Quotes of the Day

A picture of a laughing, blond two-year-old hangs on one wall of the office of Claudio Giorlandino, president of Italy's National Commission on Maternity and Birth. The boy, a twin, was delivered at 29 weeks by C-section — without which the child would almost certainly have died. Says Giorlandino: "We 'bring to life' with C-sections a large number of fetuses that, in natural terms, would never have survived to birth." That's why Giorlandino, like many in the medical establishment, feels that the World Health Organization (WHO) guideline of a maximum 15% C-section rate is far too low. To minimize situations in which the mother or infant survive the birth but are permanently damaged in some way, he argues, the realistic figure is 23%-25%. "If you examine the clinical records of last year's births," he says, "at least 25% of them have justified reasons for a caesarean to minimize fetal damage."

How common should C-sections be? A proportion higher than 15%, the WHO guidelines say, offers no additional health benefits and suggests that women might be undergoing risky surgery unnecessarily. Trouble is, the WHO devised that ceiling in 1985. Admits José Villar, head of the WHO's maternal and perinatal research division: "It was calculated by experts who just sat around a table in the '80s — without the benefit of actual data." Villar adds: "We agree that the figures are not relevant any more."

This year, the WHO has initiated a global study to determine the best ratio of C-sections to vaginal deliveries. The study will be completed in 2005, after which the organization plans to present new guidelines. Rather than one global standard, WHO may offer regional variations, adjusted for demographics and medical resources.

Assuming the WHO raises the bar above 15%, many in the obstetrics/gynecology community will feel vindicated and relieved. True, women who have C-sections must recover from surgery. But research suggests that elective C-sections may be less damaging to mother and baby than vaginal deliveries with vacuum extraction or forceps, which can bruise the baby and cause pelvic floor damage in the mother. Still, opposition remains. In his book, The Caesarean, to be published next month, French obstetrician Michel Odent — a pioneer of the natural- childbirth movement — sounds a warning note about the prevalence of C-sections. "It's a turning point in the history of mankind," he says. "We don't know what we are doing."

No wonder some women still feel a stigma attached to C-sections. Actress Kate Winslet, 29, recently confessed to an interviewer that in 2000 she delivered her daughter, Mia, by emergency C-section. "I've actually gone to great pains to cover it up," said the star of Titanic. "I was so completely traumatized by the fact that I hadn't given birth. I felt like a complete failure." Societal pressure that tells mothers that vaginal delivery is the only "real" birth is diminishing — and that's good news to women who owe their lives to emergency C-sections. "What's the option?" says Fiona Schubert, 41, whose son Max was born last year in London by emergency C-section after a 12-hour labor. "You get to the point where all you want is a positive outcome." Did Schubert feel like a failure? "Absolutely not," she insists. "I felt enormously relieved to have a healthy baby."

• JENNIE JAMES
• How many Caesarian births are really necessary?