NIH Panel Finds No Extra Risk in Caesarean Section

By Rob Stein
Washington Post Staff Writer
Thursday, March 30, 2006

Caesarean sections are not necessarily riskier than vaginal deliveries and may be safer in some ways for the mother and baby in many cases, an expert panel concluded yesterday.

The panel convened by the National Institutes of Health did not endorse delivering babies by the surgical procedure, but the experts found no clear reason to routinely discourage women from choosing that option, which continues to grow in popularity. The findings contrast with decades of medical advice aimed at trying to reduce the number of Caesareans, which for years were seen as unnecessary, costly and potentially risky.

Overall, the panel found that current scientific evidence is insufficient to recommend performing or not performing Caesareans on demand, saying the available studies suggest both risks and benefits. Elective Caesareans should not be done until the baby's lungs have developed sufficiently or on women planning to have more than two or three children, the panel concluded. But the experts said the procedure is an acceptable option for women -- especially those in their forties -- who are planning to have only one or two children.

"We think it's reasonable if a woman wants to bring this up with her physician that they have a full discussion," said Mary E. D'Alton of Columbia University Medical Center in New York, who chaired the panel. "It should be discussed with the woman, and her decision should be honored."

The report was praised by advocates of giving women more of a choice in how they deliver their babies, and denounced by opponents who say Caesareans are dangerous and overused. Both sides said they think the report will prompt more women to request the procedure, more doctors to perform it and more insurance companies to pay for it.

More than 1 million of the 4 million babies born each year in the United States are delivered by Caesarean section, which involves removing the baby from the uterus through an incision in the mother's abdomen. The procedure was developed primarily to deliver babies in situations where the mother or child is experiencing complications that put one or both at risk.

As the number of Caesareans increased through the 1970s, in part because of rising malpractice suits associated with vaginal births, medical groups began campaigns that reversed the trend. Many medical authorities viewed the procedure as unnecessarily expensive and risky, and advocates of "natural childbirth" saw it as turning a natural experience into a "medicalized" one.

But the number of Caesareans began to increase again in 1996, reaching an all-time high of 29.1 percent of all births in 2004. The trend was fueled by such factors as doctors' concerns about the safety of attempting a vaginal delivery after a previous Caesarean, women's fear of the pain and physical trauma of traditional labor, and the convenience of being able to schedule deliveries.

The rapid increase triggered an intense debate and prompted the NIH to convene the panel to make the first new assessment of the procedures since 1980, when the focus was on preventing Caesareans.

The 18-member panel reached its conclusions after studying the most current scientific evidence for several weeks, followed by two days of presentations by more than a dozen experts. Those sessions were punctuated by contentious question-and-answer and comment periods in which panelists, presenters, scientists and advocates debated the evidence.

The panel concluded that Caesareans increase the risk for some serious, potentially life-threatening complications, particularly devastating uterine ruptures during subsequent vaginal deliveries. For that reason, women planning large families should avoid them, the panel said. And the procedure should not be done before the 39th week of pregnancy unless the baby's lung development has been verified. But there was also evidence that the surgical deliveries reduced risks such as bleeding by the mother and possibly brain damage to the baby.

The evidence on other complications is mixed. The risk of infection, for example, appears to be lower after vaginal deliveries, and the risk of incontinence may be lower following Caesareans, the panel found.

The panel also heard presentations about costs but limited its conclusions to the medical risks and benefits.

Critics denounced the report for not considering evidence that they said clearly shows Caesareans carry many risks, including blood clots and miscarriage in later pregnancies.

"It's very disappointing," said Berna Diehl of the International Cesarean Awareness Network, which considers the procedure dangerous. "This will be interpreted as a green light for Caesareans, which is a risky surgery for healthy women."

But others praised the report for providing a balanced evaluation of the state of scientific knowledge.

"Previously, the party line was that it was an inappropriate thing to do on request without a clear medical indication," said Michael F. Greene of Harvard Medical School. "This report is a scholarly review of the available literature that at least brings into the realm of reasonable discussion the question of whether Caesarean delivery upon maternal request is a rational thing to do."

Proponents said the report vindicates those who advocate allowing women to choose their method of delivery.

"This really does validate the elective Caesarean section as a mainstream obstetrical procedure," said W. Benson Harer Jr., a former president of the American College of Obstetrics and Gynecology who advocated for patient choice. "It's going to remove the stigma that has been hanging over it."

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