There has been a steady increase in the number of women requesting cesarean, or surgical, birth in the absence of a medical reason in other words, “elective” cesarean. The term elective cesarean generally refers to a primary, or first, surgical delivery for non-medical reasons. The trend in primary elective cesarean births, also known as “cesarean on demand,” has created a stir in both professional and parent circles. Ethical questions focus on safety and potential complications for both mothers and babies

In a 2004 statement by the American College of Obstetrics and Gynecology (ACOG), concern was expressed about promoting elective cesarean birth in the absence of solid safety evidence. Nearly three years later the evidence remains scant, although ACOG was clear to point out that maternal autonomy, or independence, must be taken into consideration. The decision ultimately belongs to the pregnant women in consultation with her obstetric care provider, and ACOG’s statement assumed that discussions have taken place to thoroughly review risks as well as possible benefits so this important decision is a well-informed one.

The American College of Nurse Midwives issued a statement in 2005 cautioning that research evidence rather than liabilty, convenience, and economic issues should guide decisions about a major abdominal surgical procedure, such as primary elective cesarean births.

Why is there so much interest in primary elective surgical birth?

First of all there is concern about injury to the pelvic floor muscles that may result in urinary and sexual dysfuntion for women. Secondly, there is a desire on the part of some women to schedule the birth for a variety of work-related or personal reasons.

Are these concerns valid?

Research shows that genetic traits along with pregnancy seem to affect the pelvic floor muscles far more than the mode of delivery. Researchers found that it is likely birth interventions including the use of forceps and vacuum extraction rather than appropriately managed vaginal birth that increase the likelihood of pelvic floor injury.

Work-related or personal reasons can be even more difficult to justify. Obstreticians have reportedly explained the risks associated with elective cesarean birth, only to have women choose another care provider because the physician refused to do an elective cesarean birth.

What are the risks of elective cesarean birth?

Cesarean birth alone carries increased risk. In a study of 20,000 babies, those born by planned cesarean birth were twice as likely to require care in the Neonatal Intensive Care Unit (NICU) compared to those born by planned vaginal birth. Researchers found that cesarean birth was associated with difficulty breastfeeding in infants and a delay in the onset of milk production in mothers.

In addition, babies born by elective cesarean birth are more likely to be born pre- or near-term rather than full-term. Pre- and near-term babies are more likely to have breathing problems, develop jaundice, and have difficulty controlling body temperature and blood sugar. Finally, there is the risk of complications with subsequent pregnancies as a result of uterine scarring and abdominal adhesions.

How do women decide what to do?

Learn the facts. Know that elective cesarean birth remains contoversial. Know that there is little evidence regarding its safety. Weigh the benefits and the risk before making a final decision. Know that emotion, including fear, can be exaggerated by unrealistic expectations. Talk with women who have given birth. This may help you sort out your emotions, both negative and positive. Talk with women of different ages who have given birth vaginally, with and without medication, and also with women who have had a cesarean birth. Ask them what they liked and disliked about their births and whether they experienced any physical or emotional side effects short or long-term.

Know that primary elective cesarean birth is not recommended for women who think they may want to have more than two children. Also, most experts recommend waiting until a pregnancy is at 39 weeks gestation to limit the risk for delivery of a near-term infant.

If you decide to have an elective cesarean birth, talk with the International Board Certified Lactation Consultant (IBCLC) at your birthing facility and discuss ways to improve early breastfeeding such as making arrangements to have someone in the room round-the-clock to help with positioning the baby for feedings until you are able to move more freely.