As readers of this blog already know, I believe that any informed healthy pregnant woman should have her decision to give birth via cesarean delivery respected. That said, it clearly remains a highly controversial issue, and one that continues to be debated in the medical and media worlds.
One of the problems we have is that there are no short- or long-term clinical studies that specifically compare healthy women going down the planned vaginal delivery route with healthy women going down the planned cesarean delivery route. In what has become a never-ending cycle of chicken-and-egg, some medical professionals say that such a study is unethical; they claim we don't have evidence to show that planned cesarean delivery is safe enough to compare with vaginal delivery. Yet without this study, we will never have such evidence - a situation perhaps they prefer...
An ethical comparative study
Today I came across a new Australian review by Hans P. Dietz, in which he asks the question: "Elective Cesarean Section- the Right Choice for Whom?" He begins by reiterating some of the problems contemporary doctors face: "There are no scientific grounds for identifying an 'appropriate' level for Cesarean section rates, and no data to help us in counselling women who ask for elective Cesarean delivery. A 'Term Cephalic Trial' may provide such information, but poses major logistic and ethical challenges."
And here's what he proposes: "The key to a successful resolution of this issue may lie in individualized risk assessment. This has now become possible. Maternal age, a history of Cesarean Section in the parturient's mother, maternal body mass index, cervical length and/ or Bishop score, pelvic organ mobility and engagement of the fetal head are some of the factors that have recently been shown to be associated with delivery mode in nulliparous women. Individual risk assessment may soon allow us to construct intervention trials that will be ethically sound, logistically feasible and resource- neutral. Even more importantly, we may eventually be able to provide true 'informed consent' to women considering elective Cesarean delivery."
Informing women is key
This could be a very important step in the right direction. We know that women are giving birth at an increasingly older age, and we know that women's weight is often cited as an unwelcome challenge in obstetrics. Babies are getting larger and women's tolerance of risk (both maternal and fetal) is less than that of previous generations. We know that litigation (whether we like it or not) is a reality that cannot be ignored. We also know that there are other factors that can increase the likelihood of an emergency cesarean or an instrumental delivery - factors that might lead some women to opt for a planned cesarean delivery instead.
I personally feel that a comparative study of healthy pregnant women is already possible, and indeed ethical. There is no need to invite women to have a planned cesarean delivery - simply monitor and collect data on those women who have made the decision to have one themselves. Still, in the meantime, I'm happy to settle for any effort that seeks to better inform women of the risks and benefits of different delivery methods. We've been avoiding doing so for far too long already.