TMC conference ignites C-section debate

When organizers from the UMKC and Truman Medical Center (TMC) departments of obstetrics and gynecology decided on seminar titles for their Update 2000 conference, held at the downtown Marriott April 13 and 14, they wanted to spark interest and debate among the members of the national medical community who would attend the conference.

Titles such as “Strategies to Optimize a Caesarean Delivery Rate,” “Caesarean Section: Is it Time to Change the Tune?,” and “Elective Caesarean Section at Term (38 weeks) as a Cost Control Measure” were listed on a press release distributed by the hospital’s marketing and public relations department. The course director for the conference, Dr. Eugene Pearce, weighed in — perhaps not considering that his audience would extend beyond medical professionals — with an equally provocative quote: “Considering the changing status of women, coupled with the emphasis on patient choice and damage to the female pelvic floor during vaginal births, it may turn out in the future that women will prefer to have Caesarean sections,” the physician stated in the press release.

The desired effect spilled over into the public arena. Conference organizers were subjected to a letter-writing and e-mail campaign, telephone calls, and a small protest outside the conference site from groups opposed to elective Caesarean sections.

“It should be noted that the titles of the topics related to Caesarean section are purposely provocative and controversial in an effort to attract attention and to have a successful registration. Evidently, this has succeeded in attracting attention in a manner that was not anticipated,” wrote Dr. James P. Youngblood, professor and chairman of the UMKC department of obstetrics and gynecology, in his e-mail response to the dozens of protest letters he received about the conference.

“We just found it appalling that they would discuss the benefits of making elective, unnecessary C-sections an acceptable option,” says Anita Woods, president of the local chapter of the International Cesarean Awareness Network (ICAN). Woods was alerted to the conference by a TMC employee.

ICAN, a nonprofit organization, seeks to support and inform parents recovering from or wanting to prevent a Caesarean section or traumatic birth. Vaginal births after Caesarean (VBAC) have gained popularity in the past 20 years as an acceptable alternative for most women who had a Caesarean section during their first labor. Previously, scarring from a C-section would most likely rupture during a vaginal labor in subsequent pregnancies, endangering the mother’s and child’s lives. Modern incisions are low and horizontal, making the risk of rupture considerably lower.

Pearce, head of the section of gynecology at Truman Medical Center and associate professor of gynecology at UMKC, said in a telephone interview before the conference that the goal was to give medical professionals, the conference’s primary audience, information. “We weren’t proposing to increase C-section rates, nor were we proposing to give the patient the option of having elective Caesarean sections. Our goal was to illuminate and give ideas.

“I don’t have a problem at all with these groups who have sent us letters. I have the highest respect for people who assist in safe, natural childbirth — especially midwives and doulas. I just believe that these people saw the titles to the sessions and jumped to conclusions.”

Pearce, who began practicing medicine in the 1950s, became interested in the C-section procedure after learning that his mother was born by Caesarean in 1901. Whatever the choice of birth, Pearce says, the woman should receive the best in medical care; that care may not, particularly in his approach, call for much invasiveness in the birth experience. “I have a long experience in private practice,” Pearce says, “and have always practiced minimalist obstetrics and believe that we have overdone technology.”

He adds that the real issue the medical community must confront is: When it is safe for a woman to have a VBAC birth? “Twenty years ago, the C-section rate was at 20 percent in this country. When the World Health Organization said that figure was too high, VBAC was considered a safe method for the majority of women to lower the C-section rate. But now we are seeing that about one out of 1,000 VBAC births end in catastrophe by tearing the vaginal wall, putting mother and child at risk. We are simply trying to devise better methods of evaluating and assessing who is at risk with VBAC.”

Pearce says a physician’s ability to predict risk factors is not perfect and that sometimes problems occur that doctors did not expect. “Great Britain and Brazil already offer Caesarean section as an elective option. The Caesarean rate in Brazil is at 42 percent right now, higher in certain groups. One-third of women gynecologists in Great Britain who responded to a survey which asked if given the choice, would they have an elective C-section said they would. Our goal is to debate this issue and discuss ideas so that if our audience is exposed to this later, they would be informed.”

Both Pearce and Youngblood responded to the e-mails, faxes, and calls they received about the conference. Mentioned in their responses was the fact that Truman Medical Center falls below the national average for Caesareans — 14 percent compared with the national average of 21 percent, with a VBAC rate of 30 percent compared with 25 percent nationally.

Even Woods concedes that Truman Medical Center has had a very good record in reducing Caesarean sections and kept asking herself, “They have a good thing going here. Why are they trying to ruin it?” Woods admits that an ICAN informant attending the conference said conference presenters did not make direct overtures for promoting elective Caesarean sections and that they appeared concerned with vaginal delivery and pelvic floor damage, which was a topic of one of the sessions.

Woods formed the Kansas City chapter of ICAN after first having a C-section, attempting a VBAC in the hospital with her second child, and finally giving birth to her third child naturally at home with a midwife. She remembers trying to figure out why she “couldn’t give birth.” Now Woods says with an undercoat of anger, “I was just sabotaged by the system.”

“They (medical staff) told me that I had to have a C-section with my first child in 1993 because I was failing to progress,” Woods explains. “It had been twelve hours, and that is the normal cutoff time when doctors usually go ahead with the C-section. My second child was VBAC, but there still was so much technological intervention that it was a nightmare.”

Woods claims that there was no medical reason for her C-section during her first pregnancy except that her cervix had quit dilating. “The baby was in no distress and labor could have went on for as many as 24 hours and it could have been considered normal. It was a Sunday afternoon, and I think my doctor simply wanted to go home.”

The physicians during her second labor also considered her contractions abnormal, so she received drugs to induce labor. She ended that labor with a severe tear from an episiotomy. “The pain was excruciating and the recovery was as bad, if not worse, as it was from the C-section. I could not sit for three weeks, and lovemaking with my husband was painful for at least eight months afterward.”

Woods shunned the medical community during her third pregnancy and sought treatment from a midwife. “I learned that I had control over my body and that women who are pregnant do not need a doctor to rescue us. Giving birth is not an illness, and you go to the hospital for illnesses. Labor for my third child only lasted two hours, and that is a strong testimony to what the body is capable of,” Woods says.

One of the problems groups such as ICAN say is magnified by a woman’s having a C-section is the severity of postpartum (the period after birth) depression. “I never really felt like I had given birth to my first child. I felt as if he was ripped from my body,” says Woods. Other feelings Woods says she dealt with and has helped others to handle are of anger, disappointment, and failure. “Some women equate these feelings to trauma felt after a rape,” she says.

Marcia Biel, Ph.D., a psychologist who has had experience dealing with women who have faced postpartum depression, says that she has found that incidents of depression in women are higher if they have experienced an unscheduled Caesarean section.

“A C-section is an abnormal birth for most women, which leads to guilt and anxiety that they have failed. If the surgery wasn’t scheduled, then it was an unexpected outcome for the mother, and that outcome tends to push the incident of depression up,” Biel says.

She adds that if the woman is expecting the C-section and has time to prepare, she seems to have fewer issues with the procedure. “The women have had time to deal with the question of ‘why.'”

Biel says she doesn’t have studies to confirm that incidents of depression occur at a higher rate in women who have had unscheduled Caesarean sections but says she has witnessed such depression in her own practice. But not all psychologists and counselors who deal with helping women experiencing postpartum depression have found such evidence.

“I have treated a lot of postpartum depression patients over many years and have never encountered that at all,” says Cynthia Meeker, Ph.D., a licensed professional counselor. Meeker completed her dissertation for her doctorate at the University of Kansas in 1983 on postpartum depression and says her research did not uncover evidence to support a connection with C-sections.

“I do ask clients if they had a vaginal birth or a C-section, and I haven’t found that to be a factor in my practice, although I haven’t looked specifically at that question. There are many other things that contribute to postpartum depression, but I haven’t found that to be one of them,” says Meeker.

Biel says she believes that the medical community is trying very hard to educate women about the possibility of having an unexpected C-section through information supplied by doctors, nurses, and birthing classes. The problem is that women who have gone through a normal pregnancy simply are not listening or believing it could happen to them.

“I know that when I was pregnant with my first child, I didn’t listen to the numbers. I never thought I wouldn’t have a normal delivery,” says Sheila Bodelson, a registered nurse and an instructor in natural childbirth and VBAC classes. “My goal now as an instructor is to, hopefully, prepare women for a vaginal birth but also prepare them for the possibility of a C-section.”

Bodelson has had three Caesarean sections, all of them necessary, she says, because of medical problems during her pregnancies. “Neither one of my first two labors progressed, and I ended up having unscheduled Caesarean sections. I chose my third doctor mainly because I knew he was a strong proponent of VBAC and I knew he would do everything possible to help me have a vaginal birth. When it was evident that the problem I was having would reoccur during my third labor, I chose to go ahead and schedule the surgery.”

Bodelson says she didn’t experience any of the negative feelings she has heard described by some women who have had C-sections. “I think a lot of it has to do with having faith and confidence in your physician. I had full faith in my doctor’s decisions and had no question as to why I needed to have C-sections,” she says.

Woods contends that placing blind faith in the medical community is what leads most women to depression and to question themselves after a C-section. “Generally, women who go in and are advised that they need a C-section are just told, ‘This is what will happen,’ and they are given a form to sign. They aren’t being adequately informed of the risks. If their labor is failing to proceed, they aren’t told that they can choose to try to continue. They lose complete control over their bodies, and it’s as if the baby isn’t even yours anymore — it belongs to the doctors,” she says.

Woods then quotes a passage from the book Silent Knife, by Nancy Wainer Cohen, who coined the term VBAC. The book strongly advocates natural childbirth and VBAC as routine for most women. “Fear prevents them (obstetricians) from being able to see things clearly. They don’t understand the sacredness of birth; they don’t understand (that) when they maim women they lose out — the system loses out as well,” she writes.

Bodelson admits that she may have had an advantage during her surgeries because she is a nurse and in all three cases knew and trusted all of the people around her during her labor. “The first two times I was hesitant to ask for things in the operating room,” she says. “The third time, I was asked by a nurse what I would like to make me happy. I told her a mirror so I could see the baby being born, which in itself had a very calming effect on me. I don’t think a lot of women ask questions or know that they have options.”

Bodelson adds that a woman should research all of the birth options, even if her pregnancy is progressing normally. “When I was pregnant for my third child, an acquaintance gave me a copy of the book Silent Knife, and I think if I had not been an informed person, that book could have put me into real turmoil about the decision I was making. But I knew in my situation that the decision to have a C-section was the right decision and that VBAC was not worth the risk. I don’t think pregnancies and labor should be generalized in that way.”

Woods says that her organization advocates free choice for women. “As long as the woman does her own research and understands all of the risks associated with Caesarean section, of course, it is the woman’s right to choose how she is going to have her baby,” she says.

“It may not be generally known that there is an increasing initiative of many women to request a primary Caesarean section even though (it’s) not medically indicated. This is not only an issue of women’s rights but also an ethical issue on the part of the physician. One objective of this conference is to rationally discuss this issue with no real attempt to arrive at a conclusion. Only society will determine the eventual evolution of this issue and not the medical profession,” Youngblood wrote in his e-mail response to opponents of the conference.

Even Bodelson doesn’t understand why a woman would choose a C-section. “Given the option, I would have rather had all of my children by vaginal birth. Caesarean is major surgery, and I had to deal with all of the risks and recovery associated with surgery,” she says. “But at least I had the option to do the best thing for myself and my babies. Women in the past didn’t have that option. I don’t think that the method of birth is what is most important. The end result is that I have three beautiful, healthy children.”

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