Birth by appointment

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By Karen Goldberg Goff

When Emma Lincoln was getting ready to deliver her first child, she told her doctor to schedule a Caesarean section. Neither Ms. Lincoln, who lives in Salisbury, Md., nor her baby had any medical issues that would warrant the surgical delivery.

"I was terrified of giving birth naturally," says Ms. Lincoln, whose sons were born in 2006 and 2008. "I looked at the pros and cons. Some women have this sense of pride about them when they talk about how long they were in labor. You don't get a T-shirt saying 'I survived natural birth,' with 'natural birth' in a creepy font."

Elective C-sections are part of the reason the Caesarean rate in the United States is at an all-time high of 31.8 percent of births, according to numbers released last month by the National Center for Health Statistics. That number was around 20 percent in 1996.

A decade ago, surgical delivery mainly was reserved for emergency situations, such as when mothers had high blood pressure or were failing to progress in labor or the baby showed signs of distress. Today, several factors are leading to the rapid rise in C-sections, even though having one carries with it a longer hospital stay, longer recovery time and the risk of complications from anesthesia. Those factors include changing attitudes toward childbirth, the convenience of a scheduled birth for busy women, and malpractice concerns by doctors and insurance companies.

Dr. Bruce L. Flamm, an obstetrician with Kaiser Permanente in Riverside, Calif., and a spokesman for the American College of Obstetricians and Gynecologists (ACOG), says the biggest reason for the rise is a change in thinking about repeat C-sections. A decade ago, mothers who had had a previous C-section were encouraged to try to deliver vaginally in subsequent pregnancies to avoid surgery and its accompanying high cost and risk of complications. Not so anymore.

"Many hospitals and doctors feel they cannot do [vaginal birth after Caesarean] safely," Dr. Flamm says. "In a VBAC, ACOG guidelines say you still have to have an OB-GYN, an anesthesiologist and an operating room ready to go. Many hospitals feel they cannot comply."

VBAC deliveries are formally or informally banned in many hospitals nationwide, says Dr. Gretchen E. Humphries, advocacy director for the International Cesarean Awareness Network (ICAN), an advocacy group that seeks to educate and inform to reduce the number of unnecessary surgical deliveries. Dr. Humphries, a veterinarian who lives in Ann Arbor, Mich., delivered twins via C-section in 1998.

An ICAN survey showed that 841 hospitals nationwide, many of them small and rural, have banned VBAC births. Another 640 have no formal ban but also have no doctor who will agree to a VBAC. No hospitals in the immediate area of the District have VBAC bans.

"Back in the 1990s, when VBAC was in, insurance companies usually wanted a woman to try labor," Dr. Humphries says. "When there were a few spectacular disasters, the insurance companies were on the hook as well. Insurance companies are not going to get near this with a 10-foot pole now. They are not going to tell women they can't have a C-section."

Meanwhile, the typical cost of a C-section is about $10,000 to $15,000, or nearly double the cost of vaginal delivery, according to ACOG.

"Medical-legal issues have contributed to the rise in the number," Dr. Flamm says. "Obviously, if labor goes wrong, the doctor is open to a lawsuit. With a planned C-section, at least the perception of risk is eliminated."

In fact, if one looks at C-section complications, a large portion of those occur during emergency procedures because the mother or baby already has experienced complications, Dr. Flamm says. Compare risks of a vaginal birth with the risks of a planned C-section, though, and they are pretty equal, he says.

The costs stack up, too, Dr. Flamm says.

"We should try and make decisions based on safety and patient preference," he says. "Some people in the medical community actually think it will be cheaper to increase the C-section rate. It sounds crazy, because the surgery stay is longer, but when you figure in the cost of going through labor and the 1-to-1 of nurses and patients, the difference is not quite as obvious."

Finally, convenience for doctor and patient is a factor in the surgical-delivery trend. With more women working and everyone's schedule already overbooked, many families are finding it helpful to schedule an appointment to meet their little one.

Dr. Humphries could have chosen a scheduled C-section for the birth of her third child in 2001 but wanted to try a VBAC delivery. Concerned she would find the hospital resistant to that idea, she delivered the child at home instead. Her fourth child was delivered at home in 2004.

Meanwhile, Ms. Lincoln went back to the operating room last year to deliver her second child, this time with a different doctor.

"She was very understanding of my fears," Ms. Lincoln says. "I asked her which she preferred, natural delivery or elective Caesarean, and she told me she prefers the elective procedure because 'I'm in control. Doctors like to be in control.' "

Dr. Flamm says he expects to see the C-section rate rise even more. There might be a time soon when more than half of American babies are born via C-section.

"Twenty years ago, if you would have told me that, I would have laughed," he says. "The number was about 12 percent then. I think we are going toward where the culture dictates. When I started in the 1980s, I would see a lot of women request natural childbirth with Lamaze or Bradley coaching and no IV. That seems to have come full circle. A lot of women just want their baby on a certain date and to get it over with."