.D.

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