Most of us learn the word "elective" in high school, when we find ourselves with the newfound freedom to take a course like AP music theory, or advanced sculpture, or yoga. Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called "elective" cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature, as did the recent study in this month's New England Journal of Medicine, "Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes."
The large study made headlines last week in papers large and small, was mentioned on NPR, went viral on the web, and even made national TV news. It found that when babies are extracted prior to 39 full weeks in the womb, they are less likely be born breathing on their own, more likely to start life in a neonatal intensive care unit, and more apt to have infections and lingering health problems.
We already knew this from previous, smaller studies, and the American College of Obstetricians and Gynecologists' recommendation is to wait until the 39-week mark. But the study, which culled subjects from the National Institute of Child Health and Human Development network—presumably those hospitals most likely to follow best practices—found that a whopping 36 percent of scheduled, repeat cesarean sections were booked before 39 weeks.
Ah, but these are "elective" repeat cesareans, so women must be requesting them early! That's what the study's authors tell us: lead researcher Alan Tita, MD, said that women "usually" want to deliver "as soon as they hit" week 37. "Women should wait to have an elective cesarean until 39 weeks," he told Time magazine. Study coauthor Catherine Spong, MD, elaborated for the Washington Post: "Sometimes a patient is bonded to their physician...and says, 'Can we schedule it when you're in town?'...Sometimes her in-laws are coming at a certain time."
And the media dutifully followed the physicians' pointed fingers—toward mothers: "Thousands of women put their babies at needless risk of respiratory problems, hypoglycemia and other medical ailments by scheduling C-section deliveries too early..." began an L.A. Times story. "The findings could help diminish a widely popular practice...in which mothers choose to schedule c-sections, or surgical removal of the baby," reported the Wall Street Journal. "Some women opt to deliver a little earlier for a variety of reasons, including being eager to see their baby, being tired of pregnancy or for convenience," explained the Washington Post. Time magazine castigated those mothers: "Today, a trend toward elective cesareans is presenting doctors with another problem—women who insist on delivering earlier than they should, with potential risks to the newborn" (emphasis added).
To be clear, the researchers did not survey the women in this study—they were looking strictly at the health outcomes of newborns. And previous surveys of women have found no evidence of a "trend toward elective cesareans." But in classifying the deliveries as "elective," they imply patient-choice. "These are all elective repeat Caesareans without a medical indication and without labor," Spong told reporters.
It's true: scheduled, repeat cesareans are not "medically indicated," at least not according to the research evidence. After a cesarean birth, a woman is left with a scar on her uterus, and there's a small risk of that scar rupturing in subsequent deliveries, which has led to concerns about vaginal birth after cesarean (VBAC). But a VBAC baby has excellent odds—the risk of severe harm or death is 1 in 2000—the same odds as for a baby born vaginally to a first-time mother.
However, in spite of the true risk, VBACs are often vehemently discouraged. In fact, many obstetricians now refuse to attend them, and hundreds of hospitals have officially banned them. And malpractice liability fears are a strong motivation to schedule the surgery early, so as to avoid the possibility of labor—and vaginal birth. The fact is that VBAC is inaccessible to most women.
So, if a woman with a scar from a previous cesarean goes to her OB and is recommended to schedule a repeat cesarean—and is told that a vaginal birth would be risky, and that anyway it won't be done by this doctor, this practice, or this hospital—can the surgery possibly be called "elective?"
There are risks to VBAC and risks to
repeat C-section—even those done after 39 weeks—and women should
be weighing the risks and benefits with objective care providers who
will support their decision. But this is not what's happening. In a
survey conducted in 2005, more than half of women seeking VBAC could
not find a willing provider or hospital.
This is not about women "electing" to put their babies at risk. This is about women being backed into a corner and told what's best, then publicly shamed for "asking for it."
