Why so many women have C-sections

What about potential risks of CDMR?
These need to be divided between the risk to the mother and risk to the newborn. With regard to the mother, there can be injury to organs adjacent to the enlarged uterus, including the bowel, bladder, blood vessels. There is also an increased risk of infection, development of thrombophlebitis or blood clots in the legs that subsequently can cause a pulmonary embolism. There is an increase in the risk of re-hospitalization, two times that of vaginal deliveries. (But in all fairness, most of this data has been found to be true for cesarean sections done after labor. A recent NIH conference suggested that a small study of Cesarean section on demand before labor did not been show an association with  higher risks and the actual chance of maternal mortality was lower than that for vaginal delivery.)

As far as the newborn is concerned, Cesarean-on-demand has been associated with an increased risk in respiratory distress (five percent vs. 0.5 percent for vaginal delivery) and need for resuscitation as well as subsequent admissions to a special care nursery.

Are there any implications on future pregnancies for women who’ve had cesarean delivery either on demand or because of a medical indication?
Yes. It appears that it takes longer to get pregnant after C-section (however, this may be voluntary). Because of potential scarring in the uterus or in areas near the uterus there seems to be an increased risk in subsequent ectopic pregnancies and miscarriage. There is also twice the risk of unexplained stillbirth in the next pregnancy. Additionally, we know that the scarring of the uterine wall can lead to abnormal placement of the placenta (placenta previa) in the next delivery and this can lead to hemorrhage and a premature Cesarean section. The placenta may also grow into the uterine wall, a condition called placenta accrete and create serious bleeding on attempts to remove it after delivery.

And finally, the placenta can separate before delivery (abruption), resulting in hemorrhage, fetal distress or even fetal demise. There are also higher rates of surgical complications in subsequent cesarean sections (especially injury to the bladder). The rate for hysterectomy due to bleeding is 60 times higher after more than one cesarean delivery, the risk of transfusion is greater and the average hospital stay is increased among women with multiple prior cesarean sections. A woman who is having repeat C-sections is twice as likely to be readmitted to the hospital.

What about cost?
The centers for Medicare and Medicaid have found that the average physician’s charges for uncomplicated vaginal delivery in the U.S. is just under $4,500. But for an uncomplicated cesarean deliver, it is $7,000. Hospitalization costs are doubled, going from an average of a little over $5,000 to over $10,000.

I know I have presented a lot of statistics, but what surprised me most as I researched this subject was the fact that 15 percent of current in-patient surgeries nationwide are Cesarean deliveries.  This means that they may be exhausting hospital, surgical, or and nursing services and as a result increase the waiting time and nursing coverage for other needed procedures.  For every 5 percent increase in U.S. C-section rates we can expect 14 to 32 more maternal deaths and $750 million to $1.7 billion in health-care expenditures.

What are the current recommendations regarding CDMR?
The American College of Obstetricians and Gynecologists (ACOG) and the National Institute of Health (NIH) have stated that it is ethically permissible for physicians to perform Cesarean deliveries purely on maternal request. ACOG has also recommended that if a physician does not feel comfortable in performing a CDMR, she or he should refer the patient to a  physician who will do so. It should also be stated that the International Federation of Gynecology and Obstetrics feels that “because hard evidence of net benefit does not exist, performing cesarean sections for non-medical reasons is not ethically justified.”

Finally, are there psychological implications to performing a cesarean section on demand versus going into a labor and having a vaginal delivery?
Six studies that were recently reviewed found that women who had unplanned Cesarean birth or instrumental vaginal delivery were more likely to have adverse psychological outcomes compared with women who had spontaneous vaginal deliveries or planned Cesarean births. There was no difference between those who had a Cesarean-on-demand with those who had spontaneous vaginal deliveries.

Ultimately, the choice for CDMR has to be made by the patient after thorough consultation with her doctor. She should be advised of the possible complications and consequences to future pregnancies. Many women feel that they do not want to take “any chances” when it comes to medical concerns about their babies health and well-being, the timing of delivery, or fear of pain and subsequent pelvic problems. Once they have discussed all of these issues with their physician, if they wish to have scheduled Cesarean deliveries, their voice and choice should be considered.

Dr. Reichman’s Bottom Line: Ultimately, the choice for CDMR has to be made by the patient after thorough consultation with her doctor.

Dr. Judith Reichman, the TODAY show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.

PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.

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