To parents and proponents of normal vaginal birth, led by the Kansas City branch of the International Cesarean Awareness Network (ICAN), the medical conference, "Update 2000 in Obstetrics and Gynecology," on April 13-14, 2000, in Kansas City clearly signified a promotion of unnecessary elective cesarean sections. To the conference sponsors, the Truman Medical Center of Kansas City, the intent was not to promote cesarean sections, they said, but rather, "the titles of the topics related to cesarean section are purposely provocative and controversial in an effort to attract attention and to have a successful registration." Thus, the debate over whether or not elective cesareans should be performed on maternal request sharply escalated in the United States, pitting a parent advocacy group against obstetrician-gynecologists.

Noted national experts and researchers in obstetrics and maternal-fetal medicine were among the faculty in the conference program. It offered the following obstetrics sessions, the purpose of which, according to the conference brochure, was "to integrate the latest knowledge of the risk-benefit calculus on delivery alternatives":

Cesarean Section Goes Mainstream

Strategies to Optimize a Cesarean Delivery Rate

Cesarean Section: Is it Time To Change the Tune?

Vaginal Delivery and Pelvic Floor Damage

Resolved: that Normal Gravida Should Be Offered Elective Cesarean Section at Term (a debate)

Elective Cesarean Section at Term (38 weeks) as a Cost Control Measure

Elective Cesarean Hysterectomy at Term for the Last Delivery

These session titles certainly provoke, and together with such an eminent faculty, presumably attracted registrations from many maternity care professionals. The titles also attracted the attention and concern Of the Kansas City ICAN, led by its president Anita Woods. She immediately opened a dialog with the conference sponsors and began a wide-reaching public campaign to protest the conference. The events and correspondence are described on the group's website, http://hometown.aol.com/icanofkc. Letters and e-mails of protest poured in from all over the United States and abroad, and on the first day of the conference an article in the Kansas City Star reported that "Cesarean Sections' Value Comes Under Scrutiny" (1).

Meanwhile, outside the downtown hotel where the conference was being held, as Woods described, "With picket signs,: strollers, and babies in tow, mothers and fathers came to protest elective cesarean section. We passed out flyers, shared information with curious pedestrians, and even had an informative talk, with one of the obstetricians attending the conference. On the second day of the protest, at least two doctors who attended the conference spoke with us to 'clarify' that the conference was not about the promotion of unnecessary cesarean sections. Their demeanor was condescending…."

An audience poll was taken at the conference after the debate "That normal gravida should be offered elective cesarean section at term." According to Woods, 50 percent of those attending were in favor of the resolution.

This debate over maternal choice for elective cesarean in the absence of medical indications has raged for some time in the United Kingdom (2,3), and, it is quickly gathering momentum in the United States (4-6). In both countries the cesarean delivery rate is on-the rise- 15.5 per cent in England in 1994-1995 (7), and 21.2 percent in the United States in 1998 (8), respectively. As justification for maternity choice, to have a cesarean, writers often refer to the British report, Changing Childbirth, which recommends, " the woman should be fully informed and involved in making decisions about her care" (9). I wonder if the Expert Maternity Group anticipated that their recommendations for maternal autonomy would be used to bolster the arguments of those favoring cesareans on demand?

Several groups in the United States, including the International Childbirth Education Association, Coalition for Improving Maternity Services, Maternity Center Association, Lamaze International, and others have strongly maintained that women should be given accurate information about benefits and risks of medical procedures so that they can make informed decisions about birth alternatives.

Although consumer advocacy groups and professional obstetrics organizations may equally favor informed maternal choice, they are firmly grounded in opposing philosophical viewpoints. Yes, they both want a safe and healthy outcome for mother and baby, but one side sees childbirth as an always-risky event in need of medical interventions and the other sees childbirth as a normal, healthy process, requiring intervention only for specific scientifically based medical indications. These are the two ideologies that Pincus examines in her provocative essay in this issue of Birth (10), -and herein lies the crux of the gulf between the opposing groups in Kansas City.

Encouragement for elective cesarean delivery appeared in a recent editorial by W. Benson Harer, Jr., President of the American College of Obstetricians and Gynecologists (ACOG), who believes that "The time is coming-if not already here-for 'maternal choice cesarean' " (5). After describing the multiple risks of vaginal birth, which "are associated with vaginal birth in much higher incidence than with cesarean delivery," and weighing the equation of risk versus benefit versus costs of correcting the morbidity, Harer then concluded that "the perceived advantage of vaginal birth is diminished or even eliminated" (5). With such words, Harer takes the cesarean-versus-vaginal birth debate to a disquieting new level.

In response to the editorial, Kansas City ICAN reminded physicians of their oath: "Do no harm." Noting that "medically unnecessary elective cesareans increase risk to birthing women," and pointing out the higher maternal mortality with a cesarean compared with a vaginal delivery, the group asked, "How many avoidable maternal deaths are acceptable? ICAN believes that number is zero."

Morbidity and mortality associated with cesarean section are not discussed in Harer's editorial, but some recent evidence is disturbing. For example, observing that "physicians have not seemed to take much notice," Dr. Elliott Levine reported that according to a 6-year retrospective study of 1058 elective procedures, "Persistent pulmonary hypertension of the newborn may occur at a rate approaching I % following elective cesarean delivery, 10 times higher than with vaginal birth" (11). Respiratory distress syndrome continues to be seen and cause morbidity and mortality in "term" infants (12). Furthermore, women are more likely to be rehospitalized after cesarean deliveries, especially from uterine infection, obstetric surgical wound complications, and cardiopulmonary and thromboembolic conditions, according to a large retrospect investigation of 256,795 primiparas who gave birth in Washington state between 1987 and 1996 (13).

In addition, a recent study reported that nearly one fourth of 2447 women with nonbreech full-term gestations had unplanned cesarean deliveries for "lack of progress" earlier in the course of their labor than recommended by ACOG guidelines (14). In fact, 16 percent of the cesareans due to lack of progress were performed at 0 to 2 cm cervical dilation and 24 percent at 0 to 3 cm. This finding is "not necessarily bad, some experts say," noted one article (15), which quoted Harer's editorial in support of the "maternal-choice cesarean" (5).

Harer and other maternal-choice cesarean supporters suggest that women should make an informed choice for mode of delivery based on their understanding of the risks and benefits of vaginal and cesarean delivery. But what exactly do they mean by "informed choice"? As has been pointed out before (6), informed consent forms for vaginal birth after a cesarean --(VBAC) may be deliberately frightening and slanted by physicians to reflect their practice bias against vaginal birth and in favor of doing a cesarean (I 6). Women can only make an informed choice if they are given unbiased and scientifically accurate information on both vaginal and cesarean deliveries. How really "free" and how "informed" will their choice be?

In the United Kingdom, a constructive effort is being started to understand and come to grips with these issues over practice and maternal choice. The Department; .of Health is funding a National Sentinel Caesarean Section Audit "to determine factors associated with variation in the caesarean section rates" in all maternity units in England and Wales (7). The project, which began in May 2000, is a multidisciplinary collaboration of the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Anaesthetists, and the National Childbirth Trust. Cesarean birth data will be collected and analyzed "with an emphasis on the decisionmaking process and the indications for caesarean section" (7). Not only has a consumer childbirth group been invited as a collaborative participant in the project, but later in 2000 "a survey of women's views and involvement at the decisionmaking process in relation to Caesarean section will also be undertaken in a sample of hospitals" (7).

The year 2010 national health objective recommends reducing the cesarean birth rate to 15.5 percent in the United States (17), but meeting this target is unlikely. Already we can see effects-the falling rate of VBACs (8) may be attributed to the current negative bias against them (4,16). Now, since the President of ACOG has gone on record as endorsing and encouraging "maternal-choice cesareans," more obstetricians will follow his lead. This shift in thinking will further accelerate the rate of cesarean deliveries in the United States, which may be a favorable development according to the cesarean birth proponents, but one that alarms professional and consumer advocates for normal vaginal childbirth. The latter group points to evidence-based conclusions from meta-analyses that "a trial of labour should be recommended for women who have had a previous caesarean section by lower segment transverse incision and who have no other indication for caesarean section in the present pregnancy" (18, p 293).

Surely a constructive move would be for physician groups in the United States to follow Britain's lead, and join with midwifery and consumer advocacy groups to collect and examine objectively and scientifically the data about cesarean delivery rates, women's childbirth preferences, and the decision-making process. Debate is good, and efforts should be made toward continuing the dialog. As Pincus observes in this issue of Birth, however, "Fruitful dialogs will be likely only when people can change their point of view" (10). On the vaginal birth versus elective cesarean debate, collaboration, respect, and an open mind will help. Resolution between the two sides in the current medical climate, however, is another matter.

References

1. Bavley A. Delivery room decisions: Caesarean sections' value comes under scrutiny. Kansas City Star April 13, 2000.

2. Paterson-Brown S. Should doctors perform an elective caesarean section on request? Yes, as long as the woman is fully informed. BMJ 1998;317:462-463.

3. Amu 0, Rajendran S, Bolaji 1. Should doctors perform an elective caesarean section on request? Maternal choice alone should not determine method of delivery BMJ 1998;317: 463-465.

4. Sachs BP, Kobelin C, Castro MA, Frigoletto F. The risks of lowering the cesarean delivery rate. N Engl J Med 1999;340: 54-57.

5. Hater WB. Patient choice cesarean. ACOG Clin Rev 2000; 5(2):I, 13-16. 6. Young D. Whither cesareans in the new millennium? Birth 1999;26:67-70. 7. Thomas J, Callwood A, Brocklehurst P, Walker J, .The National Sentinel Caesarean Section Audit. BJOG 2000;107:579-580. 

8. Curtin SC, Mathews TJ. U.S. obstetrical procedures, 1998, Birth 2000;27:136-38. 9. Department of Health. Changing Childbirth. Report of the Expert Maternity Group. London: Her Majesty's Stationery Office, 1993.

10. Pincus J. A consumer viewpoint: Childbirth advice literature as it relates to two .childbearing ideologies. Birth 2000;27: 209-213,

11. Kim TF. Elective c-section may spur onset of PPHN. ObGyn News 2000;35(3):13.

12. Madar J, Richmond S, Hey E. Hyaline membrane disease after elective delivery at "term." Acta Paediatr 1999;88: 1244-1284.

13. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. JAMA 2000;283:2411-2416.

14. Gifford DS, Morton SC, Fiske M, et al. Lack of progress in labor as a reason for cesarean. Obstet Gynecol 2000;25: 589-595.

15. Walsh: N. One-fourth of some cesareans may be premature. ObGyn News 2000;35(9):20. 16. Phelan JP. VBAC. Time to reconsider? OBG Management 1996;Nov:62-68.

17. U.S. Department of Health and Human Services. Healthy People 2010-Conference Edition. Ch 16. Washington, DC: Author, 1999.

18. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy & Childbirth. 2nd ed. Oxford: Oxford University Press, 1995.

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