Top 5 reasons prophylactic elective caesarean delivery with no medical indication is a legitimate decision for informed women

As a speaker at a seminar on cesarean delivery the upcoming 'Controversies in Childbirth' conference in Fort Worth, Texas (March 27, 2009), I was asked to write my 'Top 5 reasons prophylactic elective cesarean delivery with no medical indication is a legitimate decision for informed women', and here they are:

1. There are risks and benefits associated with all birth plans. A healthy spontaneous vaginal delivery (even when desired) is never guaranteed since labor, even with healthy pregnancies, is entirely unpredictable.

2. The oft-quoted risks associated with cesarean delivery frequently refer to emergency surgery or deliveries with pre-existing medical indications. These risks are not the same in healthy pregnancies with delivery at 39 weeks gestation for women planning small families.

3. Birth data compiled in the U.S. does not separate emergency and planned cesareans, only primary and repeat cesareans, which muddles the true assessment of risk as it relates to birth PLAN and the corresponding birth OUTCOME. Research from overseas demonstrates vastly reduced risks with planned surgeries, although we are yet to witness a move towards research that applies emergency cesarean outcomes to the planned vaginal delivery data set, which would be more relevant.

4. The risks (and costs) associated with planned vaginal delivery are grossly underestimated, both in the short- and long-term (in fact long-term risks and costs, financial and psychological, are rarely applied in comparative birth analysis). For example, shoulder dystocia, Erb’s palsy, fetal trauma, neonatal encephalopathy, asphyxiation, intrauterine fetal demise; damage to pelvic floor, POP, sexual health; infant and maternal severe morbidity associated with emergency cesareans; litigation trauma and cost following death or injury.

5. Research has shown high levels of birth satisfaction with planned cesarean delivery and birth trauma websites illustrate high levels of dissatisfaction with planned vaginal delivery. A ‘good birth outcome’ is not commensurate with ‘vaginal delivery for all women’ and genuine birth educators should not make this assumption. For true birth autonomy to exist, cesarean delivery must not be viewed as a second-rate outcome, and at a time in history when maternal and fetal characteristics are leading to more cesarean deliveries (e.g. increased maternal age and obesity; also birth weights), it is not only potentially dangerous to focus on drastically reducing the numbers of ‘unwanted’ surgeries, it is moreover unethical to reduce rates by discouraging or denying those surgeries that are in fact ‘wanted’.