In 1916 Edwin Craigin, an obstetrician addressing a medical meeting, pronounced, “Once a cesarean section, always a cesarean section.”
The issue of reducing the number of first, or primary, cesarean sections is murky, since whether to do one is basically a judgment call in an emergency. So health planners have focused on secondary, elective operations as a more obvious target in reducing spending. A February 1990 article in the Journal of the American Medical Association noted that less than 10 percent of women with previous C-sections subsequently deliver vaginally and 35 percent of all C-sections performed in the U.S. are nonemergency previously scheduled repeat surgeries. The overall mortality rate for C-sections is one in 2,500, so it is a very safe operation. Yet there is no question that a surgical delivery is riskier for the mother than a vaginal one.
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The more militant VBAC advocates contend that doctors, particularly male doctors, perform the operation for their own convenience and financial gain as much as in response to fetal distress. Financial incentives for cesarean delivery in the United States are high–both for physicians, who collect the operative and anesthetic professional fees, and hospitals, which charge for the operating time and the extra days of hospitalization for baby and mother. In fact, when Mount Sinai Hospital managed to decrease the rate of cesarean surgery from 17.5 percent to 11.5 percent over a two-year period (by intensive physician and patient education as well as peer review), it lost a million dollars in revenue.
The issue is addressed in quality-assurance committees as well as financial circles. There are even some doctors who agree with the CPM and will not consider scheduling a repeat cesarean. They don’t feel it is a woman’s choice to request an unnecessary operation. Since 25 percent of women will need a cesarean delivery whether or not they have had a previous operation, these doctors argue that if we don’t allow a woman to request surgery in her first pregnancy, it makes no sense to allow it with subsequent pregnancies.
Other women don’t want to prove themselves or return to the pretechnological era. Some feel their bodies are beyond their control from the first nausea to the last contraction, that the essence of pregnancy is feeling out of control. A friend who had a tubal ligation (without consulting her husband) after her second child said she just couldn’t face being that crazy again. An obstetrician I spoke to who strongly advocates VBACs tries to persuade women who are reluctant to face the pain of labor again by pointing out that in the last five years new and better epidural anesthesia has been developed that provides pain relief without stopping the contractions. “Women who request repeat cesareans aren’t afraid of having a baby vaginally–they’re afraid of pain. Assure them the pain can be controlled, and they are willing to try.” Not in the spirit of Silent Knife, but nevertheless a strategy to avoid unnecessary operations.
It comes down to an issue of choice. There are women who would prefer to avoid the experience of labor, even recognizing the greater risk to themselves. They feel their position also deserves the feminist halo, since they are deciding. This point of view should not be surprising, since men and women sign up for the risk of anesthesia by the thousands in order to have plastic surgery. As one obstetrician put it, “If women are allowed to choose an elective breast augmentation, I think they should be allowed to choose a repeat cesarean.” A woman who had a cesarean after 48 hours of labor and has chosen a VBAC commented, “I don’t think women who had a baby after 12 hours of labor [the average quoted in many books and classes] should be allowed to discuss this question.”
