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"I personally like to practice under 'Do no harm,'" says Dr. Kimberly Gregory, director of maternal-fetal medicine and women's health services at Cedars-Sinai Hospital in Los Angeles. "Surgery is a major procedure." Gregory says most women ask for C-sections because they're afraid of complicated deliveries or long, painful labor. Though she has performed a few elective procedures, she doesn't do them routinely and says good doctors should be able to allay women's fears by discussing the use of drugs and breathing techniques, which can ease pain.
On the other hand, many doctors believe just as strongly that a woman should have the right to choose for herself how she wants to have her child, as long as she is fully informed of the risks and benefits.
Of course, there are risks associated with natural childbirth too. During difficult deliveries, in which the mother is pushing for three or more hours, a baby can suffocate or sustain brain damage in the birth canal. Moreover, up to 5% of vaginal deliveries result in severe tearing of the mother's perineum, which can lead to incontinence and an excruciating recovery.
According to Dr. Benjamin Sachs, a professor of obstetrics and gynecology at Harvard Medical School, a careful study of the risks of both forms of delivery suggests that one is generally as safe as the other. That's one of the reasons doctors have become quicker to cut, says Sachs, even in nonemergency situations. With malpractice premiums hovering at $150,000 to $200,000 per year, obstetricians can no longer afford to take even the slimmest risk associated with natural childbirth. And if patients want to have a caesarean section, says Sachs, why deny them without a compelling reason to do so? "The opportunity for a woman to elect to have a caesarean section should be as available as the opportunity to have a safe, natural childbirth," he says. "Our responsibility as physicians is to counsel at both ends of that spectrum, explain the issues and try to provide support for women."
Officially, the American College of Obstetricians and Gynecologists (ACOG) agrees. Last November, an ACOG ethics committee issued its opinion on the debate, finding it ethical for doctors to perform elective C-sections so long as the procedure doesn't imperil the health of the mother or child. But the committee fell short of offering guidelines, citing lack of evidence. Dr. Laura Riley, of Boston's Massachusetts General Hospital and the current chair of the ACOG obstetrics practice committee, says studies haven't fully explored the issues many women fear most: pelvic-floor damage and incontinence. "The studies are still out," says Riley, but in reference to her personal practice, she adds, "My thought is, a vaginal delivery is safer for the mother."
A Gallup poll published in February suggests that female obstetricians are sharply divided on the issue. Thirty-six percent say they would not perform a caesarean at a woman's request if it wasn't medically necessary, 32% say they would, and 28% say it would depend on the circumstances. Tellingly, 27% of the polled doctors who had been pregnant had had at least one C-section themselves, and 22% of those procedures were elective.