Another nail in the coffin:
washingtonpost.com
Elective Caesareans Judged Ethical Doctors Group Issues Statement on Popular Procedure By Rob Stein Washington Post Staff Writer Friday, October 31, 2003; Page A02 It is ethical for doctors to deliver a baby by Caesarean section even if the mother faces no known risks from conventional labor, the nation's largest group of pregnancy specialists has decided. The American College of Obstetricians and Gynecologists' ethics committee is issuing a statement today that for the first time addresses the increasingly popular elective Caesarean sections -- those performed when there is no medical necessity. The organization has never before issued guidelines or official opinions about elective Caesareans, but for years it has been among many medical groups that campaigned to reduce the number of surgical deliveries for any reason. The new statement could help accelerate a rapid increase in Caesarean sections by making doctors more willing to perform the procedure on an elective basis, some experts said. In a retreat from the "natural childbirth" movement, the number of women undergoing surgical deliveries has reached an all-time high. More than one-quarter of all U.S. babies are delivered surgically, the highest rate since the government started collecting statistics on the issue in 1989. The reasons for the increase are complex and controversial, but the trend is being driven in part by a rise in elective Caesareans. Even if their babies are not in a feet-downward "breech" position, or they do not face other possible complications, some women are choosing to forego natural labor and instead schedule a surgical delivery, either for convenience, because they fear the pain of childbirth, or because of concerns about possible long-term complications from the physical trauma of labor and delivery. The increase has led to an intense debate. Opponents argue that elective Caesareans are costly, require more recovery time, and put women at risk for infections, hemorrhages and other complications. Proponents say Caesareans pose no serious risks for most women and that expectant mothers should have the choice. Some go further, saying doctors should actively offer the option because labor and delivery carries significant risks for long-term complications, including decreased sexual sensation, incontinence and other health problems. In the new statement, the ethics committee concludes that the relative risks and benefits of elective Caesareans vs. vaginal deliveries remain unclear, and it cautions against actively advocating surgical deliveries. "The burden of proof should fall on those who are advocates for . . . the replacement of a natural process with a major surgical procedure," the committee wrote. Moreover, "given the lack of data, it is not ethically necessary to initiate discussion regarding the relative risks and benefits of elective [Caesarean] birth versus vaginal delivery with every pregnant patient," the committee wrote. But the committee also concludes that "if the physician believes that [Caesarean] delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing" the procedure. Robert Lorenz, vice chief of obstetrics at William Beaumont Hospital in Royal Oak, Mich., a member of the committee, cautioned that the statement was not meant to encourage elective Caesareans but to provide an ethical context for making that decision. "My concern is that people will take this as a carte blanche 'Let's do Caesarean sections on everyone,' " Lorenz said by telephone. "That's not the intent at all." Laura Riley of Massachusetts General Hospital, who chairs the organization's committee on obstetric practice, said the group would not issue specific guidelines about elective Caesareans until more research is done on their risks and benefits. But supporters of offering Caesareans as an option applauded the committee's statement as a significant shift. "I think it's a step to where we're going. And my guess is that as increasing evidence comes out, it will probably become a more accepted procedure," said W. Benson Harer Jr., medical director of the Riverside County Regional Medical Center in Moreno Valley, Calif., who triggered a furor when he was president of the organization by arguing that women should have the option of a Caesarean. "Before this statement, it was gray area. This clarifies it and gives it some permissibility." David C. Walters, an obstetrician-gynecologist in Mount Vernon, Ill., who actively advocates Caesareans, was disappointed it did not go further. "I do think it's a step forward in that the college has grudgingly agreed that it might be a reasonable thing to do. That's new," Walters said. "They should have said that in the absence of compelling evidence to support the superiority of either vaginal birth or Caesarean section that either one is a reasonable alternative for delivery and should be considered equally." But Tonya Jamois, president of the International Cesarean Awareness Network, which opposes overuse of the procedures, criticized the statement. "There's lot of evidence that shows that Caesareans are much more dangerous for the mothers and the babies," Jamois said. "What I'm worried about is that this will be interpreted to justify ethically a physician agreeing to give a woman a Caesarean when there's no medical indication. I think it is a bad thing for society." © 2003 The Washington Post Company
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