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Elective Caesareans Judged Ethical
Doctors Group Issues Statement on Popular Procedure

By Rob Stein
Washington Post Staff Writer
Friday, October 31, 2003; Page A02


It is ethical for doctors to deliver a baby by Caesarean section
even if the mother faces no known risks from conventional labor, the
nation's largest group of pregnancy specialists has decided.

The American College of Obstetricians and Gynecologists' ethics
committee is issuing a statement today that for the first time
addresses the increasingly popular elective Caesarean sections --
those performed when there is no medical necessity.

The organization has never before issued guidelines or official
opinions about elective Caesareans, but for years it has been among
many medical groups that campaigned to reduce the number of surgical
deliveries for any reason.

The new statement could help accelerate a rapid increase in
Caesarean sections by making doctors more willing to perform the
procedure on an elective basis, some experts said.

In a retreat from the "natural childbirth" movement, the number of
women undergoing surgical deliveries has reached an all-time high.
More than one-quarter of all U.S. babies are delivered surgically,
the highest rate since the government started collecting statistics
on the issue in 1989.

The reasons for the increase are complex and controversial, but the
trend is being driven in part by a rise in elective Caesareans.

Even if their babies are not in a feet-downward "breech" position,
or they do not face other possible complications, some women are
choosing to forego natural labor and instead schedule a surgical
delivery, either for convenience, because they fear the pain of
childbirth, or because of concerns about possible long-term
complications from the physical trauma of labor and delivery.

The increase has led to an intense debate. Opponents argue that
elective Caesareans are costly, require more recovery time, and put
women at risk for infections, hemorrhages and other complications.

Proponents say Caesareans pose no serious risks for most women and
that expectant mothers should have the choice. Some go further,
saying doctors should actively offer the option because labor and
delivery carries significant risks for long-term complications,
including decreased sexual sensation, incontinence and other health
problems.

In the new statement, the ethics committee concludes that the
relative risks and benefits of elective Caesareans vs. vaginal
deliveries remain unclear, and it cautions against actively
advocating surgical deliveries.

"The burden of proof should fall on those who are advocates
for . . . the replacement of a natural process with a major surgical
procedure," the committee wrote.

Moreover, "given the lack of data, it is not ethically necessary to
initiate discussion regarding the relative risks and benefits of
elective [Caesarean] birth versus vaginal delivery with every
pregnant patient," the committee wrote.

But the committee also concludes that "if the physician believes
that [Caesarean] delivery promotes the overall health and welfare of
the woman and her fetus more than vaginal birth, he or she is
ethically justified in performing" the procedure.

Robert Lorenz, vice chief of obstetrics at William Beaumont Hospital
in Royal Oak, Mich., a member of the committee, cautioned that the
statement was not meant to encourage elective Caesareans but to
provide an ethical context for making that decision.

"My concern is that people will take this as a carte blanche 'Let's
do Caesarean sections on everyone,' " Lorenz said by
telephone. "That's not the intent at all."

Laura Riley of Massachusetts General Hospital, who chairs the
organization's committee on obstetric practice, said the group would
not issue specific guidelines about elective Caesareans until more
research is done on their risks and benefits.

But supporters of offering Caesareans as an option applauded the
committee's statement as a significant shift.

"I think it's a step to where we're going. And my guess is that as
increasing evidence comes out, it will probably become a more
accepted procedure," said W. Benson Harer Jr., medical director of
the Riverside County Regional Medical Center in Moreno Valley,
Calif., who triggered a furor when he was president of the
organization by arguing that women should have the option of a
Caesarean. "Before this statement, it was gray area. This clarifies
it and gives it some permissibility."

David C. Walters, an obstetrician-gynecologist in Mount Vernon,
Ill., who actively advocates Caesareans, was disappointed it did not
go further.

"I do think it's a step forward in that the college has grudgingly
agreed that it might be a reasonable thing to do. That's new,"
Walters said. "They should have said that in the absence of
compelling evidence to support the superiority of either vaginal
birth or Caesarean section that either one is a reasonable
alternative for delivery and should be considered equally."

But Tonya Jamois, president of the International Cesarean Awareness
Network, which opposes overuse of the procedures, criticized the
statement.

"There's lot of evidence that shows that Caesareans are much more
dangerous for the mothers and the babies," Jamois said. "What I'm
worried about is that this will be interpreted to justify ethically
a physician agreeing to give a woman a Caesarean when there's no
medical indication. I think it is a bad thing for society."