Patient Choice Cesarean

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These are easy to read and understand and are beautifully presented.

In the main this week comes the Green Journal with a clinical review with a lead article called "Patient Choice Cesarean". I am physically ill reading this crap.

The past few years have seen a re-examination by physicians of their role in the once rising cesarean section rate. Lots of committees and conferences and studies were implemented to lower the cesarean rate and now the boomerang effect....

This guy, W. Benson Harer, Jr, MD suggests that it is the culmination of feminist autonomy for obstetricians to agree to cesarean on demand and the height of paternalism to do otherwise: " In america. women's access to abortion and contraceptive services has gone from being tightly regulated with criminal sanctions to unrestricted access. This fits a pattern of restrictions by law and custom that limited women's' property rights, education, and voting that has gradually given way to permitting them to make their own decisions. the role of physician has concurrently shifted from dictating care to collaborating with the patient who is the one to make final decisions about available options -- except in the matter of the delivery of her baby"

He goes on to cite some weak references to studies of incontinence and claims that if the cost of correcting these morbidities that result from vaginal birth were included in comparisons of birth route that the "perceived advantage of vaginal birth is diminished or even eliminated. if given the information regarding the greater length of life expectancy (women living 30-40 years beyond menopause -sam) during which these morbidities (incontinence) increases and may be costly an difficult to alleviate, wouldn't more women request cesarean delivery?"

Every OB/GYN in the country who subscribes to the Green Journal (which is a lot of practicing docs, this is the number one journal in the field) has seen this article and many of them have read it. Now some of them are thinking "Yeah, I am sick of all these old women with prolapse and incontinence and I can do something to prevent women's future suffering."

Of course, few insurance companies will pay for cesarean on demand (we have had some clients try this -- don't ask), but once the lobbying campaign starts, will it be long before this is hailed as the ultimate in empowerment and something insurance companies cannot refuse???

This is really sad. Does anyone else think this is a reaction to the increasing popularity of midwives and the docs have to re-assert their power??

His arguments are identical to those in the amazing but popular book called Just Take It Out, by D. Campbell Walters, M.D. I think this book has been very influential in the Patient Choice Cesarean Section movement. To give you a taste, if the title did not clue you in, here are the chapters on cesarean sections with selected quotes:

What's So Bad About a Cesarean Section Anyway?

"Indeed the fact that 22% of deliveries in the US at the current time are cesarean deliveries reflects this INTUITIVE UNDERSTANDING on the part of obstetricians that cesarean delivery is not appreciably more dangerous for the mother."

One More Stitch

He believes that vaginal delivery is detrimental to one's future sexual enjoyment " Further circumstantial evidence to support this hypothesis derives from the fact that in certain areas of Brazil the cesarean section rate is as high as 90%!. Brazilian women prefer cesarean section to avoid injury to the birth canal (or should I say, conception canal?)."

Brain Damage

" In the light of ubiquitous social concern regarding the avoidance of traumatic head injuries, it is surprising to me that here is not greater concern over the possibility of traumatic head injury during labor and delivery."

Dead Babies

Mostly about post term babies. "But one woman will arrive at the hospital full of expectation and anticipation of joy and the nurses will find no evidence of life in her pregnant belly" He believes this will be because the prevailing view in the US is that an ob is not supposed to recommend to women that they are sectioned at 39 weeks.

Your Doctor And You

Begins: " Trust me on this one. Your doctor is one of the good guys. I know this because I have spent more than a decade hanging out with these folks"

This book brings a new piquancy to the phrase: "unencumbered by data" He includes sample letters to insurance companies and elected officials for women to push for elective sections and hysterectomies. And the opening and final chapters of the book make it clear that he considers himself to be a visionary along the lines of Semmelweis. My family was in stitches as I read it aloud to them. However even my 12 year old son is more knowledgeable about normal birth than this guy. He cites a grand total of 0 RCTs, 1 prospective study, and 2 retrospective studies in the cesarean section of the book.

He believes that vaginal delivery is detrimental to one's future sexual enjoyment.

Only because of their episiotomies that tear into the rectum. I have read this article, it was just faxed to me late last week. It is sickening. I think this man just needs to go live in Brazil, he seems to love what they do there so much. Cesarean as a "life-enhancing operation"? Geez, FOR WHOM?

As gross as it is, I guess I think it should be a woman's right to choose a cesarean delivery versus a vaginal birth, with appropriate informed consent. I would hope that the insurance companies would label it elective surgery and decline to pay for it, but I really vacillate about this too, since it discriminates against poor women. It is sad that some women would choose this, but it might be just what we need to get another big consumer movement going like what happened in the 70's - a move toward homebirth and natural childbirth as a reaction to the medicalization of childbirth. More books like "Have It Your Way," "Spiritual Midwifery," "Heart and Hands," and especially "Immaculate Deception" that stir the hearts of young midwives-to-be as well as childbearing women. Our current literature selection is just not as powerful. That may be just what we need to get past this hospital/epidural/high tech road we are already on!

I know that obstetricians are feeling a little threatened (one of ours was recently overheard telling someone that the midwives at Kennewick General were "out of control") but we can boomerang right back at them. Thanks to VBAC pioneers like Nancy Wainer and Nan Koeler, we have a large number of women who have had it both ways. I have rarely heard "I wish I had had another C-section!" I really believe that we can be heard over any pitiful roar ACOG wants to create.